HomeMy WebLinkAboutBuilding Permit #196-2017 - 40 COMPASS POINT ROAD 8/24/2016 BUILDING PERMIT F NORr q
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: ' /J" Date Received L-f ' �R°DR IED�e¢ cy
�SSACHUS��
Date Issued:
I ORTANT:Applicant must complete all items on this page
LOCATION
T� Print
PROPERTY OWNER �'C.
Print 100 Year Structure yes
MAP 1 o b . PARCEL:'1 (o ZONING DISTRICT: Historic District yes
Machine Shop Village yeso
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building ❑ One family
❑Addition fXTwo or more familv ElIndustrial
,
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement- ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
D Septic W-11 ❑ Floodplain ❑'Weflandsa — Watershed]®istnet5-
Wale
ter/Sewer
DESCRI TIO OF WO K TO E PERFORMED:
_ ( i QM
i
CA q(-kTUqle
Iden
tifica ion- Please Type or Print Clearly
OWNER: Name: Phone:CAD
Address: 3C) -�i)('- 0 CA-7
Contractor Name: Phone: ck3m
Email: -02 ► .' Lr : C.0
Address: `
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date: I,
ARCHITECT/ENGINEER ( Phone: Q-lp J57 6�LSD_
Address: up-r nd "n Reg. No._3 I Cr 0
FEE SCHEDULE:BULDING PERMIT.•$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ � 1 ��S FEE: $
Check No.:
6/1 Receipt No.:
NOTE: Persons contracting ith n egistered contractors do not have acces to he A aranty fund
t �
Location e-7 ''N
No. 1�G' 1i�( Datel `� l�
• TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $—16 ►t'
Foundation Permit Fee $
J
Other Permit Fee $
TOTAL $ .
Check#�
`� / Building Inspector �%
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art ❑ Swinunl g pools ❑
well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ I'
Private(septic tank, etc. ❑ ElPermanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF e U FORM
PLANNING M DEVELOPMENT Reviewed On L3ll� Signature_
COMMENTS /9 111117
I -
CONSERVATION Reviewed on I Si nature
COMMENTS — — y t. c �n - I�J- i-v\
HEALTH Reviewed ori Signature
COMMENTS
t
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
1
Planning Board Decision: Comments
Conservation Decision: Comment
D'—
Water & Sewer Connection/s► nature Date 1 ivewwwa Permit
DPW Town Engineer: Signature:
FIRE DEPA + I Located 384 Osgood Street
RTMEN Temp_jDu mpster on,siteex,yes
Loc�ated.at'�124MameStreet " {{�> �, ,r� j ,; ' :: + s • ;- --,• 1 -
Fire De .V`� t Nib" •. 'tf #S"ySLr,if� ." `� ! _ M
p gnatu;re/date t.. ;►gin► � r a rt
I. artmeiit•!i 4T, :,.�.., � .tir.,. �, u ,I -
+' .-.. f' �`�» , � �• V. . .s(�`!-° ''tT'�,yp,'k ^,y,t�.'�(���`r-�N! 7X�y�,*,t.T�yr.-•'ivy..,.-�f� 'Zy,`.,`�,�"r+��
COMMENTS-a- ♦ 1. 4,,�L.
I
Dimension
� Y7nens1®1`d
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.$1oo-$1000 fine
NOTES and DATA.— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
r
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
Department from Fire De a
OTE: All dumpster permits require sign off p 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/Cross Section/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
OTE: 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
2012 I ECC Energy code
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 2014
5/4/2017"
b'
���` '• CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number: 196-2017 Date: May 04,2017
THIS CERTIFIES THAT
THE BUILDING LOCATED ON: 40 COMPASS POINT
MAY BE OCCUPIED AS IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE
AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Berry trust Ilc
c:2III
Building nspector
This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/##/records/24598
Of�r
1/1
5/4/2017"
P q
. •
Ir U• ,
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number: 196-2017 Date: May 04,2017
THIS CERTIFIES THAT
THE BUILDING LOCATED ON: 40 COMPASS POINT
MAY BE OCCUPIED AS IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE
AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Berry trust Ilc
Building Inspector
This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/4/records/24598
❑�{Ir
1/1
pO R TH 'l
Town of t sAndover . i
O - 0
No. �_ 6
o h ver, Mass,
C0C"1C"1W.C" A.
1_
%
Aw&4 16 _W_
RATE D rP�,`'��
U BOARD OF HEALTH
Food/Kitchen
PER Septic System
THIS CERTIFIES THAT ................... ... .... ....,. ...L. ... ......................... ..... ...... ............
LD
BUILDING INSPECTOR
has permission to erect ......."dinJ TFoundation
.. .. .... ... ..... ... •...............3 ough Fac ✓1e`
to be occupied as ..�j ......�� .... ...... ... .. . . � .. . . � Chimney, --t
to d �.
provided that the person accepting this permit shall in eve respect conform to therms of a application final a
on file in this office and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
p Y 9 p
Construction of Buildings in the Town of North Andover. UMBING INSPECT R
�2
"7
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final ���' �.
,1;
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR..,:
UNLESS CONS 10 Rou z --2e4 do
Service
,.. .. .. ..... ...... ..... ...... ... ..... ..
BUILDING.IN... ECT..
GAS INSPECTO
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final �� f
No Lathing or Dry Wall To Be Done FIRE DEPAT2 ENT
Until Inspected and Approved by the Building Inspector. Burners
Street No.^7
Smoke Det.d � 9207
ser xL46 _j
R
f
Enter construction cost for fee cal - North Andover Fee Calcination
Construction Cost
$ 271 ,875.00 m
$ - $ 3,262.50
Plumbing Fee $ 407.81
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 407.81
Total fees collected $ 4,178.13
40 Compass Point
196-2017 on 8/24/16
single family condo
NORTI1
Town of s ndover
O .�
y
oh ver, Mass,
GO[MIC hlwKw �1'
ADRATED A �(2
S V
BOARD OF HEALTH
Food/Kitchen
PER ND Septic System
THIS CERTIFIES THAT Foundation BUILDING INSPECTOR
.
has permission to erect .......................... buildin son ...... ........ .... .. .. ...............'�. .
