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HomeMy WebLinkAboutBuilding Permit #120 - 46 CAMDEN STREET 8/11/2009 1 p10 R T!t BUILDING PERMIT o`tt,�o ,bgtio TOWN OF NORTH ANDOVER o? APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received gAreo'P"' 9SSACHUS�� Date Issued: (� IMPORTANT:Applicant must complete all items on this page a LOCATION L t1► ` 9 �S �C�M(� J Print --q- PROPERTY OWNER I b C1�te '`l ,, ( Print MAP NO: PARCEL: :ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ew Building One family Addition Two or more family Industrial Alteration No. of units: `Z Commercial Repair, replacement Assessory Bldg Al Others: Demolition Other Septic Well Floodplain Wetlands Watershed District ater/Sewe) /�o C)11*,At?. 10 �� YL Al DESCRIPTION OF WORK TO BE PREFORMED: (Z4�.e � ��l)�wc �t,o �cr ►rn�Lei (:(tib 12 e�(�l C� l,v� �1�l Identification Please Type or Print Clearly) OWNER: Name: S� rn '�� C_ ( eke ��+le'� � �1 hone: q Tf Address: W S ue Cy( °� L'o CONTRACTOR Name: G Phone: Address: �'- Y ofl y. Supervisor's Construction License: 31 �(S 0 Exp. Date: -+ Home Improvement License: Exp. Date: ARCHITECT/ENGINEER (StV 4 �J�.\G� Phone: Q7LT)l S 1I Address: ��C� I�P�t' �� U�)� � Reg. No. i FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: I I Receipt No.: O�3 NOTE: Persons contracting with unregistered contractors do not have access to a guaranty fund gnature�of Agent/Owner Signature of contracto i Location No. �QO Daie' NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy CHusEt� Building/Frame Permit Fee $' Foundation Permit Fee $$ /U U Other Permit Fee $ TOTAL $ ��0 Check # Q/ 22515 B alai g Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL ublic Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales / / Food Packaging/SP Private(septic tank,etc. Permanent Dumpster o' /Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF . U FORM !A&71-- & I. aYk / DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on ( Signature COMMENTS (AML > IUD ' Vb) OZM2LCi HEALTH Reviewed on Signature A11A COMMENTS (� Q Zoning Board of Appeals:Variance, Petition No: �`�� �6 Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comment 7.22-3 Water & Sewer Connection/si nature Driva Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dump er on site yes no Located at 124 Main Street Fire Department signature/date , .. — 2 - o COMMENTS R/ Dimension Number of Stories: - Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ��o 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 use) I I i I . I i i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 i 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 NOTE: 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Application Revised 2.2008 J Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. i Roofing, Siding, Interior Rehabilitation Permits I ❑ 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 PP 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 NOTE: 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 Affidavlt ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application J Doc:Building Permit Application I Revised 2.2008 M ` k 11712 Ps I4? 17-29-213C .9' ABOVE FOR-REGISTRYOFDEEDS USE ONLY COVER SHEET THIS IS THE ][FIRST PAGE OF THIS DOCUMENT DO NOT REMOVE GRANT R GRANT E ADDRESS OF PROPERTY CITY/TOWN TYPE OF DOCUMENT MLC ASSIGNMENT TYPE DEED 61) MORTGAGE NOTICE TYPE DISCHARGE SUBORDINATION AFFIDAVIT CERT DEC OF HOMESTEAD UCC TYPE TYPE DEC OF TRUST n OTHER � b �` D SCRIBE , Robert F. Kelley, Register 354 Merrimack St. Suite 304 Lawrence, MA 01843 (978) 683-2745 www.1awrencedeeds.com RECEIPT Printed:07-29-2009 ® 13:59:50 Essex North Registry Robert F. Kelley Register Trans#: 105196 Oper:STEPHENM Book: PL Page: 16125 Ctl#: 268 Rec:7-29-2009 9 1:59:38p DOC DESCRIPTION TRANS AMT --- ----------- --------- PLAN Surcharge CPA $20.00 20.00 5.00 TECH FEE 5.00 Plan recording 50.00 Document Copy -Man 6.00 Total fees: 81.00 ------------------------------------- -------------------------------------- Book: 11712 Page: 142 Inst#: 22276 Ctl#: 269 Rec:7=29-2009 9 1:59:38p DOC DESCRIPTION TRANS AMT --- ----------- --------- NOTICE Surcharge CPA $20.00 20.00 50.00 recording fee 50.00 5.00 TECH FEE 5.00 Total fees: 75.00 *** Total charges: 156.06 CHECK PM 8698 156.00 a Town of North Andover ZONING BOARD OF APPEALS E D E�V E D Albert P.Manzi III,Esq.Chairr�ax ��L Ellen P.McIntyre,Vire Choirwan T(j�.'r! �? {��('S OFFICE Richard J.Byers,Esq.Clerk ot;,U.T,'�tio Joseph D.LaGrasse •`•,r ' %-7 °e 2009 JUL -7 AMl' 40 Richard M.Vaillancourt f°. p Atroaate Menrhers +' '� T o`��i OF Thomas D.Ippolito .«,.... +r 4, NORTH ANDOVER Daniel S.Braese,Esq. ��•"+,,.o�''tc'' MA11�` TS Michael P.Liporto Ssweause 1 ane tamp This is to certify that twenty(20)days have elapsed from date of decision,filed without filing of an appeal �vn Any appeal sliall be tiled within Notice of Decision Date (20)days after the date of filing Year 2009 Jaya*A,F3 dshew of this notice in die ot'frce oftlic Too 010 Town Clerk,per Mass.Gen. L.ch. 40A,§17 Property at: 46 Camden Street NAME: Jeffco Inc.,77 Muin Street,Andover. HEARING(S): April 14,May 19,&June 9,2009 MA 01810 ADDRESS: 46 Camden Street PETITION: 2009-006 North Andover,MA 03M45 The North Andover Board of Appeals held a public hearing at its regular meeting in the Town Hall top floor meeting roonn. 120 Main Street,North Andover, MA on Thursday,June 9,2009 at 7:30 PM upon We application of Jeffco Inc.,77 Main Street,Andover,MA 01810,for premises at:46 Camden Street(Map 85,Parcel 11),North Andover, MA requesting a Special Permit from Section 4,Paragraphs 4.122.14B,4.122.141),and front Section 10, Paragraph 10.3 of the Zoning Bylaw in order to raze and construct a new two-tinnily dwelling on it pre-existing, non-conforming lot. Said premisc affected is property with frontage on the Northwest side of Camden Street within the R-4 Toning district. Legal notices were sent to all names on the abutter's list and were published in the Eagle- Tribune.a newspaper of general circulation nn the'rown of North Andover,on March 30 and April 6.2009. 'rhe following voting members were present: Ellen P.Mchityre,Richard J. Byers, Albert P. Mani, 111, Richard M. Vaillancourt and Daniel S.Braese. The following non-voting members were present: Thomas D. 1ppolito and Michael P. Liporto. Upon a motion by Richard M. Vaillancourt and 2"'t by Richard J.Byers the Board voted to GRANT it Special Permit from Section 4,Paragraphs 4.122.14B,4.122.14D.and from Section 10,Paragraph 10.3 of the Zoning Bylaw in order to raze mid construct a new two-family dwelling an a pre-existing,non-conforming lot per: Site: 46 Camden Street(Map 85,Parcel 11),North Andover,MA 10845 Site Plan Title: Plan of Land in North Andover, MA.prepared for owner/applicant,Jeffco, lnc.. #77 Main Street,Andover,MA Date(&Revised Dates): March 13,2009,rev.:June 1,2009 Registered Professional Stephen E. Stapinski, R.L.S.