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HomeMy WebLinkAboutBuilding Permit #1290-2016 - 41 BRUIN HILL ROAD 6/9/2016 %A0RTH BUILDING PERMIT oFs�LEo ,6 10 ���I TOWN OF NORTH ANDOVER 46 APPLICATION FOR PLAN EXAMINATION o � nod Permit No#: IC4-16-7-61 �O Date Received 2,11 �RA�Rg7¢o Peet �SSACHUS�'G Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION yI &eUTA/ Ar-(e RP Print PROPERTY OWNER 4SZ•l_,z ysa4l Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑Addition ❑Two or more family ❑ Industrial )'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic q Well: El Floodplain 11 Wetlands ❑ WatershedtDistnct ❑`Wates/S_ewer_ - _ __ _ __ - DESCRIPTION OF WORK TO BE PERFORMED: T21vG woad st-ouc l,,sAer sxwe dfs Fei�lgw .C�szer Identificatio - Please Type or Print Clearly q OWNER: Name: /JO�N1C t-r1N5d1V Phone: Address: /4// 13,'(1z1v 11xee Aa . Contractor Name: 77/G/` 5 1I#Alv Phone: e13 Email: 77%f dt✓72 C r ISG 6AV-7Z . Co Address: FY y1 111 lot-CLrlrC'K Rb. Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: r.. Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 9 '19 �' FEE:-$ Check No.: 22 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I Location4l No. �-2�� DateLl��I� 7 • - TOWN OF NORTH ANDOVER 1'49 Certificate of Occupancy $ Building/Frame Permit Fee $ /t�0 -- Foundation Permit Fee $ Other Permit Fee $_- 1 TOTAL $ Check#71 J �; f. 5 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinwiing Pools ❑, Well ❑ Tobacco Sales ❑ Food Packaging/Sales '❑` Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o D FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments M .,Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town]Engineer: Signature: Located 384 Osgood Street FI_REjDEPAR<TMNT sTemDum 'ste q b r n.site yej� of o L'ocatedtaf�12i4 -'—AtSt[eet_ 'Fi:retDe�pa_�rnent�sgnatui-e/date.. __ _ _ ° .. COMMENTS Dimension Totals square feet of floor area Number of Stories. q , based on Exterior dimensions. I 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 NOTES and DATA—(For department apse) 1-7 ® Notified for pickup Call Email Date Time Contact Name Doc.Building Paint Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained, Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit ,,Photo Copy Of H.I.C. And/Or C.S.L. Licenses . Copy of Contract 4. Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All durnpster 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/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 p Affidavit Two Sets of BuildingPlans One To Be Returned to Include Sprinkler Plan And ( ) p Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code 4- 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 I I NORTH own of 0 No. 2AIp - O z Mass Int c_ 2,s � h ver, _ o ..K. 1 coc-1icnewrcw � RATED pPa��� U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT .. `o o'J`e L,) A4,s 54 ') BUILDING INSPECTOR .. Foundation has permission to erect .......................... buildings on ....!.� .. ... ..................................................... ...... Rough to be occupied as ................ .. :ep,lfA( .... .!S.r', ... :..:..1.... ���-`�f.� ................... Chimney provided that the erson aca tin this permit shall in eve respect conform to the terms of the application Final p p p g p every p 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ST S Rough Service ... .. ... . .. ..... .... ................................. Final UILDING INSPECTOR 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. ESTIMATE T.M Contracting Bonnie Wilkinson 94 Van Kleeck Rd 41 Bruin Hill Rd. Millis, MA 02054 No.Andover, MA 01845 Phone: (774) 217-3343 (978)258-4141 Email: kilma6@msn.com/tmcontracting9@gmail.com Estimate# 000101 Date 05/16/2016 Description Total Remove and disposal Of existing zero clearance wood fireplace $0.00 T.M Contracting will remove fireplace mantel,open up wall and rear of Chase wall for the purpose of removing an existing zero clearance wood fireplace and all chimney. Mendota Full view Zero Clearance Gas Fireplace $2,200.00 Reframe fireplace opening to accept Mendota full view gas fireplace. Price includes removal and disposal of existing fireplace,and framing and installation of new gas fireplace.Vent will be horizontal at approximately 8' height above existing