. .....I ... !I..... .. ......... ! Rough
to be occupied as .. . . Chimney
provided that the person accepting this permit shall in eve respect conform to therms of a application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR,..:.
UNLESS CONS IO Rough
Service
.. . ..... ...... ..... ............. .......
' Final
BUILDING IN ECT
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
i
Plans Submitted ❑ Plans Waived ❑ Cerfified Plot Plan ❑ Stamped Plans ❑
FSewer
GE DISPOSAL c
YTanning/MassageBody Art ❑ Swimlm gPools ❑
Tobacco Sales ❑ .Food Packaging/Sales ❑etc. ❑ Permanent Dumpster on Site ❑
I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING DEVELOPMENT Reviewed On Signature_
COMMENTS P /� �i� - • yo 6
U
CONSERVATION Reviewed on
COMMENTS
WEALTH Reviewed on Signature
COMMENTS
t
1�.
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
' as
Planning Board Decision; Comments
Conservation Decision: Comment
!!later& Sewer Connection/si nature &Date
Drivewa Permit
DPW Town Engineer: Signature: `
_. 3 Osgood FIRE DEPARsTMENT' :Te � Lo 84 Osgoo Street
f = ,, 5��r 01 mpster g site .�y y. ;,,tr *
u n. es
L-ocate�tl�at,124�Mamt t eet'
r1'Ttr .---,a, .•`J['.'- .yr {'�t .�+-+i t ''� i'• •. -.. ;. ..` ,`.: �� t ` .r t,L, + '�.
�FirdiD.epaC•tment sjgfjature/date .+ . ,��,, ; �'
rr t.ttf ' l 4•�Ki 4'+ ( /til tt4Mt:Y.N.�.. �...._. -., �.. ��a•w...�
COMMENTS k' _: . ''.
. 1a'�-' .w"
BLDG"E"
EXISTING
FOUNDATION
BLDG"F"
EXISTING
FOUNDATION 4
BLDG"D" o EXISTING EXISTING `
ry• FDN
OUNDATION BLDG"H"
4 BLDG"G" ,`
3 ryo 4, QO\
h
N \\
�6p 2j0. EXISTING
CO �� FOUNDATION
BLDG"I"
R EXISTING
O / FOUNDATION
BLDG"J"
j �$O
O
•O.
CERTIFIED PLOT PLAN
NO OTHER USE INTENDED
BOUNDARY LINES AND EASEMENTS SHOWN ARE BASED ON THE APPROVED,
RECORDED PLANS FOR THIS PROJECT. THE FOUNDATION AS SHOWN DOES NOT
VIOLATE ANY ZONING REQUIREMENTS REGARDING STRUCTURE TO PROPERTY LINE OWNER/APPLICANT-
OFFSETS.
ONE HUNDRED FOURTEEN
THIS PLAN IS NOT TO BE USED TO ERECT FENCES, OTHER ANCILLARY TRUST
STRUCTURES, OR FOR LANDSCAPING LIMITS, 51 MOUNT JOY DRIVE
TEWKSBURY, MA 01876
THIS CERTIFICATION IS NON-TRANSFERRABLE, AND IS FURTHER MADE WITH. THE
PROVISION THAT THE INFORMATION SHOWN HAS BEEN ACCURATELY FURNISHED BY ASSESS.MAP s LOT#
THE OWNER TO THIS FIRM.
106D-63
?" c A- FF1UNDATIElN AS-BUILT BUILDING "J"
PATRICK C. GARNER, PLS MERRIMAC CONDOMINIUMS
-14 ROUTE 114, NORTH ANDOVER, MASS.
�tN OF N4'4-!-v
PROJECT NO, NAND13 SCALE; 1'=40'
40,
gc PATRICK.
C. DRAWN BY: PCG DATE: 10/24/15
GARNER w
o No 32661 t. CHECKED BY: SC SHT; 1
90�� 9FGlSTEPt�
SS��NAI LANDSJ�y�$ REVISED: OF, 1
V q i�
REScheck Software Version 4.6.2
Compliance Certificate
Project 160714Trust_MerrimackCondos_BIdgj_UnitsB-B-B-B_NAndover
Energy Code: 2012 IECC
Location: North Andover, Massachusetts
Construction Type: Multi-family
Project Type: New Construction
Conditioned Floor Area: 2,326 ft2
Glazing Area 12%
Climate Zone: 5 (6322 HDD)
Permit Date:
Permit Number:
Construction Site: Owner/Agent: Designer/Contractor:
Bldg J, Unit J3
North Andover, MA
Compliance: 0.0%Better Than Code Maximum UA: 327 Your UA: 327
The%Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules.
It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home.
Envelope Assemblies
Gross Area Cavity Cont.
Perimeter
Floor 1st Floor:All-Wood Joist/Truss:Over Unconditioned Space 416 30.0 0.0 0.033 14
Wall 1st Separation:Wood Frame, 16" o.c. 96 15.0 0.0 0.077 7
Wall 1st Ext 2x6:Wood Frame, 16" o.c. 812 21.0 0.0 0.057 40
Window DH:Vinyl Frame:Double Pane with Low-E 32 0.290 9
Door Front Ground Fir entry: Glass 20 0.260 5
Door Back: Glass 34 0.290 10
Door Metal: Solid 18 0.160 3
Floor 2nd Over garage/entry:All-Wood Joist/Truss:Over Unconditioned Space 481 30.0 0.0 0.033 16
Floor 2nd Over entry:All-Wood Joist/Tru ss:Over Outside Air 39 30.0 0.0 0.033 1
Wall 2nd Floor 2x6: Wood Frame, 16"o.c. 855 21.0 0.0 0.057 39
Window DH:Vinyl Frame:Double Pane with Low-E 100 0.290 29
Window Fix: Vinyl Frame:Double Pane with Low-E 19 0.280 5
Window CSMT:Vinyl Frame:Double Pane with Low-E 12 0.260 3
Door Slider: Glass 34 0.290 10
Wall 2nd Fir Separation:Wood Frame, 16" D.C. 279 15.0 0.0 0.077 21
Ceiling Bay Win: Flat Ceiling or Scissor Truss 6 30.0 0.0 0.035 0
Wall 3rd Floor: Wood Frame, 16" o.c. 749 21.0 0.0 0.057 36
Window DH:Vinyl Frame:Double Pane with Low-E 86 0.290 25
Project Title: 160714_Trust_MerrimackCondos_BldgJ_UnitsB-B-B-B_NAndover Report date: 08/10/16
Data filename: Page 1 of 9
\\suttonnas.corp.koopmanlumber.com\Sales\Ebbeling_Ed\160714_Trust MerrimackCondos BldgJ_UnitsB-
B-B-B_NAndover\REScheck\160714 Trust_MerrimackCondos_BldgJ_UnitsB-B-B-B_NAndoverj3.rck
Gross Area Cavity Cont.
Perimeter
Window Awn:Vinyl Frame:Double Pane with Low-E 7 0.270 2
DoorFrench: Glass 18 0.260 5
Wall 3rd Separation: Wood Frame, 16"o.c. 243 15.0 0.0 0.077 19
Ceiling Main: Flat Ceiling or Scissor Truss 936 38.0 0.0 0.030 28
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 2012 IECC requirements in
REScheck Version 4.6.2 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist.
Name-Title Signature Date
Project Notes:
Building J, Unit J3
Project Title: 160714_Trust_MerrimackCondos_BldgJ_UnitsB-B-B-B_NAndover Report date: 08/10/16
Data filename: Page 2 of 9
\\suttonnas.corp.koopmanlumber.com\Sales\Ebbeling_Ed\160714_Trust MerrimackCondos BldgJ_UnitsB-
B-B-B_NAndover\REScheck\160714Trust_MerrimackCondos_BIdgJ_UnitsB-B-B-B_NAndoverj3.rck
REScheck Software Version 4.6.2
Inspection Checklist
Energy Code: 2012 IECC
Requirements: 0.0% were addressed directly in the REScheck software
Text in the "Comments/Assumptions" column is provided by the user in the REScheck Requirements screen. For each
requirement,the user certifies that a code requirement will be met and how that is documented, or that an exception
is being claimed. Where compliance is itemized in a separate table, a reference to that table is provided.
5ecttonPlaht:W. e#d hfIed FfVer#f, d
# Pre Inspecticn/Plan Rev#ew
VComp'#est Comments/A77
sst�mpt�r�rs "
alue 'Vdl.de
103.1, !Construction drawings and '`❑Complies
103.2 documentation demonstrate ❑Does Not
[PR1]1 energy code compliance for the
:building envelope. ❑Not Observable
" ❑Not Applicable
103.1 'Construction drawings and I !❑Complies
103.2 'documentation demonstrate ❑Does Not
403.7 i energy code compliance for
[PR311 'lighting and mechanical systems ❑Not Observable
Systems serving multiplet j❑Not Applicable
;dwelling units must demonstrate Via,
;compliance with the IECC
Commercial Provisions. -
302'`1 ,Heating and cooling equipment is; Heating: Heating: iLJComplies
403:6_ 9sized per ACCA Manual S based Btu/hr ; Btu/hr ❑Does Not
[PR23. on loads calculated per ACCA Cooling: Cooling: ❑Not Observable i
Manual J or other methods Btu/hr Btu/hr '❑Not Applicable
approved by the code official. pp
Additional Comments/Assumptions:
11 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3`;Low Impact(Tier 3)
Project Title: 160714_Trust_MerrimackCondos_Bldgj_UnitsB-B-B-B_NAndover Report date: 08/10/16
Data filename: Page 3 of 9
\\suttonnas.corp.koopmanlumber.com\Sales\Ebbeling_Ed\160714 Trust MerrimackCondos Bldgj_UnitsB-
B-B-B NAndover\REScheck\160714 Trust_MerrimackCondos_BIdgj_UnitsB-B-B-B_NAndoverj3.rck
'# Fbundatinn lnspectron = iromjsiles? :` Comments/Assumpt�ans
303:2.1 .. A protective covering is installed to ❑Complies
FO.11P protect exposed exterior insulation []Does Not
and extends a minimum of 6 in. below
grae. ❑Not Observable
d
i❑Not Applicable
4Q3$ "Snow-and ice-melting system controls'❑Complies
FC312�1 (installed. '❑Does Not
J ;❑Not Observable'
❑Not Applicable
Additional Comments/Assumptions:
1 I High Impact(Tier 1) 2 Medium Impact(Tier 2) 3`Low Impact(Tier 3)
Project Title: 160714_Trust_MerrimackCondos_Bldgj_UnitsB-B-B-B_NAndover Report date: 08/10/16
Data filename: Page 4 of 9
\\suttonnas.corp.koopmanlumber.com\Sales\Ebbeling_Ed\160714_Trust MerrimackCondos Bldgj_UnitsB-
B-B-B_NAndover\REScheck\160714_Trust_MerrimackCondos_Bldgj_UnitsB-B-B-B_NAndoverj3.rck
5ectfon Pfarts Ver+fed ffefd Vrrfied ,
# Framfng/Rough fn lnspectipn Crin}�fies? amments/Asumptfons.
6:Req.f1[!
Vdfue Vallee
402.1.1, Door U-factor. U- U- ;❑Complies ;See the Envelope Assemblies
402.3.4 j❑Does Not ;table for values.
(FRl]1
❑Not Observable
i❑Not Applicable
402.1.1, :.Glazing LI-factor(area-weighted U- U- ;❑Complies See the Envelope Assemblies
402.3.1, average). '❑Does Not 'table for values.
402.3.3,
402.3.6, '❑Not Observable
402.5 '[]Not Applicable
[FR2]1
303.1.3 ;U-factors of fenestration products 3 ,1, ❑Complies
[FR4]1
.are determined in accordance jEl
Does Not
'with the NFRC test procedure or
taken from the default table. p„ ❑Not Observable
❑Not Applicable
402.4.1.1 :Air barrier and thermal barrier € ❑Complies
(FR23]1 installed per manufacturer's u ❑Does Not
instructions. h
g❑Not Observable
x # "❑Not Applicable
402.4.3 Fenestration that is not site built '❑Complies
[FR20]1 is listed and labeled as meetingA❑Does Not
;AAMA/WDMA/CSA 101/i.S.2/A440
❑Not Observable
or has infiltration rates per NFRC
`400 that do not exceed code - as ❑Not Applicable ;
limits.
402:4 4 IC-rated recessed lighting fixtures (❑Complies I
sealed at housing/interior finish ❑Does Not
and labeled to indicate<_2.0 cfm
' leakage at 75 Pa. ($ 4,j❑Not Observable
a❑Not Applicable
403.2.1 ;Supply ducts in attics are I R- R- :❑Complies
[FR12]1 insulated to>_R-8.All other ducts ; R_ R_ ❑Does Not
in unconditioned spaces or
outside the building envelope are; ❑Not Observable
insulated to ;!:R-6. ❑Not Applicable
403.2.2 ;All joints and seams of air ducts, ';❑Complies
[FR13]1 ;air handlers, and filter boxes are ?❑Does Not
sealed. ❑Not Observable
❑Not Applicable
403:2 3 ;Building cavities are not used as ? " ❑Complies
tFR15]3 'ducts or plenums. _ ❑Does Not
❑Not Observable
l❑Not Applicable
403:3 IH CAV piping conveying fluids R i~R- ❑Complies
)FR37} ,above 105 4F or chilled fluids l -❑Does Not
3elow 55°F are insulated to zR ;❑Not Observable
} ;❑Not Applicable
403.3.1 :Protection of insulation on HVAC j❑Complies
[FR24]1 ;piping. Not
.
j j❑Not Observable
,,3,. '❑Not Applicable
40 :4 2 Hot water pipes are insulated to R R- i❑Complies
[FRI8]2 >_R-3. ;❑Does Not
❑Not Observable
❑Not Applicable
1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3)
Project Title: 160714_Trust_MerrimackCondos BIdgJ_Units6-B-B-B_NAndover Report date: 08/10/16
Data filename: Page 5 of 9
\\suttonnas.corp.koopmanlumber.com\Sales\Ebbeling_Ed\160714_Trust MerrimackCondos BldgJ_UnitsB-
B-B-B_NAndover\REScheck\160714 Trust MerrimackCondos_Bld6j_UnitsB-B-B-B_NAndoverj3.rck
Sec#ion Plans Yerifred Fleid Yer�lFied;
# raming/CtaugwIln Cnspec#ian Co nplres? Camtr►enM Assurnptioas
¢c-Re .CCi Value Value
403:5 ;Automatic or gravity dampers are; , ❑Complies
fFR191. ;z installed on all outdoor air ❑Does Not
intakes and exhausts.
I j❑Not Observable
❑Not Applicable
Additional Comments/Assumptions:
1 IHigh Impact(Tier 1) 2" Medium Impact(Tier 2) 3 Low Impact(Tier 3)
Project Title: 160714_Trust_MerrimackCondos_Bldgj_UnitsB-B-B-B_NAndover Report date: 08/10/16
Data filename: Page 6 of 9
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Section pians Veri a Field Verifle
# in5ulatfon Inspection Cismpties' comments/Assumptio►s
303.1 ;All installed insulation is labeled FIC
STN]3] or the installed R-values %R❑Does Not
;provided.
- $ ❑Not Observable
°i❑Not Applicable
402.1.1, ;Floor insulation R-value. R- R- ❑Complies See the Envelope Assemblies
402.2.6 Wood ❑ Wood ❑Does Not ;table for values.
[IN1]1 Steel ❑ Steel ❑Not Observable
❑Not Applicable
303.2, 'Floor insulation installed per zj❑Complies
402.2.7 manufacturer's instructions, and ❑Does Not
[IN2]1 in substantial contact with the k
underside of the subfloor. ❑Not Observable
❑Not Applicable
402.1.1, ;Wall insulation R-value. If this is a; R- R- ❑Complies ;See the Envelope Assemblies
402.2.5, !mass wall with at least 1/2 of the F-1Wood ❑ Wood ❑Does Not i table for values.
402.2.6 wall insulation on the wall Mass ❑ Mass !❑Not Observable
[IN3]1 ;exterior,the exterior insulation
requirement applies(FR10). ;❑ Steel ❑ Steel i]Not Applicable j
z
I
303.2 'Wall insulation is installed per ;_;❑Complies
[IN4]1 `manufacturer's instructions. i )❑Does Not
a
' j[]Not Observable i
❑Not Applicable
Additional Comments/Assumptions:
1 I High Impact(Tier 1) 2 Medium Impact(Tier 2) 3`Low Impact (Tier 3)
Project Title: 160714_Trust_MerrimackCondos_Bldgj_Units6-B-B-B_NAndover Report date: 08/10/16
Data filename: Page 7 of 9
\\suttonnas.corp.koopmanlumber.com\Sales\Ebbeling_Ed\160714 Trust MerrimackCondos Bldgj_UnitsB-
B-B-B_NAndover\REScheck\160714 Trust_MerrimackCondos_Bldgj_UnitsB-B-B-B_NAndoverj3.rck
5ettran Rkans Verified Field Yer�fied
# F�nai lnspect7on Rrovisiorxs 1Wamplie5? Coilnmen#s/Assume#ion$";
&Req.tD Value
402.1.1, ;Ceiling insulation R-value. ; R- R- '❑Complies ;See the Envelope Assemblies
402.2.1, Q Wood ElWood ;❑Does Not ;table for values.
402.2.2, Q Steel ❑ Steel jQNot Observable 1
402.2.6 =❑Not Applicable
[Fill pp
I
303.1.1.1,;Ceiling insulation installed per j❑Complies
303.2 manufacturer's instructions. i❑Does Not
(FI211 ;Blown insulation marked every i
300 ft2.
EJ
Observable
4 µ . ❑Not Applicable
41)2.:2 3 ,Vented attics with air permeable ❑Complies
[i 1212 insulation include baffle adjacent r I❑Does Not
to soffit and eave vents that
�,extends over insulation. �❑Not Observable
t r °❑Not Applicable
402.2.4 ;Attic access hatch and door R- R- ,❑Complies
[FI311 "insulation -aR-value of the ;❑Does Not
adjacent assembly. UNot Observable i
❑Not Applicable
402.4.1.2 Blower door test @ 50 Pa. <=5 ACH 50 =y ACH 50 = ;❑Complies
[FI17]1 :ach in Climate Zones 1-2, and ❑Does Not
<=3 ach in Climate Zones 3-8. ;QNot Observable
_ ❑Not Applicable
403.2.2 'Duct tightness test result of<=4 cfm/100 cfm/100 ❑Complies
[FI4]1 -cfm/100 ft2 across the system or ' ft2 ft2 ❑Does Not
<=3 cfm/100 ft2 without air ;QNot Observable
handler @ 25 Pa. For rough-in
tests, verification may need to ❑Not Applicable
occur during Framing Inspection.
403.2.2.1 ;Air handler leakage designated £ :9❑Complies
[FI2411 ;by manufacturer at<=2%of i Y " ;j❑Does Not
;design air flow. a %?
+,,(❑Not Observable
❑Not Applicable
403,11 ,Programmablethermostats i❑Complies
[F�9j2 installed on forced air furnaces. ] i❑Does Not
i QNot Observable
❑Not Applicable
4-03:1 2 Heat pump thermostat installed "❑Complies
[F1101) on heat pumps. `I❑Does Not
§ ., A `-jQNot Observable
❑Not Applicable
403.4 3. Circulating service hot water § ❑Complies
[Filly systems have automatic or = 1❑Does Not
':accessible manual controls.
+: k n QNot Observable
§❑Not Applicable
403.5 1, ,;All mechanical ventilation system i „x ❑Complies
1925.1 ,fans not part of tested and listed ❑Does Not
HVAC equipment meet efficacy l
and air flow limits. ;❑Not Observable
h +❑Not Applicable
404.1 75%of lamps in permanent r 0 plies
[FI611 'fixtures or 75%of permanent a. \❑Does Not
%;fixtures have high efficacy lamps ❑Not Observable
:Does not apply to low-voltage
lighting. ,
❑Not Applicable
1 High Impact(Tier 1) Ti;Medium Impact(Tier 2) 3 Low Impact(Tier 3)
Project Title: 160714_Trust_MerrimackCondos_Bldgj_UnitsB-B-B-B NAndover Report date: 08/10/16
Data filename: Page 8 of 9
\\suttonnas.corp.koopmanlumber.com\Sales\Ebbeling_Ed\160714_Trust MerrimackCondos Bldgj_UnitsB-
B-B-B_NAndover\REScheck\160714 Trust_MerrimackCondos_Bldgj_UnitsB-B-B-B_NAndoverj3.rck
Settron Plans Peril fed Freit!Verged
# finalnspectlon•Provisions; Complies sramments/Assumptions
Ss Req.(iy value = Value
464,11.1. Fuel gas lighting systems have .:❑Complies
(F123V no continuous pilot light. ;: ❑Does Not
VV ti❑Not Observable
J❑Not Applicable
4013 ;Compliance certificate posted. f (❑Complies
❑Does Not
❑Not Observable
I❑Not Applicable
303:3 Manufacturer manuals for ❑Complies
Y h� s.
(F11.8] 'mechanical and water heating ,❑Does Not
systems have been provided.
' ❑Not Observable
,�A, .
,��. ❑Not Applicable
Additional Comments/Assumptions:
1 I High Impact(Tier 1) j2 `J Medium Impact(Tier 2) 3:::Low Impact(Tier 3)
Project Title: 160714_Trust_MerrimackCondos_Bldgj_UnitsB-B-B-B_NAndover Report date: 08/10/16
Data filename: Page 9 of 9
\\suttonnas.corp.koopmanlumber.com\Sales\Ebbeling_Ed\160714 Trust MerrimackCondos Bldgj_UnitsB-
B-B-B_NAndover\REScheck\160714_Trust_MerrimackCondos_Bidgj_UnitsB-B-B-B NAndoverj3.rck
2012 i cc Energy
Efficiency certificate
Insulation Rating �R-Value
Above-Grade Wall 21.00
Below-Grade Wail 0.00
Floor 30.00
Ceiling / Roof 38.00
Ductwork (unconditioned spaces):
Glass&Do --77-
Window 0.29
Door 0.29
..
Heating System:
Cooling System:
Water Heater:
Name: Date:
Comments
Kanayo Lala,P.E. .............03/03/2014
PROJECT: Merrimack Condominiums
J-TYPE BB-Compass Point,N Andover,MA
DESIGN FOR-GIRDERS/JOISTS/RAFTERS Third Floor Beam T1
Supporting Floor,Wali,Attie&Foa-A Liadd Fion, T6
LOADS: DEAD LOAD 22.54 PSF 323.00 PLF Ce= 1 CF= 1.00
SNOW LOAD PSF 0.00 PLF Cq= 1 Cs=
LIVE LOAD 30.00 PSF 429.90 PLF qs= 29.10 Cd= 1
TOTAL LOAD 753 'PLF I= 1 Cm=1
WIND SPEED 100 MPH 29.10 PSF
POINT LOAD 3510 LBS 3.25 FT
Ra= 2925 LBS 7341 LB=TOTAL REACTION
TRIBUTARY WIDTH 14.33 LF E= 2000000 PSI
JOIST/GIRDER SPAN 19.5 LF Fb= 2900 PSI
WIDTH- 1N 10.30 PSL/LVL 11:876 1N = d Fv= 285 PSI
ROOF PITCH- N:12 Fc= 2700 PSI
Fcp= 750 PSI
MOMENT= 35786 LB-FT
MOMENT2= 9506 LB-FT 246.78 =S provided OK
S= 187.42 IN13 1465.24 =I
Deflection= 0.836 IN =U 240 For Total Load Required L/240
Deflection2= 0.139 IN =L/ 421 For Live Load Required 1-/360
Fcp'= 652 PSI OK 1.50 In Bearing Length
Fv'= 123 PSI OK
USE BETTER HEADER#65 (FLITCH BEAM) 2-LVLs 117/8'WITH 1/2-STEEL PLATE td Of
BOLTED WITH 5/8"DIA@12"O.C.IN TWO ROWS.
iiANAYOH.
+�
L&A
N
NQ 337140
S» RL
Kanayo Lala, P.E. .............03/03/2014
.1-TYPE 6g-Cmmnass PoInt.M And ver,MA
�Cclnnl C/�O /nloflcncll/110TC /OArTCOO TI,.;+J rl......o........T'1
Suppnrrinq floor,wan at ALLIC
LOADS: DEAD LOAD 22.54 PSF 322.95 PLF Ce= 1 CF= 1.00
LIVE LOAD 30.00 PSF 424:90 PLF qs= 28.10 Ctl= 1
V/aN 3.SPFF:n inn MPH 7q 1n PSF
1 DC G'144 1 -Tf1TAl CCAI-TIP1t.J
IINIOUIMMI VVIUII-I 1'7.00 Lr d:- - tVUVVVV PSI
7 71
W01-1-l- IN 1.00 r5uLvL 11.616 IN = 0 rv= X05 r51
=SI
FCp= 750 PSI
NICK IICt.IT7- n I Q Cr 40A G'1 -C
�C .vv.v.. ..• v .......... -
LCIlecuV11L U.VUV IIV -L/ JYV 1'VI LIVG LVpV RCIl lSS C`J W400
Fc-V'
Fv'= 112 psi vr.
f l U,,RTV YA
Kan9yo Lala, P.E. .............03/03/2014
t'Iw�w i IN-WAI al.n vunuvuluuuula ��II��
- 1 rC.O��VV11�fraaoo. v�..y�r - �..��
pFCir,Ki PnP /RAFTFRC Thirii Flnnr Roam T3
Supporting Floor &Point Load From T1&T2
LOADS: DEAD LOAD 20.00 PSF 350.00 DLF Ce= 1 CF=1.00
D ..n .cc-R 54C.^n O F 2= Mig Cd= 1
Wo'NO GPEcED ivu WIFH 29.10 PSF
I-UIIV I LU/'1U 104/1 LDO 0.4J r 1
Ra= 11197 1 R.q 7R..sn 1 R=TOTA1 RFAt'Ti13N
I KIbU 1 AKY VVIU I N 1t3.UU Lt= E= •LUUUUUU NSI
-1/'1K-T/CInnr'p cnAll -1-7 1 c r_w- nnnn not
WIDTH- IN 14.00 PSULVL 11.875 IN = d Fv= 285 PSI
- _ - _-_
731
Fcp= 750 PSI
LS-FT
—1;)= 4q.t1'A 1,R-PT 194 nA =R nmwiriori nK
S=
T-O--a:__ ... n •nn w —1 r nen 1"....T.-a..1 a ....d !"l-«..:-...i 7 IN Aft
Uetlemon"L= U.3/ti IN =L/ 41V hor Live LOarj Kequnren!+'tt_0
Fv'= 189 PSI OK
O f11 TCR lAiii'LS�iG�r'Sin rn, -. _ _- iKi Tlnii- w1-iniL` _��i.
USEL.t�-.i'..,,-
a�
Nn".3371M
I
Kanayo Lala, P.E. .............03/03/2014
J-TY,^::
r)FSIC,N FOR- i:R.:, Thirti-riinmr no-a 11 i -a i cc3
Supporting Floor &I-0111t Loao from I IN !Z
LC+DS: DEAD!nn11 20.00 PSF 360.00 PLF Ce= 1 CF= 1.00
LIVE r OAD 3n_An nLr„ nn r
y; !�nn�� Cd=1
y_._ c.
vVnvv o-'-LLD IUv W17"i Lu I3 c-JF
1`VIIVI LV/'�V IVYI1 LUV J.LJ 1�1
Ra= 13327 LBS 7650 LB=TOTAL REACTION
TK!6u tHKY vvIU I C1 1C.UU Lt t= zuuuuul/U r.61
irIIQT/r.'.IPrWP CPOAI 17 1 G Fh= ')dnM PCI
WIDTH- IN 6.60 36.K.SI W7?x?n 72,3-1 !N' _ d Fv= 162Q0 PSI
Fcp= 405 PSI
MOMENT2= 43313 L3- Til 36.6v -S uiuviucu vi{
.i- of.&i 11r o I6.vv =I
rloflonfinn= n 97A IN =1 r Fnr Tntni 1 narl Rom irari 1...12M
^:� 114 =}J v;4 1o LiVq i naq KSQUIr@O L/30U
Fv'= 10,200 PSI OK J
USE
)7a,
No.337MC 1C
d
' -moi•R'r- �r6
Kanayo Lala, P.E. .............03/03!2014
J„TVnr ..A
DESIGN FOR-GIRDERSi ivlo 1 J I(ti/11 1 L'11J 1 f iil a wv, . ''S
Supporting f=loor&Watt
LOADS: DEAD i DAD 24.00 PSF 240.00 PLF Ce= 1 CF= 1.00
LIVE LOAD 30,00 PSF 300 nn nl r_ ns- 2r1!0 Cd=1
V4ii,v v �Cu iVC n"^11 LPSF
f VIIY 1 6V/11J LUJ 1 1 7�'
Ra= U LSS 35-16 LD-1 V I HL rM1C/1l�1 IVN
I RiLSU IAIKY vvlU I h 'IU.UU LF t= 2UUV000 t'JI
.Ir)I.T/r;iRDFR.PAN 13 I F Fh= 99Cji1 rji
WIDTH- IN 3.50 PSL/LVL 11.875 IN = d Fv= 285 PSI
P.,r.r--nlrCu - Cn- 77 nn DCI
FCp= 750 PSI
IV,111VYLt,1 G- Ju 1 lJ-i i Zr.r- p: ,. , '(
J- 41.LV 11Y'J 400.4 1 =I
Deflection= 0.355 iN =L! 439 ForTotal Load Required L1240
U,(VVU !N =U ivu For Uve Loaa KequlreO L/3bV
GrJ- RRO DQI nv 4 Gn In Raarinn I ann4h
Fv'= 127 PSI OK ✓
kx
Net.3371t3•CFS,ri0 m .si'
Ka:.0-io Lala, P.E. .............03/03/2014
r'i\VNl-V 1, IY}IGIIIIIial.it VVllV VltlllttV{ll3
J-TY-L .r .. ....y .l..a
DFr.Z'IlliV FFR-l]IRUGR.7/JIJIJ 1 J/RA 1 E R 8 Llid moor Beam S1
Stipnnrting Floor&Wall
LOADS: DEAn i nnn 94-r"? 0
n flet 240, 0 of F Ce= 1 CF= 1.00
..1 .. n nn .•__ _
L('.!-- 4Mnn ni Gd= 1
V. :.� �rccv 1.L3 .r.pii 2'o..3 rSF _...
i-Vlt%1 LVP'YU LUJ 1"t
Ra= 0 LBS 4100 LEt=—I U I NL RChv 1 IvM
I KILAJ INKY VVIU I H 1U.UU LF E= Guuuuuu tai
Ir'$ICT/(:Ipnr-p CPAKI 114 I F Fh= 7900 PSI
W!^TH- !N Z_CA PCL/LVL 11.875 IN = d Fv= 285 PSI
rf/1I•ir IIITlH 1 _ �; .��.- Gn_
0700 PSI
Fcp= 750 PSI
IYI . lu Ivv u i i
M3;vZv 1 L= 0 LU-F T 8;.;o- =a pruvided OK
S= 55.y4 11w.0 ffoo.41 =1
npflprtinn= 0.4.2.1 IN =L/ 371 For Total Load Reauired L/240
Uefilection2= U.UUU IN =L/ 5y;i For Utile L nati we! '-ren LjA60
Fcp'- ?9 1 DCI nw A nn In Rcorinn I onrith
Fv'= 150 PSI OK
� [ LALK VMS
rub.e4fl(lc Ji�
Kanayo Lala, P.E. .............03/03/2014
PROJUM Merrimack Conduiiii-&jais
J-TYPE BB-Compact Pnint,N Andover,SIA
D!:S!C-K! cl�O , Tclr"EOT l(11GTQ 10 ACTSRS 2nd Floor Beam S2
r;F 0.33 ALF v = 1 Cs=
LIVELVNU 4V.UV ror 03.LV 1"LI tis= L:f.7V Oki= i
TOTAL LOAD 73 PPF I= 1 Cm=1
WIND SPEED 100 MPH 29.10 PSF
Pr')INT I.r)An Alsn I RC 'I 9s; rT
Ra= 3467 LBS 713 LB=TOTA!REACT ON
Tn+nl Pr n\/AAli nTI_I A Oo 1 r r.- nnnnnnn nel
JGwTrnlnflEO COA_Itl 10.5 LF Fb= 2900 PSI
.. ;.. _._. ..._ _ .. = =Sl
ROOF P,T–r'H- N:12= Fc= 2700 PSI
F%j1= 53 f IJl
MOMFNT= 3477 1 R-FT
VOMENT2= 11267 LB-FT 82,26 =S provided OK
C- F1 n1 IAIAI;� A?? Al =1
Dellec ion= 0.244 IN =U 318 FG"T^x'11—A ra �..:_ , r�•eJ
Fcpl= 398 PSI OK 3.0^ In°caring Length
Vol
1 LALA r!N
I.�
Kanayo Lala, P.E. .............0^.'^3`_'014
rI�VJCV I IYICllllllal.A VVIIUV1111111t11 YI(1.�
.!r:. .. .��. �... .......... ...... a rvuuvv�fl MA
DF_SIGN FOR-GIRbEkjiwio-i o inAFT-ERG Gaiauv uuul i-ivau'at 33
Supporting Two Floors;Roof,Wall&Point i^ma Fmm T1
LO^.IDS: ^S^^1^^4 73.72 PSF 718.75 PLF Ce= 1 CF=0.96
h..-
LIVE I non 71,n^ nr ,r, ".:. . (d- 1.15
r'UIN 1 LUMU 4;UU LDJ a r Y
Rd= 31,io LFJS 14657 Lis=-I 0 i'HL REACTION
TR!RI-ITRRY WIDTH 9.75 LF E= 2000UUU N51
.I0I.gTlf.IRDFR RPAN 1R F I.F Fh= 9900 PSI
WIDTH- IN 6,2" PS!�L N!L 18 IN = d Fv= 285 PSI
alflllr nITl�I_I AI .An- Cn- 77n01 DCI
~ Fcp= 750 PSI
--__—= fdivivir-ly 1= vuYu i LU-i i --- -- — - ----
MU1VIEN I L= 1610; LG-V I1 3Gy .vv =aN'.Y1Uou vi{
J= 264.6/ I N"J 2226.94 =I
Deflection= 0.665 1N =U 240 For Total Load Reauired L1240
n+cn !N =U .4'� F�r I I..P I gad Required 2/360
v..-
Cnn— 6 77 DQI flit R AA In Ronrinn I annul
Fv'= 24.5 PSI OK
UJv'L-LvLS 11 %/2S"rum tSG/LYj.J4. .#
/��1114MN11J `�rn�
No.0JA
-
AfcISTEa�
K/i -C 1."�^.` ., -".LA, P.E........-03103i2014 '
SPECIFIC CALCULATl0N.5Fn[?TWr-lAmnn rtn�ICTpI lrTtnnl try
38,40,42&44 COMPASS POINT,NORTH ANU VER,MA
iii�i i.i i..it. .i3&J4 2h X.391
DA Tirl i nA.IS: '
GROUND SN()IAI L OnD 54 PSF
UVC LVMU YU rJr
^.D 18 PSF �
.;h l.r. ft
Btiildinn Width 26 ft Rl furling Aspect Ratio= 1.38
lilr,linn 11Ano, U-.t h #♦ 14e Sh....-1 J 1nr^II—
BG. . p��fne 447 pl F
....
i oiai i-ieigni 45 it
214 1-13
i �....Z:—�W';l i 47C, as i) i P- T A t"'`%ur-inir �:CiP i6" A RN TC
DL SY5"1 17A0 IB-FT WITH TWO 2X SYP PLATES
_T
Win_ ��:..._^. . --- --- v 'FT
Wind Moment Long Wall 15116:i'L Long VV m -7UUlZb NU UVLIF'i
I.E. NO UPLIFT EXISTS AT THE BASE OF THE BUILDING. SHEAR ANCHORS ARE ADEQUTE.
_quaAo%ALAI t nAnft( lTV RV TART F 23!76.2.1(
/2 l/Jb/ %.'V^ rL-I VVI Irl UV IVMILJ/'1i V VIV LUVLJ!'IIVV V VIV 1 IL-LV 41Uf-LI LLY i•til
SHEAR WALL REQUIREMENT BY TABLE R602.1 U.1.20
1/"f RR WITH 1hF)iWAii Z,r.T1� env .-� .�.�...,. ,�- � —'-- — - - -'—� - -^.- ..,i i�u FT
CONTINUOUS SHEATHING_,AVAll_ARi.F ALONG. l-ONG WALL= 19 FT
Tl-""-!.A nr.IT AI m AM A•r r1 m /%nrkIIlkIlnQ 10 nr_.oIerrn n\,-r1_Ir_ n ACTl1 f r%r\kIgIGGTInAI DI 4TGQ As
UC 1 MILCU UN 1 r1C rt-MIVJ.
673 LBS. A SIMPSON PC66 POST CAP-LATERAL CAPACITY 12861-135-UK.
TW- :('.L1if•iiiuTWini,�;isir:-,�:� ivy.'--=�.
AMENDMENTS TO IRC2009. ,.ar...
r S.
I;Cin
f �.LSIO AC ,.`
ti• - I
i
The Commonwealth assachusetts
. o fM .
Department oflndustrialACCidents
I Congress Street,Suite 100
Boston,MA.02114-2017
www mass.gov/dia
Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TBE PEPJMT'TING AUTHORITY.
Applicant Information Please Print Le0bly
Name(Business/Organization/Individual): T-,V, -
Address: Q()`-g c5Y
City/State/Zip: Phone#: O
Are you an employer?Checktlie apliropriate box: Type of project(required):
1.Q I am a employer with :.. employees(full and/or part-time).* 7.. New construction
2.E]I am a sole proprietor or partnership and have no employees working for mein 8. Remo deUg
any capacity.[No workers'comp.insurance required.]
Demolition
I Q I am a homeowner doing all work myself_[No workers'comp..iusurance required.]t
9. ❑
10 0 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or.additions
proprietors withno employees. 12:FJ Plumbing repairs or additions
5NM I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.-0 Roof repairs
Thesesub-contractors have employees and have workers'comp.msurance.T
' 14.❑Other
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c.
152 §1(4).and we have no.' loyees.[No workers'comp.insurance required-]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
Homeowners who sulimif flus affidavit indicating they are doing all work and then hire outside contractors must silbmit anew affidavit indicating such.
(Contractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. Ifthe sub-contractors fiave employees,ley'must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees:'Beloit/is thepolicy acid job site
information.
Insurance Company Name:
Policy#or S elf-ins.Lic.#: 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year iinprisonment,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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby crY*yudert epains and penalties ofperjury that the informationprovided above is true and correctiSi ature• Date: S J L,Phone#•
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one): i
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and. Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver-or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 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 common'Tealth•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=contractox(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 cavy 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•Ifidustrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers'
compensation policy,please call the Department•at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"rob 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. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext.7406 or 1-877-NIA.SSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
REPRESENTATIVEURPRUUUGtR,ANU IMttaro1rwAltnuL.Lrtrc.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the orms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Coonan Insurance Agency, Inc. PHONE 508 987-7122 1
FAX N : (508) 987-7152
267 Main Street ADDaRESS: cind @coonaninsurance.cora
Oxford, MA 01540 INSURE AFFORDING COVERAGE NAIC M.
INSURER A:Travelers
INSURED INSURER B:
TJK, Inc. -INSURER C:
PO Box 12 INSURER D:
South Grafton, MA 01560 INSURER E:
I NSU RER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPEOFINSURANCE POUCYNUM3ER MM/ODIY MMIDdYYYY
A GENERALLIABILITY 680-335MI703-15 11/3/15 11/3/16 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAM"
GEENTED
TOR $ 300,000
CLAIMS-MADE FX_1 OCCUR MED EXP(Arty one person) $ 5 000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2. 000 000
GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000
FX] POLICY PRO LOC $
JE
AUTOMOBILE LIABILITY COMBINEDTINGLEINGLELIMIT $
ANYAUTO BODILY INJURY(Per person) $
ALLOWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
HIRED AUTOS _
NON-OWNED
PROPERTY DAMAGE $
eracddent
UMBREILALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$
A WORKERS COMPENSATION IE-UB-9914N01-3-16 1/26/16 1/26/17 X `/"C STATU- I OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTNE YIN N/A E.L.EACH ACO DENT $ 100,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If Yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
120 Main Street
North Andover, MA 01845 AUTHORIZED REPRESENTATIVE
Cindy Davis
@ 19ff8=20,J0 ACORf3 C0RPORATI0N. Alf rightsIteserved.
ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail: tdbuildinq@aol.com
ayrr,r�ra7rurea4Il 1/0-j�a:uac.wjeffi
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration,.,,.143758 Type:
Expiration 7�2913t?18 DBA
BARLOW BUILDING,
TIM BARLOW
13 DEPOT ST
a .\
S.GRAFTON,MA 01560 Undersecretary
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-059359
'
Construction Supervisor .
4
TIMOTHY MICHAEL BAR OW
P.O.BOX#12
SOUTH GRAFTON Mk.01600
Expiration:
Commissioner 0112412018