#29876, Merrimack Engineering Services, 66 Park Lund Surveyor: Street,Andover,Massachusetts 01810 ShceV1)rawin : Y:\R14\DWGS\7719\ZBA\7719-O1.DWG 6/1/09 Building Plan Title: 46 Cannden Street,Plan#D-15:20 x 28 Duplex&20 x 28 per unit By: Alan Carroll,P.O.Box 5066,Andover,MA 01810&Colonial Drafting Services. 170 Main St., Unit#204,Tewksbury,MA 01876& Shect/Drawing: [1 slicet] & [front elevation,8015 right,left,rear elevation. 8015 First Floor Plan, 8015 Second Floor Plan Page 1 of 3 j ATTEST: A'Prue Copy a 24-,w- 1,own Cleric 1600 Osgood St.,Bldg 20-Suite 2-36,North Andover,MA 01845 Phone-978-688-9541 Fax-978-686-9542 Web-www..o•,vnofnorthandover.com 9 Town of North Andover RECEIVED ZONING BOARD OF APPEALS 701t'N l_-FRK'S OFFICE Albert P.Manzi III,Esq.ebcirrxan 2009 JUL —7 AM ' 4 Ellen P.McIntyre,Viet-Cbdroyan MORTH Richard J.Byers,Esq.Clerk of`t6.° ,.- Joseph D.LaGrasse 3: •t:+ - OL TOWN O F Richard M.Vaillancourt NORTH ANOOVEI� Assoaale Mtmberr At MASSACHUSETTS Thomas D.Ippolito '^e ,« , ,r 41 Daniel S.Braese,Esq. *•°� Michael P.Uporto SS,�C H Town Clerk Time Stamp With the following conditions: 1. The proposed two-family dwelling shall have both driveways accessed via Concord Street,as shown on the above Plan of Land. 2. A lot line landscape buffer of Arborvitae trem two feet taller than the decks,shall be planted along the Camden Street lot line in order to act as a screen beAveen the proposed decks and the 55 Camden Street dwelling. 3. Existing trees on Camden Street shall not be removed without the owners of Map 85,Parcel 11 requesting a modificationW.this condition from the Zoning Board of Appeals. Voting in favor: Ellen P.McIntyre,Joseph D.LaGrasse.Richard J.Bycrs,and Richard M. Vaillancourt. Albert P. M:u&III abstained. Tine Board finds that Camden Street is in the Residential Four Zoning District,and that the Zoning Bylaw allows two,three,tour,and rive dwelling units by Special Permit. The Board finds that there are multi-fancily dwellings on Camden Street,Bunker Hill Street and on Concord Street,which will be the proposed new duplex street address. The use,as developed,will not adversely affect the neighborhood because the proposed two-family dwelling,as designed,will confornn to the character of the neighborhood in size,structure,and appearance, per the applicant's submission of the above building plans. The Board finds that the applicant's immediate abutters on Camden Strect were present at the meetings and their spoken concerns:no access via Camden,retaining the existing trees on Camden.and adding a lot line landscape buffer between the decks and the abutter were addressed by the Board's conditions. The Board finds that there will be no nuisance or serious hazard to vehicles or pedestrians because the lot can accommodate the required 4 off-street parking spaces. Adequate and appropriate facilities,electricity. plioue.Towu water, and Town sewer lines are provided to Concord Street lots. The Board finds that the applicant Inas satisfied the provisions of Section 4,Paragraphs 4.122.14.A.B.4.122.14.D,and Section 10,Paragraph 10.3 of the Zoning Bylaw in order to construct a two-family dwelling on a conforming lot and that the granting of this Special Permit for the razing of the two family dwelling facing Camden Street and constructing a new two fancily dwelling facing Concord Street,(Map 85, Parcel 11)is an appropriate location because there are other two-family dwellings on Concord Street. The Board finds that the granting of this Special Permit is in'harncony with the general purpose and intent of the above-cited bylaws,and this two-family dwelling unit shall not be substantially ncorc detrimental than the existing single and two-family dwellings in the Concord,Bunker Hill, and Camden Street neiglrborlcood. Note: 1.This decision shall not be in effect until a copy of this decision is recorded at the Essex County Registry of Deeds,Northern District at the applicant's expense. 2.The granting of the Variance and/or Special Permit as requested by the applicant does not necessarily ensure the granting of a building permit as the applicant must abide by all applicable local,state,and federal building codes and regulations,prior to the issuance of a building pernnit as required by the Inspector of Buildings. Page 2 of 3 i 1600 Osgood St.,Bldg 20-Suite 2-36,North Andover,MA 01845 Phone-978-688-9541 Fax-978-688-9542 Web-www.townofnorthandover.com NORTH T "'. .. 7 "�own of Andover 0 11% No. j 2 1dover, 2 Mass., L AX 0 C7 f?A'r E BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR z// alfAl — , THISCERTIFIES THAT.....................................................................................42 .... ........ ....... . .... .......... Foundation has permission to erect........................................ buildings an .....e1.6. co/o/^c1te"I r/_................................................................. Rough 17 to be occupied as................. 2e.v.c..V o z4.).... .... .2..S.A ......1:5Chimney q,, provided that the person accepting this permit shall in every respect conform t ei�m of the application on file in Final 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 CONSTRUCTION STARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE D.EPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE] Smoke Det. JEF COING DATE QWa+sir INSURANCE BINDER THIB AINOk_R IS A TEMPORARY INSURANCE CONTRACT. 8Ug4ECT TOTHgCONDITIONS SHOWN ON TME REVIEW P De OFTHI6fOfiM. PRODUCER PFJ BINQER1067906 Pic 9788880038 Aced ImmIsc. 'r1oN �fPErT NbTIME HtJ81nn NOW England(WILSO) x AM 09!18109 X 1:A1 AM 299 Bagardvale St 08119109 12:41 PM NOON Wilmington,MA 01887 X PER BINDER 16 POLICY ISSUED TO EXTEND COVERAGE IN THF.ARM NAMED COMPANY Binder CODE: BUB CODE: AGE2C 53794 peaC111PTIDN OF OPlRATION I1VlMIOLE8IPROP6RTY(ImMA.g lAUUen) MONI JeHCO IncLocant 40.48 Concord St,North I Andover,MA 01845 George Hughes P.O.Box 802 Andover,MA 01810 LIMITS COVERA0154 DEDUCTIBLE 001145% AMOUNT TYPE OF INBURplICE• COVIRMIFOIWa 300,000 PROPERTY CAUSES OF Lo��ss Builders Risk 502 BASIC ❑BROAD L^J SPEC as Sm.Co dations C voyages GENERALUABWTV EACMOCCURRENCE 6 07iMAG TO NO 6 COMMERCIAL GTdNERALUABIIITY RENTE MEpEamparaon) S CLAIMS MADE OCCUR PERSONAL i ADV NJIXtY S GENERALAGGREGATF S RETRO D TE FOR CLAIMS PRODUCTS•COMPIOP AGG 6 COMBINED SINGLELINIT S AUTOMOBILE UABILITY BODILY IN,AJNV(POI xaan) S ANY AUYO BODILY INJURY IPar aa6110fit 6 ALL OWNED AUTOS PROPERTY DAMAGE 6 SCHEOLLED AUTOS MEDICAL PAYMENTS 6 HIRED AUTOS PERSONAL INJURY PROT S NowowNFD AUTOS UNINSURED MOTORIST S AUTO PHYSICAL DAMAGEACTUAL CASH VALUE DEDUCTIBLE ALLVF.HICLES SCNERULEOVENICLES STATED AMOUNT S ooullTiDN OTHER OTHER THAN COL'_ AUTO ONLY•EA AL'Clp T S GARAGE UAMfrf OTHER THAN AUTO ONLY: ANY AUTO EACH ACCIDENT i ACCREOA'f• i exesu LIABILITY EACH OCCURRENCE 6 AGCREOATE f _ UMBRELLA FORM SELF-INSURED RETENTION 6 OTHER THAN UMBRELLA FORMRGTRO OATS FO 6ARJ4 MADE: W C STATUTORY LIMITS E.L.EACH ACCIDENT _ 6 WORKERa