deck. Exterior Chase will be restored to its original condition. Price includes labor and material for removal and instalation of old/new fireplace,and does not include any interior finish options. Price does not include any electric or plumbing costs that may be needed.Existing Chase top,will be patched with sheet metal and Bithane as part of the install price. Old fireplace and chimney will be removed from site. Optional/ Removal Of Existing Chase Top $365.00 At clients request,we can remove existing aluminum Chase top. It will be replaced with solid plywood with Azec, Bithane and Azec trim to create a drip edge.This would be the recommended method to ensure a watertight finish. Price includes material. Optional Wall Prep For Cultured/ Quarter Stone $410.00 As part of our install,we will be installing durarock around the new fireplace approximately 8" extended on three sides to meet the manufacturers requirements. However,we do recommend installing durarock over the entire surface that is to be covered with cultured stone,approximately 56 sq.feet,to ensure proper and permanent bonding of the finishing material.While it is not required, it is very highly recommended for a proper and permanent finish. Quoted price includes Durarock and required screws. Electric Requirement $0.00 The Mendotta fireplace does not require a dedicated circuit. For ease of installation and to keep costs reduced for homeowner,we will make the electrical connection within the fireplace and bring a lead through the floor of the chimney chase and into the basement.We do recommend an electrician make the final connection. Warrantee $0.00 T.M Contracting will warantee the workmanship on this project,for a period of three years. Manufactures warranties on the products being used are seperate and their own terms and conditions. Pagel of 2 t ESTIMATE TA Contracting Bonnie Wilkinson 94 Van Kleeck Rd 41 Bruin Hill Rd. Millis, MA 02054 No.Andover, MA 01845 Phone: (774) 217-3343 (978) 258-4141 Email: kilma6@msn.com/tmcontracting9@gmail.com Estimate # 000102 Date 05/27/2016 Description Total Real Stone - Bluestone 6x24 Panel $678.00 Install Real Stone,6 X 24 blue stone over anels prepared durarock surface.Stone is a finish P product.Area to be covered is approximately 42 sq ft. If area to be covered is increased,the work will be billed at 20 dollars per sq ft. Finished wood trim, provided by the customer will be installed on the right and left side of the stone only. If customer chooses to add more trim it will be billed at 55 per hour plus materials if not supplied.As with all tile/stone some setteling may occur. If it is necessary to return during the curring period"approximately two weeks"to rework some panels, this would be billed at a reasonable rate for the homeowner and contractor.Area to be covered is floor to ceiling approximately nine ft.wide. Pricing for this part of the project is labor only, materials-Stone, Mastic/Mortar and bonding agent supplied by customer. Subtotal $678.00 Total $678.00 Notes: When mentioning some setteling on the stone, it does happen occasionally. It is not a time intensive issue...it is usually as simple as just adding some additional mortar to a joint. Pagel of 2 I j ... V Mendota FullView FV41 & FV46 Direct Vent Gas Fireplace Specifications G _ is FV41: 31-1/2"a d x 28-1/32" High A X4' =g ��' k'sTUHficabons �a1-Hi ao,000 Lo 13,000 t! m E FV46: 36-3/4u B 48 B 51-1/2" FV46-Hi 45,500 Lo 13,600 Wide x 32-1/2 High -- — C 42-1/2" C 48" Efficiency Exceeds D.O.E.Efficiency Requirements �Finished Opening Dimensions: D 18" D 16-5/8" (A.F.U.E.)for DirectVentWall Heaters FV41: 32-3/8"Wide x 28-1/2" High E 19-1/2" E 22-1/2" Gas Supply Natural or LP F 42-1/2" F 48' Vent Size 5"Exhaust,B"Intake(Coaxial) FV46: 38"Wide x 33-1/4" High G 9" G 9-3/8" Safety system AGA Certified IPI Auto Electronic Ignition • Deep • • • - Mantel H 42-1/2" H 47" System Activated with Thermostatic Finished Opening Dimensions -FF 72" I 72° Remote Control Willow Doors Safety Tested IntertektoCGAJAGA/ANSIStandards D •' • • - '; YFV41: 34-5/16"Wide x 29-7/16" High weight FV41-225 Its.FV46: 39-7/8"Wide x 34-1/4" High Standard Equipment FV46-325 lbs. One ceramic plaque burner&one tube bums((back bumer tum-off from remote control),premium fiber A B H I log set,grate,embers&coals,AGA certified safety system,IPI electronic ignition,two blowers,remote ( control with flame&fan modulation&accent lighting control,FireLight accent lighting. 'FV46 has two tube bumers. Products,specifications and prices subject to tr ns: change without notice.Consult our owner's / Mendota fronts&doors;Black Porcelain Reflective,Limestone Brick,Natural Aged Herringbone&Red Manual for all final dimensions.Mendota Gt Soldier Course Brick interior linings;'Classic andirons. products are manufactured In the U.&A. r 'You must select an interim lining to operate the unit.Check with your dealer for colors and availability. ( The Commonwealth of Massachusetts Department of IndustrialAccidents <z d X Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant-Information � /� Please Print Legibl Name(Business/Organizationadividual): 7%101W5O1WS / 1yO/*/✓ �/! e CSN rie4er'/y 6/ Address: 9f 4ig/1 1f-eAe�ee ep. Ar,/«�s /lam �,V City/State/Zip: .�'LL��S //W Phone#: Are yon an employer?Check the appiopriate box: 'Type of project(requred): L❑Tama employer with employees(fall and/or part-time).* 7. New construction 2�Ia am'a sole proprietor or partnership and have no employees working for me in 8. Remodeling ny capacity.[No workers'comp.insurance required] 9. Demolition 3.F1 I am a homeowner doing all work myself[No workers'comp.Jusurance required.]t ❑ 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 []Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12..F j Plumbing repairs or additions S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ � � � � 13.❑Roof repairs These stab-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and ip officers have exercised their right of exemption per MGL c. 14..gOther 152,§1(4),and we have na.employees.[No workers'comp.insurance required.] /✓S%.¢LL m . . *.Any applicant that checks box#1 must also fill.out the section below showing their workers'compensation policy information. T Homeowners who submit phis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. If the sub-contractors have employees,they must provide their worxeis'cgmp.policy number. , .[am'' an employer that is providing workers'compensation insurance for my employees.'Below is the policy and jab site information. Insurance Company Name: Policy#or Self-ins, //L,,ic.#: UU Expiration Date: Job Site Address: Tel ���U��/�' A67,le City/State/Zip: 11/ 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 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I•do hereby certify under thepains andpenaldes ofpeijury that the information provided above is true and correct. Signature: � Date: 0/, 116 Phone 7 /.�l�• 33 y� 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): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: Fax Server 6/8/2016 11 : 25 : 51 AM PAGE 3/003 Fax Server DATE(MM/DD/YYYY) ACoRo CERTIFICATE OF LIABILITY INSURANCE ��. 6/8/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS I ')N THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE CG .SAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms 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 ROGERS AND GRAY INS AGCY CLSC NAME: NGM Insurance Company AcNNo Ext: 866 456 4909 AC No; (866)332-4776 55 West Street E-MAILADDRESS:servi.cecenter@msagroup.com INSURER(S)AFFORDING COVERAGE NAIC A Keene NH 03431 INSURERAMain Street America Assurance 29939 INSURED INSURER B: Thomas Moran INSURER C: 94 Van Kleeck Rd INSURER D: INSURER E: Millis MA 02054-1267 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 Master Certificate 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 CONTRACT OR 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IN WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYV X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE � OCCUR PREM SES Fa.lccu ence $ 500 ,000 MPT6881P 8/21/2015 8/21/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 M'OTHER: L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY� PRO ❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be allached if more space is required) CERTIFICATE HOLDER CANCELLATION (978) 688-9542 gabrown@townofnorthandover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Bldg 20 Suite 2035 AUTHORIZED REPRESENTATIVE No Andover, MA 01845 Donna Blouin/DLB ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 OM401) i ' T--- it _777-7 t4 i I -=14, _• L M By signing this document, the customer agrees to the services and conditions outlined in this document. Bonnie Wilkinson Page 2 of 2 SPECIFICATIONS MODEL FV41 Hirth Fire _Adjustable to- Low Fire IL BTUH. (MODEL FV-41) NAT. GAS 40,000 13,000 BTUH. (MODEL FV-41) LP GAS 40,000 15,000 - PA US NOTE: LPG CONVERSION KIT,#New#, MUST BE PURCHASED SEPARATELY TO �r���k W'It CONVERT TO BURN LPG IN THIS FIREPLACE. MAIN ORIFICE[0-2000ft(610 m)]: REAR BURNER:#42 NAT. GAS[#54 L.P. GAS]—FRONT BURNER:#42 NAT. [#54 LP] OVERALL EFFICIENCY: .....................AFUE 711/6, PA FE 72.66% CO-AXIAL DIRECT VENT FLUE: ..........5"INNER, 8"OUTER TOTAL WEIGHT: ...................................225 POUNDS SAFETY: ................................................AGA/CECERTIFIED IPI AUTO ELECTRONIC IGNITION SYSTEM ACTIVATED WITH THERMOSTATIC REMOTE CONTROL. APPLIANCE CERTIFICATION AND TESTING AGENCY INTERTEK TESTING SERVICES, ICBO#AA647-4 Certified under ANSI Z21.88(2005)•CSA 2-33(2005)"Vented Gas Fireplace Heaters"not for use with solid fuel. Approved for bed- room installations and mobile homes. UL307B approved for"mobile homes,after first sale of home, not for recreational vehicles." GAS REQUIREMENTS..........................SUPPLY PRESSURE: GAS INLET: 1/2"N.P.T. NAT. GAS: 7"W.C. (5"W.C. MIN., 11"W.C. MAX.) L.P. GAS: 11.0"W.C. (11"W.C. MIN., 13"W.C. MAX.) ELECTRICAL REQUIREMENTS...........120 VAC, LESS THAN 1.5 amps APPROVED VENT SYSTEMS...............DURAVENT,SELKIRK,AMERIVENT,SECURITY MINIMUM CLEARANCES TO COMBUSTIBLE CONSTRUCTION UNIT TO FLOOR Oin. (Omm) GLASS EDGE TO ADJACENT SIDEWALL 18in. (457 mm) UNIT TO ENCLOSURE SIDEWALL 1/2in. (13mm) VENT PIPE TOP TO COMBUSTIBLES tin. (51 mm) UNIT TO ENCLOSURE BACK WALL 1/2in. (13mm) VENT PIPE SIDES TO COMBUSTIBLES 1in. (25mm) UNIT BOTTOM TO ENCLOSURE CEILING 50in. (127 cm) VENT PIPE BOTTOM TO COMBUSTIBLES lin.(25mm) UNIT BOTTOM TO ROOM CEILING 72 in. (1829 mm) 8"MANTLE ABOVE DISCHARGE AIR OPENING 18 in. (457 mm) MINIMUM COMBUSTIBLE ROUGH FRAMING DIMENSIONS WIDTH=45"(114cm) HEIGHT=47"(119cm) DEPTH = 19-3/16"(49cm) THIS FIREPLACE INCLUDES A SEALED COMBUSTION SYSTEM,8-PIECE CERAMIC FIBER LOG SET&COALS, FIREBRICK LINED FIREBOX,NEO-CERAM GLASS, ELECTRONIC IGNITION SYSTEM, DUAL BLOWERS,AGA CERTIFIED SAFETY SYSTEM, ACCENT LIGHT and THERMOSTATIC REMOTE CONTROL. OPTIONS: BLACK, VINTAGE IRON, SWEDISH NICKEL, ANTIQUE GOLD, ANTIQUE COPPER STEEL DOORS, STAINED GLASS FRONT, BOULEVARD DOORS, SERENADE AND PORTRAIT TRIMS and other accessories. CAUTION NOTE:This installation must conform to local codes. In the ab- THESE INSTRUCTIONS ARE TO sence of local codes,you must comply with the National Fuel Gas REMAIN WITH THE HOMEOWNER. Code,ANSI Z223.1-latest edition in the U.S.A.and the Natural Gas and Propane Installation Code, CSA B149 Installation Codes This appliance may be installed in an in Canada. aftermarket, permanently located, manufactured home (USA only)or mobile home, where not prohibited WARNING: Do not operate this appliance with the glass removed, by local codes. cracked or broken. A licensed or qualified person should do re- This appliance is only for use with placement of glass. the type(s)of gas indicated on the rating plate. HIGH ALTITUDE INSTALLATION INFORMATION: Prior to installing at altitudes higher than 7500 feet, please contact the Mendota technical service department for specific venting requirements and venting restrictions. 85-03-00890 6 1 P a g e Information anInstrnetions 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 contraot Ahire, express or implied,oral or written." An,employer is defined as"an individual,partnersbip,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 bd deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any. applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.". r Applicants Please fillout 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 certificates)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 foi•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"fob 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-o.a dog license or permit to burn 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.4 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia