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HomeMy WebLinkAboutBuilding Permit #908-15 - 540 BOXFORD STREET 5/12/2015 BUILDING PERMIT P ✓ r �' of No pTH qti (,� TOWN OF NORTH ANDOVER 9to t`I' G� 1 „`�� APPLICATION FOR PLAN EXAMINATION o Permit No#: �� Date Received .AreD C �SSACHU`��� Date Issued: , 7 MPORTANT:Applicant must complete all items on this page ►L0cAT,ION ' / Prmtr , R1100 RTYfOWNER.. .Print T1oosYea structure yes" MAP 'C1� PARCEL e,1 G2 ZONING DISTR_ ICT:�Historic;District yes,, no' f .,_ _ ,. opU age yes Machine Sh ill o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ew Building Fv6ne family ❑Addition ❑Two or more family 0 Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic 1Ne11' j ❑'Floodplain ]+Wetlands I 0 'LWatershetll Di-Jr ct Water/ ever I _ ,DESCRIPTION OF WORK TO BE PERFORMED: Coij G(C� � i34 E F4 m I L t/ b[�c.1 E c�i IUG !Y�F&0/Z o o M fyJ.li g eA( C_ S qs c (v\ Identification- Please Type or Print Clearly 9-2 - to5-193 5 c).- OWNER: Name: I, 1AorneS LLC- Phone: q7P, - wP,-APW1 Address: 10 Mid . 01 AR-1 Contractor Name: � � tG1C�' Phone q JC 't _ M1 EmbiLAI Addres_s i i }�'1 1OA�O; 'ilk � } t' I `' `. .. .' it ., .•:,' .F. , Supervisor s'Construction 4LCicense .�-1 (� Exp ,Date Home,lrnprovement License '4. �/ _ Exp Date. ARCH ITECT/ENGINEER,4&iT 0. pts •E4 Phone:g�?5-'?- Is ;) 9 Address: A fN � ' e rrP4owlg P f033Zeg. No. 2-7765- FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS BASED ON$125.00 PER S.F. Total Project Cost: $ 11 FEE: $ ' Check No.: 11 Receipt No.: 2 1u NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund RN _ -• - R 1J44` , , _ _i. w..2-. a- 7K-in Location /74 � " No. V Date . • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� � Foundation Permit Fee $ �� � Other Permit Fee TOTAL Check# �� 28764 uilding Inspector Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans x TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanniug/Massage/Body.Art ❑ Swimming Pools ❑ Well X Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On S'y`tS Signature_ w COMMENTS_ /9e2 Qm(U &WgA d= /,pr l it Lot '2- ComLined df swW GU c — does At or cbyy" > I ae-rz CONSERVATION Reviewed on nature ' COMMENTS- (-V0 K ( s� ;h lam` ro r✓. 1.�e-t1�- r�1, f r Ci �rc?L 125 CT 1 WEALTH Reviewed on Si nature I COMMENT / S UG k JV�'�112 Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes `"ss Banning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/Si natufV & e 92 Dnwa permit </ //, DPW Town Engineer: Signature: Located 384 Osg od St Pet i FIRE DEPARTMENT.�Temp Durnpster ons' . yes rnn� y Located at 1p,1 Main Str e F're Depa, men si.g , ature/date -COMM NTS �.� 2 � �— 1�✓ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions,-,) Total land area, sq. ft.. -F*7i ZD S ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA- (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Buildinb Permit Revised 2014 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 IS OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4� Building Permit Application iL Certified Surveyed Plot Plan 4 Workers Comp Affidavit 4 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) 4 Mass check Energy Compliance Report (If Applicable) 4. 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 Per-mit Application 4, 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 ti i P 2012 IECC Energy code aEngineering 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 Doe:Building Permit Revised 2014 50 Washington Street Westborough, MA 01581 IECC 2012 &MA Stretch Energy Code Duct Tightness Verification ED/ Fait Date: Permit No.: Street Address: zzir Total conditioned floor area- Source of Area Calculation: ?Z-09 rv5 I HERS Rater: 1 CLEAResult. Certification Number: I `�6 Signature: Builder: �,l70/rle..� Builder Contact: ' HVAC Contractor. 2012 IECC-New Construction Post-construction test I ❑ Total leakage-4 cfm/100 W maximum allowed Testing result: ............... cfM/100 f 2 Rough-in test- Totol/eakage Air Handler Inst led? Yes-4 cfm/100 ftl maximum allowed ❑ No-3 cfm/100 ftp maximum allowed Testing result: ---------- ' (p---_cfM/100 ftp MA Stretch Energy Code-401.3 Prescriptive Optiorr for Residential Additions and 401.5 Prescriptive Option for Alterations, Renovations or Repairs Applies to all systems except those in which the air handler and all ducts are located within conditioned space ❑ Leakage to outdoors-4 cfm/100 ft2 maximum allowed Testing result: cfm/100 f 2 . Results aov/v to the system as tested on the date above. ComDhance is voidifonv chances t-LtMeSUItopyng LAWRENCE H. OGDEN,P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 979452-8318 fax 978-352.2858 cells 978-582-5921 October 1.3 2015 Mr.BilI Lumbard Comfort Reality LLC 14 Bemis Circle Tewksbury,Ma. 018'76 �5ya RE Lot 1.692 Boxford.St.North Andover Dear Mr.Lumbard As you requested;I conducted a site visit 10/9/15 to review the installation of the Engineered Materials consisting of LVLs,'beams utilized in the framing of the above project.. The Lvls are shown on plans prepared KIK Design dated 4130/15 with the framing plans sheets 3,and 6 and Detail sheets D-1 to D-4 certified by me 5/4/15. I can certify that to the best of my knowledge the INLs members and associated details utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1&2 Family Residences. This certification is based on what I could visibly see at the time of this visit when the framing was complete. The purpose of this site visit was to form an opinion and comfort level that the construction appears to be constructed in compliance with the drawings. This certification should not be construed as a thorough detailed inspection of the construction and framing. Please note at the time of this visit the house was framed,the roofing and garage door trim were in place,:which limited the viewing of certain details. At the time of this site visit l.noted certain iten3s that required remedial or additional work see attached list. Nothing in this certification relieves the Licensed Construction Supervisor and or.the permit holder of the responsibility for construction of this project per Section 1 I0.R5.2,and sub section 110.R5.2.15 or of the Massachusetts Residential Code 280 CMR 51,or the proper execution of the details and framing requirements of the drawings, including but not limited to materials, blocking, manufacturers installation requirements and nailing schedules or other requirements of the code. Should you have any questions please do not hesitate to call. s Fours truly; 4wj aott La /ence H. Ogden P.E. Structural 27765 Enter construction cost for fee cal- North Andover Fee Cakulat%Oh Construction Cost $ 317,000.00 m $ - $ 100.00 Plumbing Fee $ 475.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 475.50 Total fees collected $ 1,151.00 540 Boxford Street Lot 1 908-15 on 5/13/15 Single Family Home I -�- ------ - - i■I I I I = - - --_-_ �-dlilrlli/► - - elrlr111■11111■. - _ rtn/Iruulruul�n _- _ _ - - - ---�IMEN _ l■111112lpl/uluAill1 ■■■I = Mlpl�lEllli%rllli�Irlllll�lll�•rlld/ - - =- .i1111r11111■IIIIIrI1111rIUIIrIEl11� �I► = -_ �Ilr'1IIr11111rI1111r1111■IIBIIr11111■II' /fllrlr� - - ■■ - - i�IItllrlillirl1111r1ElIIrIlI11r1111'' illlrlllllrh - _ - - - ■tllq■111/I■11111■11111■1111/' �I�i1111rIU11■IIS-77 - �Ilrlllnrnlnrnulminrtullrtl` ..iu11■unl■nn!rnn, - - _- .tBit 111■11111■IDlirlll/IilElllrlllr' .It/IrI1111rlllllrlpllrlll/r► - - uu rnmr�uwMm�i4nuign�u�11�11111■III/IrI1111rI11AlEll'1111t - - 1...)= _L..I! ,_, _1...1 , , I...IL..I I■.■I I■..II : - - .� am lox — ----L..I --1:a1= .■.11...1= I�...I - ;. . — min — ___ 1 _�spoil, I_J »I� , 19IOU T tc-')Pcn---51b1111y of ffic coadcf compllorce wilh oll s 'r bulldiV bulldinilr r • he , prior ProcceatIng w11h con,,O(uchon, D _ . /2 �,o 51 i ®®®® ®®®® 01011:10 1:10011 1301111 ❑o®o ®IJ k �2' fCyhf f/evatlon 'eai flevafion 5Gft1:.f,11811P a GENERAL NOTES: 1. ALL DIMENSIONS AND MATERIALS SPECIFIED ARE TO BE VERIFIED' 4. ALL STRUCTURAL' MATERIALS SHALL BE VOID OF ANY DEFECTS THAT BY THE CONTRACTOR AND ANY ADJUSTMENTS MADE ACCORDINGLY. DIMINISH THEIR CAPACITY TO FUNCTION IN AN' ADEQUATE MANNER. STRUCTURAL ENGINEERING' OR ANY OTHER' PROFESSIONAL SERVICES 2. ALL WORK SHALL BE COMPLETED IN COMPLIANCE WITH ALL THAT MAY' BE REQUIRED SHALL BE PROVIDED BY OTHERS UNDER APPLICABLE BUILDING, PLUMBLING & ELECTRICAL CODES. ANY SEPERATE CONTRACT AND TERMS. OTHER LOCAL, STATE AND / OR FEDERAL CODES THAT MAY APPLY TO THIS PROJECT SHALL BE CONSIDERED AS PART OF THE 5. FRAMING LUMBER SHALL BE NO. 2 GRADE SPRUCE-PINE-FIR OR BETTER,. CONSTRUCTION DOCUMENTS. 3. ALL WASTE MATERIALS AND DEBRIS SHALL BEREMOVED AND 6. FLOORS ALLNSHALLIONS BEC COMPLETELY FIREPLUMBING, TRICALCAULKEp TING, ETC.) THRU DISPOSED OF PROPERLY: C2? I • i w<MI.� Baga{as � pry GBTA{c. sl+eert p.t 40 r-gr! 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LVLS wtTt+ I Z Rows SCR.Ears e lG'1-PC- SEE GSEE DETA tt_ ---- — — — — — — — — T+P T'tP L-- t'1PL a-2xgPIJtLc Stiect D-3 AMC I'looi rfomiry P 5IMPS0 , WS L10-2 Woof rrarri� ------- - --� TSO ---�� T Sd P Poa-r a R?tc ua the ttr SG�tLF I/8"� - J rQ*C� Z•t.�,f x y Zs 1.u� 3 Row$ Ib WC. WAVC A•ruv RAartto xf✓��N IPldge Venl 2-12 lPldge 000rd NOTES: 1. ALL DIMENSIONS AND MATERIALS SPECIFIED ARE TO BE VERIFIED POOP G0N-'57TUG7-I0N; BY THE CONTRACTOR AND ANY ADJUSTMENTS MADE ACCORDINGLY. --- 12 2x10 iPaflcrs®/6"ac, j________-- X10 2. FOR ADDITIONAL FOUNDATION INFORMATION SEE FOUNDATION PLAN. 2x6 Go/lar T/cam®�2"o.e, L———_——__ I/Z"GDX P/ywood L,———————— Pell Poof/nq f aper I i X42 i hspho/t f5hin4/es I i troth P-58 Insulollon I 3/4"GDX P/y, I Gab/c i 142.9pi IPldge Venl 2-121Pidge 5�00rd W/Pro�;cr Venf I Nailed ff Glued I ���I `�' 1mpson T/es to 2x10 @16"o,c. L----J Each 1Poof r0fter 12 1P00I`GONSTIC UGTION. Floor Joist Vented.5off# 699 t%41 Kto P44re. 10 2x10 PaRer5 a 16"o,c, �ljQQT ��3Z 2x6 Gollar Ties a 32"o c. Acy t=aarg GDX Plywood ;' \*, WAt_L.GONSTI'UGTION: 2x6 Studs®16"Oz. - - - _-- >=e/t k�ooflnq Papel ' TaG P/ oo�� /tsphalf Shingles � P-2/lnsulat/on 9-164 P-4041UAV �;' Moiled ff Glued \\,\ 1/2"COX Plywood 2x10 ml6"o.c, Z /0 cl6"o.c, 5ir7pson Ties to !`loot Jo%t Oulld/nq Paper �- Geilinq Joist Each Poof rafler '5Idlnq;T,D,D, . Par7ily Pig, Vail}es Geillnq p �r 9'_9" IrJ v. t0-g 92-5/8"Pre-Gul i !! 3/4"TOG Plywood j Nailed ff Glued TGG Plywood � 8 2xIO 016 o.c. Trlple.1-.>ill Nailed-F Glued Floor JoistI -2x6 p,t, 2x10 6l6"ac. ! L 2 -2x6 kd, i Floor Jolt i W/-5/// ea/er I r-------------------I r------------------- r. o,d,f�nchor 13o/ts ;' i ------- i__________________ I 2x6 0/6 oc, I I I I I r �'-30- Knce wail 6'O" O.C. 'i i Insulation - I I I I I I I 12"t"ror?Corn,--f--, II I I II Ir Oo--c cnt Slab -I I a. Garagc 5106 Domp Proof/rg Wcl!Compact Gravel De/ow Grade h'w 45 �ro55 .5ed on l � mOr". = FOR ROOF S COA)STRUCrEpt G4P5r�, IN�TH TA00r- 'R VSSE g i2eOD• $I�CyI/'..lwrNG t�+UD Jnr", 4"swoop 4Ji atf>sr►><a�rlrtg tine ehcrvn 6 841-1 A1C,- 'r'O BE DF 5 EC A.1EP ANE3 �'1�AA�1» ' ;" to baa fn coteam me a ab Regd Ab Space I�E4`A{LEG, �!� l`EZI,155 fMi1G1F�IG11. N L ' E t 46 Q 7 0C. rat la t 0.02.3(1)of the 2X Stocking ® 16" o.c. /2111114 11•t3�� Maeedchuealte Gr�cl�ar8th S:vsfom at stud rim to first Joist ' t 1 , See P/anS and Sections I ,• 1 1 1 1 for Hurr/cone Clips ----- and •-- 1 r 1 1 and C®iling Rafter connections. ! NA F6 I jJ(� .�. �ta0 n2.//e p f3 M Q.G. � •y ' nSN ek7 _ C� 9 Toe fti1 ZX BiackJng �t M.t, t•' (3) - 8d nails (3) - Bd Halls 6"a., S t r p�vrm G(v51,6\ avwtsct Luny{lJ�v/l with Et A i res tU or 8 ecrmuis per block (typ.) Connect Drywol/ with �- ®{? {¢1P� COFLNCP� D�"I'xc,tt_ �OGPteW LGR+(jTH - - - �Lr! O.C.pmr A, 7?1 �4 - type W or 5 screws d4 12"o.c. {� fry t+�- 1 I 4 C tooz per ASM f C 1002 with o ' 2 x 4 B/ock/ng m/nlmum penetration of 5/8" erg S ���II ed roe mot/o 6 o e. at Hor/xantol Sheathing Joint �•�6tn+Ai 4I ?�. � FeW Connect Wall & Roof Sheathing da?_ 4�?� ?, !. .. 1 r .blotwifh 8d Hol/s 6� 6" o.c. C.panel edges and 4i 1 t�{ 7712" O.C. In the interiors. ZX Blocking 16" a.c. ' lils� Cli'Z'�OC6`CDGof stud rim to IJrsf Joist 7M�l�Alternate Attachment ' �. �y°x.la{� D/�" 16 Fo. 1 3/4" s�op/es _ 9 at 3' o.c. at'ponvi edges 15ilE(a,r tNG, {h-ttsF "�+4" Y70uiple BJock/ng 4?P{Ar 2t7►>f71F1_I and 6" o,c, of interiors Joist f NArtb(N�r WG:mCx•• ✓O/oE Gr • ander .� ihR 'JT&.a di I M 130 A R O .....•��"� ` � i gtRy07�,tr , ••' 'Intsrlcrr 5t�w{t Dt 7A it, E fANt'4 "Cow t;pRAOE.F Bd W/140 -Z kv,x 0.113" Stu f Gtl w1t�t lij 8d Toe Nall IID 6" o.c. RIM �oAgp 1!2°x 0.135" Rim ✓alst to plate (typ.) (3) - 16d Hafts 0 16"o.c. S[x lG' ' I ' w 14 eA.i I of Sraeewall into flL Q, eft 1tw`. 04v Is* •1ymTftli i 1 1 1 0.0 is Joist/Blocking 1 1 r 1 Ie!(Jyry 1 1 1 i Note. _ 1 1 1 1 Rkooa.{o•� All e Hornailed talwith Sheathing Joints G`145UM P8l"a�IlFJI P C5'/�Al/CLlldl EGE'►�119N to be nailed with Bd nails @� 6' o.c. fo Blocking unless otherwise ObAf � nate3dILo�F�/dY 4.p/ s io fi/oor Fr 1/1 to Floor Fr4nrlrrcy 2X Blocking 0 16" a.c. 'METHOD GB-GYPSUM WALL PANELS CONSTRUCTION at stud rim to first ✓olsrtWN�t1Ie ;m �3'/t' •►9{, 't"1415 M +oD APPt-t E5 Ta lsr� ► BRgceO Wq•Vt_ LI/v E `Z. IST FI.ohR f ed Toe Noll s" 2..c. Ian iaR IN + g�,pt:K TO $rLCOND 940 Or; Rlm Joist to Plate 8d toenail (tyP•) Joist ; u v s" o.c, DiAIL r. 1 i ""- 5L0r_r-(WC. 0F 1409-i2oNrAL S NEAT«1tNG e 4pM 1/2" dio. AJ07 Anchor acif with nut and washer. 3 t/2"mfJ p t N7S 1.9 Reaul{zriD PCA (3 Rgcgp { • n. - 12'max. . o, I.y Q{ L L l Nf~5 L- '3, (=1 C.STI Flz oe " ;..,•° from end and max. 6'-G1" 2..c each plots 2",9:, .° �. ' -p•.'• or as shown on the drow/ngs. 3 Bevr op FG.0 CR ° minimum 2 Bolts per wall plate. ;,�.°� GRRprCrF CORatfc`R DE,TAr(• '.w.- P.•.- .� q{-{. dT►+ER L1 tvF,S Go N oT 1 {L E{ 6ivtp Q LvcK-tNG Pervendicular 6d Halls - 2 1/2" x eOW'ta.t•�r Parallel > to F/aor Framing 16d nalls - 3 1/2"x o.1ss" to Floor Framing 6AP ziA1101sr4► NOTE:THIS DRAWING IS SCHEMATIC FOR THE WALL BRACING FOR THIS PROJECT'IS BASED ON SECTION b02.10 OF THE 8�EDITION a`i o r,,or PURPOSE OF SHOWING REQUIRED CONNECTIONS � � Braced Wa/J Pane( Additional Connections •.SEE PLANS FOR LAYOUT,DETAILS,FRAMING OF THB MASSACHUSETTS STATE BUILDING CODE FOR 1&2 FAMILY DWELLINGS, for 2.1/ exterior wg/ls 602. 1d OTHER WALL BRACING DETAILS AND ALL OTHER IRC2Q09 AND ALTERNATIVE DESIGNS AS INDICATED ON THE DRAWINGS.DO NOT Z.6L n c,i a METHOD CS-WSPSTRUCTURAL REMODIFY DOOR OR WINDOW OPENING SIZES AND LOCATIONS OR HEIGHTS AND CONTINUOUS STRUCTURAL PANEL SHEATHING q REQUIREMENTS LENGTHS OF WALLS.AS INDICATED ON THE ARCHITECTURAL DRAWINGS WITH OUT � , n� OVAL OF THE ENGINEER AS THIS MAY RESULT IN NON-CONFORMANCE WITH TETE WALL BRACING REQUIREMENTS OF THE CODE.. ot: All other nailing not shown to beLAWREMCF oma' In conformance with table R602.3 (1) HMOLD N Of the Mass. Code 8th Editions PROJECT: Tg LAWRENCE H. OGDEN.P.E. WALL BRACING O l-&T l C.o Z- g bx F o RD ST 19$EAST FAIN STREET TPLI C4 O r-TA t t.,. on i GEORGETOWN,MA.01833 i N 09-711; .4 IV 0 w2. {2• r,A L le o 978-352-831'8,Cel1978-502-5921• DETAILS FOP, Q{{.•L t.U M 8,41L P �urn r4arar t� . �Xtaraca /Aaadar to*Mayo tablet A60Z10,4W mRd Ffe"ROMV,441 4 41 oanaw d P47S/ avow ret P4AV cell has/c4ft opdnlav wleh reg of pAPW porda/v rcp l�laem aad mmqumcd taneron etas a,�rxne ad w 9"a s k ~' Comm .yy w/t/t Z/Y 4w AodMIt It .A/ka P.0 IS ` b Q 3 t N%P%C u L SrA 3 ro• , n - did t3/re+s ;;«� a + ♦ «+�i+i+ « ..«*+ ffi!A{'7ypf1 BtI'� a t t 9f1lCtF-A a+ « e a + °ef ♦ +�°o+'ii°� A i and or opawro r .add/trem!atuda tura dd rarw Neo krt an lrmkdm Pace of wA/l t rer D04V t � �Lr"ac, eqp,.;J /n p 4wt~to gap or wall t if Iammd6ad t t n u n u tt r t ' 8 h n Goawaot t3/farmtla W fo Nom• u n n U �� Cvakaetat ' +' 'to 1�90w it It " 11 II II i) wlth ed Mala ra 9 ,&a q with 2 Amw/Fa'Blmka P3+aecr/jytltas l�paJr�rr i U u n u 9 �p AW& m.3`as 1 Awwd am 1/ C AP046 rERE= {@ faPrd 40+haws ti n ev S/o¢ "Vw•h' oeng iPWHJ/R ; u e3bceehrrp/Jo ii t .b a t lecweron wrthln /dd/o: " '; ii IL Fourtamt rorc 46d SIk w A Nana tad; u Marla-All OW410,P"CA ' l¢ t tor Mnrcmr I ad%* t n It dills t 04mkhw a 1 0.01 GbubJm C)mw it it Covxt�t 5t:anb mrth 7 now i hmaf/al n n It t! ICILY no//*a 4"v.4, t t fol-B✓@"4nclaear bolts " ©C�r wnh.a//?"x a Ila"X 8/I6"lL Platin " $/nprpn BrNG/4 8ttttp rim >�• 7 (a»rJ •4 /old o st maw,and ,$r�'fi�s�thln l�' ulrt�rint8 ala sx e �- of wa/r paaynra •4 Raba;with a"L r I a or wa// �s" s (m1n J rM Caw— 20" 2O•, I 2a„ L 1 1 Ramat Pcr •""t."*+rw� '.; tntmrrradieto ParLN/rte a 0 it txd>k --'Y 00416:01400 L7oww r,�.° 0/07 hold dwNrw lr -� o• C��rac�� 17yc�r ;� ;� � °° t��,� CondlErt�nas t„�.im►/t�E/eine 1. S'1114Y9�8 L •i7 a Own °- P4mW Amob 4- 09d4C9r1 1JO, wmeerf/ . two '•';';,,I °: ld"•+1�tOl� r'h/B OWN/ /B tachVM ft/c, " waiwa /ro }C v na FJ orad G.(ell LiA% Alm C.&roll sow l 0w ,,sthan Pier/ for Go/exnld/Gtir�Ii'E/ lel/ P&W1 /dPM /G 13EICn ���,jH 4F,y� l man!t7'to!1' S f 'a.�•'MOaw411iurianuo nwwarMow" waaawa !r/>�u!/Xed/mq�th Or 970-90 �.'1. l Gf��t�l� 6Er;"8 .1 'a r�I1 Aor 04PA LAWN 1Ci@ G a.M°'""r w�w`wunw•p ° nr"mw"'°"'" bVp�lr le Howisad MAW�Y/e9/7 CG "B1�E/ CCJ?T fbA UD N k ten' axrawe�u.�r rw,ron X 42 iarth a mar/aa w p Lor/ py( e «r"w r�a�.oaw t t6rticdl op4nrncJt al 9.0. 0 � M pw"".wir�'..r�mrw�iarreeouuMa�.`� ' Ory 1D I "► DOOR PFN LCT l 6aZ BbocFoRo STREET .'. T :s NOR'hi f4a+DOc�� (_ Mq Comb �,�.Q1$33 WtcT*op Pr-4 5j4 l!$ 97&•352-01.3vCOB 9"-M-5921 • Foci 6tL� c.uf�n6ARD 19. WALL BRACING FOR THIS PROJECT IS BASED ON SECTION 602.10 OF THE 8'"EDITION OF STRUCTURAL GENERAL NOTES: THE MASSACHUSETTS STATE BUILDING CODE FOR 18x2 FAMILY DWELLINGS,IRC2009 AND ALTERNATIVE DESIGNS AS INDICATED ON THE DRAWINGS,DO NOT MODIFY DOOR OR WINDOW OPENING SIZES AND LOCATIONS OR HEIGHTS AND LENGTHS OF WALLS AS I. ALL LVL BEAMS SHALL BE BOISE CASCADE VERSA-LAM,OR APPROVED EQUAL INDICATED ON THE ARCHITECTURAL DRAWINGS WITH OUT APPROVAL OF THE Faom 3P+4c.tN� Crag c-iaG� ALL INSTALLATION TO BE PER THE CURRENT MANUFACTURES ENGINEER AS THIS MAX RESULT IN NON-CONFORMANCE WITH THE WALL BRACING +D • RECOMMENDATION'S AND SPECIFICATIONS.E=2,000,000 PSI,.Fb-3100 PSI, REQUIREMENTS OF THE CODE. ALL COLUMNS DESIGNATED ON DRAWINGS AS VERSA=LAIv1TO BE BOISE 20. THESE GENERAL NOTES AND ALL THE PROJECT DRAWINGS TO WHICH THEY ARE A PART OF ; .Z wow$ CASCADE 1,7E 2650 Fc,DO NOT KNOTCH OR CUT LVL BEAMS OR PENETRATE ARE INTENDED FOR THE SPECIFIC LOCATION AND PROJECT INDIACTED. 2` I o WITH ANY HOLES EXCEPT AS ALLOWED BY MANUFABTURER DO NOT DEVIATE FROM THE DETAILS,DIMENSIONS AND MATERIALS SPECIFIED WITHOUT 2. ALL LVL INDIVIDUAL MEMBERS IN BUILT UP BEAMS OF THREE MEMBERS OR APPROVAL OF THE ENGINEER. fi LESS TO BE CONNECTED TOGETHER AS SHOWN ON DRAWINGS. 21. AT THE COMPETION OF THE FRAMING WORK'THE LICENSED CONSTRUCTION SUPERVISOR IS TO PROVIDE A CERTIFICATION TO THE OWNER THAT ALL WORK WAS PERFORMED � oc.. " 3. ALL LVL INDIVIDUAL MEMBERS IN BUILT UP BEAMS OF MORE THAN THREE ACCORDING TO THE DRAWINGS,DETAILS,NOTES,MANUFACTURES INSTALLATION +0 MEMBERS TO BE BOLTED TOGETHER WITH 3 ROWS OF t/2" dia. BOLTS, REQUIREMENTS AND THE 8TH EDITION OF THE MASSACHUSETTS BUILDING CODE � -- ANSUASME STANDARD B18.21-1981 @ 12"oc. STAGGER OR OFF SET EACH ROW BOLTS SHALL BE PLACED IN SNUG HOLES,WITH A MIND"EDGE DISTANCE OF FOR I&2 FAMILY RESIDENCES. 2" AND WITH STANDARD WASHERS AT BOLT HEAD AND NUT,OR AS SHOWN ON DRAWING. ENGINEER: LAWRENCE H.OLDEN P.E. +, o - 4. ALL LVL BEAMS TO BEAR ON BUILT UP POST OF A MINIMUM AS LISTED BELOW 2 .198 EAST MAIN STREET42 {- TO 3 LVLS USE 3"X 3.5", 4 LVLS USE 4.5"X 3.5", 5 LVLS USE 6"X 3.5"OR ON GEORGETOWN,MA.01833 POST AS DESIGNATED ON DRAWINGS OR ON STEEL AS SHOWN ON DRAWING. 978-352-8318, cell 978-502-5921 pct w C a iv tr°rj;4 4 �+ 5. BEARING ENDS OF ALL BEAMS TO BE BLOCKED 14,5"SOLID EACH SIDE FOUNDATION NOTES . 6. ROOF SHEATHING TO BE ATTACHED TO FRAMING WITH 8d NAILS @ 6"OC. @ -PANEL EDGES AND 12"OC.FOR ALL FRAMING MEMBERS NOT AT PANEL EDGES. FOUNDATION ANCHOR BOLTS NOTES: 7. WALL SHEATHING TO BE ATTACHED TO FRAMING WITH 8d NAILS @ 6"OC, @ 1/2"DIAMITER WITH WASHER 7"EMBD. 1) SCREWS TO I39 FASTEN MASTER TRUSS LOK 3 Y,"MIN. 12"MAX.FROM END OF EACH OR SIMPSON SDW SCREWS PANEL EDGES AND 12"OC.FOR ALL FRAMING MEMBERS NOT AT PANEL EDGES. PLATE A!ND MAX.6ft-0 in O.C. 2 x Pi�xK ��STq�4 SEE DRAWING$FOR LENGTH-OF SCREW AND CORNER STUDS TO BE ATTACHED TOGETHER WITH 16D NAILS @ 12"OC. OR AS OR AS SHOWN ON THE DRAWINGS. A�� gpAp t V1 ON CENTER SPACING. SMWN ON DRAWINGS 8. GYPSUM BOARD 7 O BE ATTACHED TO FRAMING WITH TYPE W OR TYPES FOOTING REINFORCING "' 5 2) FROM ONENE SID ALL 2 ME.LVL BEAMS To HAVE SCREWS J SID CONTINUOUS FObTINGS 3#4 BARS 5«hPSoN 3) ALL 3 OR 4 MEMBER LVL BEAMS TO HAVE SCREWS IN ACOORDANCE WITH ASTM C 1002 @ 12"OC.AND SHALL PENETRATE 18"LAP HORIZONTA L r5z sreA? a SCREWS FROM ONE SIDE UNLESS FRAMING A MIN.OF 5/8" INDIVIDUAL FOOTINGS wrrH 8 10 d+� i " N n,aie.s 'to aaar�.R � OTHERWISE NOTED ON DRAWIIdGS, 9. ALL OTHER FRAMING TO BE PER THE BTB. EDITION OF MASSACHUSETTS STATE 4#4 BARS WITH 3 in COVER EACH WAY >3 I b�K s+ 135 4) USE TYPE OF SCREW SPECIFIED DO NOT ORAS SHOWN ON THE DRAWINGS. � .� sevD sran,p Ta f'l' SUBSTITUTE AS CAPACITY MAY NOT BE BUILDING CODE,IRC2009.FRAMING LUMBERftr-875 psi, E= 1,300,000 psi MAP Ta f+l ADEQUATE, 10. ALL JOIST AND BEAM HANGERS TO BE BY SIMPSON STRONG TIE MINIMUN WALL REINFORCING C£hJ04 Joi sr O TIE, HORIZONTAL AL50 vsrt AT INSTALLATION AND NAILING TO BE PER MANUFACTURERS RECOMMENDATIONS, 2#a BARS TOP cEauw �f5f �P H z.%A• s DE'T'AIL OF CONNECTING i P iv E LVL MEMBERS TOGETHER SPECIFIED HARDWARE MAY REQUIRE SPECIAL ORDER ALLOW SUFFICIENT WITH 18 in.LAP AND MID HT of WALL D lSin #+vi CORNER BAR: ' LEAD THIS FOR DELIVERY. USE SIMPSON HURRICANE TIE AT THE EAVE END � �.'" ate` OF EACH ROOF RAFTER OR TRUSS.ALL EXTERIOR HANGERS AND HARDWARE 10"FOUNDATION WALLS EXCEEDING ANGc R TO BE CORROSION PROTECTED PER PRESSURE TREATED LUMBER THE BELOW LISTED CRITERIA MAY N --- „ •16 NAILS REQUIRE VERICLE REINFORIPING _ 1 ^ MANUFACTURES RECOMdvHINDATIONS AND SIMPSON STRONG TIE CONSULT ENGINNER OF RECORD PLATE T6 RECOMMENDATIONS,OR STAINLESS STEEL, 611 " WALL HEIGHT UNBALANCED FILL HT. RIM pyNy O r O CL s, . p. ..w� 11. TSE CONTRACTOR SHALL BE RESPONSIBLE TO OBTAIN ANIS'FOLLOW THE MANUFACTURES LATEST INSTALLATION RECOMMENDATIONSAND 9ft. 6tz >Ia�-rasre�r". �� TQ 12. ALL SUPPORTS UNDER BEAMS TO HAVE SUFFICIENT UNiNTERUPTED S Eft. sft. e 5 SPECWICATIONS FOR LVL BEAMS , STEM WALLS Oft: VPPORT jN RAISED nGA'"'E= RAFTER 'Y►1R1PdT ACeti'rttl YQyp(�t'C"1't3t1V/l1l,;,. gGIZ'RW$ ALL THE WAY DOWN TO THE FOUNDATION OR ONTO LVL BEAM. WALL REINFORCING GRADE 60 A'I" 13&M {,dA)k*e 1Z$ 13. BRING ALL SCREPANCIES,PROPOSED DEVIATIONS AND ACTUAL FIELD CONDITIONS THAT ARE DIFFERENT THAN DEPICTED TO THE ATTENTION OF THE SLAB REINFORCING 6.6 W2.0*W2.0 ENGINNER PRIOR TO PROCEEDING WITH CONSTRUCTION. CONCRETE 14. COORDINATE ALL WORK WITH THIS DRAWING AND ALL OTHER.PROJECT FOUNDATION WALLS AND FOOTINGS DRAWINGS INCLUDING SHOP DRAWINGS. ''° AND BASEMENT SLAB 3000 PSI AIR ENTRAINED 15. ALL STEEL COLUMNS,BEAMS AND PLATES TO BE A-36 STEEL. F'c $ Eget GARAGE AND EXTERIOR SLABS 16. ALL BIGFOOT SYSTEMS TO BE INSTALLED PER INSTALLED PER BIGFOOT F'c 3500 PSI AIR ENTRAINED INSTALATION MANUAL 17. LOADS FIRST FLOOR LL 40 PSF,SECOND FLOOR 30 PSF,DL 15 PSF,ROOF GROUND BEAM R ON 1/2 in PLATE S N o SNOW LOAD 50 PSF,DECK LL 40 PSF WIND LOAD 100 MPH.EXPOSURE B. BEAMS TO /BEAR ,n�PACE SIDES AND 18.'FOUNDATION TO BE CARRIED DOWN TO UNDESTUR BED SOIL HAVING A END OF ALL BEAMS — -- ,------------ MINIMUM BEARING CAPACITY OF 2 TONS/SQ FT L OT I G bZ $c*,FoRD sr , 3 LAW"NCE H.OGDEN.PX GENERAL NOTES ti oaTM PrivDov E F. m,4 198 EAST MAIN STREET FOR -S{t.L A.vM64 ft P GEORGETOWN,MA.'0.1833 LUT..CONNECTION DETAILI 978-352-8318,ceR 97840;-021 II , EXTERIOR DECKS,PORCHES&STAIRS 9-10-13 i ,. ', P�GtA7(, S Pact ae SPAGtNG f•.spae.e u�4� �t PO DESIGNED FOR S „ ..... . ..!. . DEC PORCHES AND EXTERIOR STAIRS TO BE HE J ,I O LOADS. FOLLOWING L S. ! �, '� - - ♦ LIVE LOAD 40PSF.,SNOW DRIFT IF APPLICABLE AND WIND LATERAL AND UPLIFT FORCES, t4 GUARD AND HANDRAILS:200 LBS.IN ANY DIRECTION AT ANY POINT. ,1 S1Mp9PaM1� . . .. p� COMPONENTS,S S. ORIZO ALO AN AREA EQUAL . • � INFILL0 LB HORIZONTAL N ARE QUAL TO 1 SQ,FT };D�. T►lRii?FiQ...TVO STAIR TREADS THE GREATER OF 40 PSF OR 300 LBS CONCE Nj.dT, z \ht IiC�t SND OF: LD1G6 S NTRATED LOAD. DECK CONSTRUCTION IS COVERED IN SECTION R502.2a OF THE 8*EDITION C NNE c7 d c 3 ��It A�.r 'rl }S 7 -F�. OF THE MASS STATE BUILDING CODE FOR RESIDENTIAL CONSTRUCTION. L ED E rz >r,c OTE:NEW SECTION R502.2.23 REQUIRES A DECK LATERAL LOAD - „ CONNECTION-SEE ALSO MASS.AMEDMENT TO SECTION R602,10 FOR MW i d•- �� .8(+4• Game R, 5P�ce vc ( PS pec(t L� UNCONDITIONEDPORCkIES. p tl REFER T MERICAN FOREST&PAPER ASSOCIATION AF&PA �ww.a� core _. D E..G K. � 11 o c ]i O AM ) Y I A RESCRIPTIVE RESIDENTIAL WOOD DECK CONSTRUCTION GIIDE(DCA6^09) p L•r.i4- 5 ►Q►L 1�\- t t a t p �„y\pL 5 a c . AS REVISED MAY 2013, MASS AMENDMENT 8301.1.1. j CONSULT A REGISTERED DESIGN PROFESSIONAL FOR ITEMS THAT ARE NOT { ; -� .c K.-.-i •5to<uP e�RS. w t CIE q-" o c• IN COMPLIANCE WITH THIS GUIDE. � �_t" �+ �4' w im SIMPSON STRONG-TIE ALSO PUBLISHES HELPFUL GUIDES TO DECKT G wItoL 13 LLET4NCONSTRUCTION. j �rn,,rrSt 1 S 2 z' 3 fiat.._ . ang DEc.K_ LmD,_, e.rP cvsT,pr LLA t i ON ( p- D URS bti A?VO 011.4 E!2. ALL WOOD FRAIVIING MATERIALS TO BE PRESSURE TREATED. pFT t pspN i p�at�: tCbtt1 i TISs3Aq ..Ll�""� R ALL EXTERIOR CONNECTIONS TO BE CORROSION PROTECTED. j • � �..� f 1--_, _ I (R .C C�f'^ !` ��'��.�'V ., • .. ; . . '.. .L..._:... _ _ . CONTRACTOR TO COORDINATE TYPE OF CORROSION PROTECTION t.T.4°. .I. 9i ,.._ .(�.R .tkU�c�',R.. _Gd�.I�1� ,R! A.I. . ._ �� Q ' j G k L DG E R. coN�1ecp D REQUIRED WITH THE TYPE OF PRESSURE TREATED LUMBER SUPPLIED FOR EXTERIOR FRAMING AND . ' RIOR THE CONNECTION MANUFACTUERS !_., .•.....;.. Fkhl B-{1�h►!�i Gi A*► v\eA P R CSG F'tN I L , • Gay--•,�''�'- '!f�'1r';' PoacK Dq,T+a�Ls RECOMMENDATIONS. ' Narf ��R'C" 6NeLE v.nio {tib Wp•' �P, t1j�LK 'V�.�S� �lf��. -f�le�1*�•1? MPso '"'"' 5 5 uze �`}T A AGK U StC�ni I re HAve.Lp WINj 4 To -CV.vTeR.1401 OF iwr.vD SPfG�.CbrTo APFT� F�wr CDNNLGItO t R _.... _,•. REAM ?Ago s"% o.PC 2 44ps OR 1L'!�EJctSirwG GTvpS {�{ 114=H I F AC61RR G6(v GApC FOP.6+G POsl' i P+•AN R•C$•op,q GC,4 G4P5 FoR 4-4-Pas (.EDGE2 tom I .. . ALL. G"+tv er-rORS T0,1112- •• L4 WIHGW+i �F61 SIMPson! MNx" S1(15r'NG RIM SDA KO 9 i Rall tF AAPDt.t'cA',$L? 2xt0 .Lt!,O Eft 1 vsL pNLY RAST fSv@RS Fe^OVe- 6%01NG p i 5PR4tf 1E'R Rok�MKS�" eo..vDCm0.g q.,,p•GONNEGT t ALL LUM913& -