AmKwATION E.L.DISEASE-EA EMPLOYEC S EMPLOYERS LIABILRY E.L. POLICY LIMIT S { '"Continued From Additional Interests Section'" FEES S 6cP7pEH�CII�TAIONfI AXES 6 GOVENAGE6 see attached gMCondltionslOther Cove a, ESTIMATEOTOTAL PRE UM Is NAME FS X MORTGAGEE H.pOITMMAI INSURED William MacLeod LOSS PAYEE One East River Place LOAN u Mathuen,MA 01844 AC0R*7611061101)1Inr 3 066365 NOTE!IMPORTANT 6TATE INFORMATION ON REVERSE SIDE LB001 0 ACORO CORPORATION 1993 Com►narzweaft of Massachuse&S 1-4 Deparbnear of Industrial Accidents rice q f Lrneszkadions 600 Nrashington Street MA 02111 "nVW-m=sgrry/din Workers' CampeQsafion I:nsiu-anee ' Af�icisvi Sunders/Contractors/Electricians/PiQmbers A licaat Inforagation Please Print Leeibl Nagle (Business/Organi2R6On/individual): hUl/ S e��• City/state/Zip, Phone#: . Are you an eO*YerT Check.the appropriate-box: i:❑ l,am a employer with 4. ❑ I am a Type of project(required): employees(fun andlor _* getneral contractor and i . part-time). have hired the sub-comzactors 6. ❑New construction 2•❑ I azn.a sole proprietor or .ptr'trter_ listed on the attached z 7. ship and have no employees' sheet. ❑Remodeling Theme strLs-contractors have working for me in any capacity. workers' comp.instusrtce. 8' ❑Dewhtion [No workers'comp,insurance . 5. We ao c a corporation and its 9• ❑Btulding addition ��d.] officers have exercised their 10•0_ElecHcal repairs or additions 3•❑ i am a homeowner doing all work right of exemption MOL 1!. ❑plumbing mys•"•!f[No-work='cotnp. .r l52, §!(4),'and we have no r'epaira or addifitms insurance required.]t .-emPlaYeees:[No workeas' 12.[] Roof repairs '/,ny applir�trt Cher COMP• insurance required.] !3.❑.Other t#tecks boz'#I mutt tttso ti[t rntttiu section below ahowir:g theirworkers'iiompensefiori policy infomratioa t Homeowner¢who sribmit this sEndavit indicatin th arz _ �Co Mwton;that cheek this boa rnustatrsoh�sa cdditr.,- ,sh showwo and thm hire outside connectors must submit a.neiv affidavit iodi ntg•the+mme of tFm suh-contractors and.ymir e S such I ant not Krorta:es'cetna a r'-:;rfi,..,..«. enr oyer that is p,7uidmi r wRrpe^-T,0-l" EFcS LL mforaraatEon �- � 'riawv=e,for nty. Plnves B I..w r-� to Ilse }'.mea jou site Insurance Company Name: ti eL Policy#or Self-ins.Lie.#: Expfimfion _ b a t t,�. : Job site Address: _ELAttach a copy of the workers' com � � m' Al( t ' �' `, peusation policy deciaraiiau page(showing Failure to the policy,number and expiME013 date}, secure coverage as required under Section 25A of MCIL fine up to 51,500.00 and/or one-year c. 152 can lead to the imposition of criminal perta}ties of a imprisonment;as veep es civil penalties in the farm of a STOP WORK of up to$250.00 a day againstthe violator. Be advised that a copy of this statement may be forwarded to the _C3RD£R and a fine Investigations of the insurance,DIA for insance coverage verin"cafion, Offrce of I do hereby cerfijy under the pains and penatdes of pa jW y that the in armavon pro ' f p tnafed above is dyne and eonrrt ff.2 Daterse odo no&y. t write isthis area,to he eompled�d by*'or town off":,wwn: PermWLicenceuthority(circle one): f Keaitb Z laniiding Department 3.City/Town Clerk 4. Electrical Inspector 5.Plnmbi�Inspctor rson: Phone#: Information aL nd Instructions Massachusetts General Laws chapter I S2 requires all amp 3 overs 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,partrsership,assorriatiart, corporation or other legal entity,or any two or more of the�fomping engaged in a joint enterprise,and fncludi"g the legal rgxLtentafives of a deceased employer,or the receiver ortrustx•of an individual,partnership,associatiori or other legal entity,=pioying 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 mai mtananee,construction or repair wcirk on such dwelling house or on the gmunds or building appurtenant thereto shall not because of sucb employment bo deemed to be an employer," MGL chapter i S2,§25C(6)also states fiat"every state o•=-local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or *a construct buildings is the commonwealth for any applicant who has not produced acceptable evidence of compliance with the.insurance coverasge required." - Additionatly, MGL chapter IS2,§25C(7)stuftos"Neither t1ho commonwealth nor any of its political subdivisions shall enter isrtp amty contract for the PM*ffmmm ofpublic work- until-acceptable evidence of compliance with the insurance regwremc:n s.of this cl.0 ptu have been presented ed to.thc cOT&acfmg authority," Applicants Please fill out the workers'compensation•affidavit cornpl-e--tely,by decking the boxes that apply to your situation and,if necessary,supply sub-contactor(s)name(s),addreS:Kes):$rd phone number(s)along with their certificates)of inm m Limitnd Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employes other than the members or partners,arc not required,to carry work='Oci-ittpmsaiion insurance. Van LLC or'LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidwi s for confirmation of insurarim 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 pmxmff or license is being requested,not`the Department of Industrial Accidents. Should you have any questionsm acs-ding the law or if you are required to obtain a workers' oompensation policy,please call the Dcparterexmt at the•nizimber.listed below, Self-insured cornpanies should enter their (" self-insumicie-lic©nse number an th:•appropi•iste line. City or Town C"fic6is Please be sure that time af5dzvit is complete and printed 6-W-biy. Tho Departmmt hes 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 numbe:rwhicb w iilI be used as a reference number. In addition, an applicant that must submit multiple pwniWhc*m a applications in any given year,need only submit one affidavit indic2ting-eurTent policy information(if necessary)and under"Job Site Addr-en"the applicant should write:"all locations in (city or town)"A copy of-the affidavit that has been officially stamped or marked by 6-a city or inwn may be provided to the appii=Tt as proof that a valid affidm is on file for future permits or licenses A new affidavit must be Med out each year. When a home owner or citizen is obtaining a license. or permit not related to any business or commercial venture (Le. a dog license or permit to bum leaves etc.)said pmsori is NOT required t4 complete this affidaviL Tho Of fin of investigations would like to thank you in advance for your cDoperatfon and should you have any questions, please do not hesitate to give us it call The Department's address,telephone and fax number. The Commonvrealth of Massachusetts Dcpariment of 13Sdustdal Accidcnis Office of LnvestiQatvions 600 Washington Sttr=t Boston, MA 02111 TeL#617-727-4900 6=406 or 1-8.77-MASSAFF- Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia N' fctN Massachusetts- 1)cpa►rtrn U►ns n Board ofBuid•Stant of.public dards ldinl�R�„ul. Construction Supervisor License License: CS 59106 Restricted to: 00 GEORGE A HUGHES 128 ANDOVER ST ANDOVER, MA 01610 Expiration: 1013112010 Tr#: 4337 � (ummisa,mer e 1 ` REScheck Software Version 4.1.2 Compliance Certificate Report Date:07/03/09 Data filename:Untitled.rck Energy Code: 2006 IECC Location: North Andover, Massachusetts Construction Type: Single Family Builidng Orientation: Bldg.faces 180 deg.from North Conditioned Floor Area: 1600 ft2 Glazing Area Percentage: 11% Heating Degree Days: 6322 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: Left Side Unit"A" Jeffco,Inc. No.Andover,,MA Compliance:0.6%Better Than Code in • . �.. Ceiling 1:Flat Ceiling or Scissor Truss 396 38.0 0.0 12 Ceiling 2:Cathedral Ceiling(no attic) 81 30.0 0.0 3 Wall 1:Wood Frame,16"o.c. 296 13.0 0.0 15 Orientation:Front Window 1:Vinyl Frame:Double Pane with Low-E 93 0.350 33 SHGC:0.55 Orientation:Front Door 1:Solid 20 0.390 8 Orientation:Front Wall 2:Wood Frame,16"o.c. 415 13.0 0.0 34 Orientation:Right Side Wall 3:Wood Frame,16"o.c. 465 13.0 0.0 31 Orientation:Back Window 2:Vinyl Frame:Double Pane with Low-E 46 0.350 16 SHGC:0.55 Orientation:Back Door 2:Glass 40 0.370 15 SHGC:0.55 Orientation:Back Wall 4:Wood Frame,16"o.c. 415 13.0 0.0 27 Orientation:Left Side Window 3:Vinyl Frame:Double Pane with Low-E 83 0.350 29 SHGC:0.55 Orientation:Left Side Wall 5:Wood Frame,16"o.c. 155 19.0 0.0 9 Orientation:Front Wall 6:Wood Frame,16"o.c. X17 19.0 0.0 13 Orientation:Right Side Wall 7:Wood Frame,16"o.c. 155 19.0 0.0 9 Orientation:Back Wall 8:Wood Frame,16"o.c. 217 19.0 0.0 13 Orientation:Left Side Floor 1:All-Wood Joist/Truss:Over Unconditioned Space 560 30.0 0.0 18 Floor 2:All-Wood Joist/Truss:Over Outside Air 13 30.0 0.0 /- 0 Furnace 1:Forced Hot Aill AFU€ Project Title: Page 1 of 5 Data filename: Untitled.rck Report date: 07/03/09 t 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 buildinR has been designed to meet the 2006 IECC requirementsin REScheck Version 4.1.2 and to comply with the mandatory requireme list i the REScheck Inspection Checklist. !l 3 '1 Name-Title Signature Date Project Title: Page 2 of 5 Data filename: Untitled.rck Report date: 07/03/09 t REScheck Software Version 4.1.2 Inspection Checklist Date:07/03/09 Ceilings: ❑ Ceiling 1:Flat Ceiling or Scissor Truss,R-38.0 cavity insulation Comments: ❑ Ceiling 2:Cathedral Ceiling(no attic),R-30.0 cavity insulation Comments: Above-Grade Walls: ❑ Wall 1:Wood Frame,16"o.c.,R-13.0 cavity insulation Comments: ❑ Wall 2:Wood Frame, 16"o.c.,R-13.0 cavity insulation Comments: ❑ Wall 3:Wood Frame,16"o.c.,R-13.0 cavity insulation Comments: ❑ Wall 4:Wood Frame,16"o.c.,R-13.0 cavity insulation Comments: ❑ Wall 5:Wood Frame,16"o.c.,R-19.0 cavity insulation Comments: ❑ Wall 6:Wood Frame, 16"o.c.,R-19.0 cavity insulation Comments: ❑ Wall 7:Wood Frame,16"o.c.,R-19.0 cavity insulation Comments: ❑ Wall 8:Wood Frame,16"o.c.,R-19.0 cavity insulation Comments: Windows: ❑ Window 1:Vinyl Frame:Double Pane with Low-E,U-factor:0.350 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No i Comments: ❑ Window 2:Vinyl Frame:Double Pane with Low-E,U-factor:0.350 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: ❑ Window 3:Vinyl Frame:Double Pane with Low-E,U-factor:0.350 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: Note:Up to 15 sq.ft.of glazed fenestration per dwelling is exempt from U-factor and SHGC requirements. Doors: ❑ Door 1:Solid U-factor:0.390 Project Title: Page 3 of 5 Data filename: Untitled.rck Report date: 07/03/09 ti ' Comments: This door is exempt from the U-factor requirement. ❑ Door 2:Glass,U-factor:0.370 Comments: Floors: ❑ Floor 1:All-Wood Joist/Truss:Over Unconditioned Space,R-30.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. ❑ Floor 2:All-Wood Joist/Truss:Over Outside Air,R-30.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Heating and Cooling Equipment: ❑ Furnace 1:Forced Hot Air.90 AFUE or higher Make and Model Number: Air Leakage: ❑ Joints,penetrations,and all other such openings in the building envelope that are sources of air leakage are sealed. ❑ Recessed lights are either 1)Type IC rated with enclosures sealed/gasketed against leaks to the ceiling,or 2)Type IC rated and ASTM E283 labeled,or 3)installed inside an air-tight assembly with a 0.5"clearance from combustible materials and a 3" clearance from insulation. Vapor Retarder: ❑ Vapor retarder is installed on the warm-in-winter side of all non-vented framed ceilings,walls,and floors;or it has been determined that moisture or its freezing will not damage the materials;or other approved means to avoid condensation are provided. Comments: Materials Identification: ❑ Materials and equipment are identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. ❑ Insulation R-values,glazing U-factors,and heating equipment efficiency are clearly marked on the building plans or specifications. ❑ Insulation is installed according to manufacturer's instructions,in substantial contact with the surface being insulated,and in a manner that achieves the rated R-value without compressing the insulation. Duct Insulation: ❑ Ducts in unconditioned spaces are insulated to R-8. ❑ Ducts in floor trusses are insulated to R-6. Duct Construction: ❑ Air handlers,filter boxes,and duct connections to flanges of air distribution system equipment or sheet metal fittings are sealed and mechanically fastened. ❑ All joints,seams,and connections are made substantially airtight with tapes,gasketing,mastics(adhesives)or other approved closure systems.Tapes and mastics are rated UL 181A or UL 181 B. ❑ Building framing cavities are not used as supply ducts. ❑ Automatic or gravity dampers are installed on all outdoor air intakes and exhausts. ❑ Additional requirements for tape sealing and metal duct crimping are included by an inspection for compliance with the International Mechanical Code. Temperature Controls: ❑ Thermostats exist 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 is provided. Heating and Cooling Equipment Sizing: ❑ Additional requirements for equipment sizing are included by an inspection for compliance with the International Mechanical Code. Circulating Hot Water Systems: ❑ Circulating hot water pipes are insulated to R-2. Project Title: Page 4 of 5 Data filename: Untitled.rck Report date: 07/03/09 Circulating hot water systems include an automatic or accessible manual switch to turn off the circulating pump when the system is not in use. Heating and Cooling Piping Insulation: HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-2. Certificate: A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R-values;window U-factors;type and efficiency of space-conditioning and water heating equipment. NOTES TO FIELD:(Building Department Use Only) Project Title: Page 5 of 5 Data filename: Untitled.rck Report date: 07/03/09 2006 ECC Energy Efficoency Certificate e MUM Ceiling/Roof 38.00 Wall 13.00 Floor/Foundation 30.00 Ductwork(unconditioned spaces): Window 0.35 0.55 Door 0.37 0.55 Forced Hot Air Furnace 90 AFUE Water Heater: Name: Date: Comments: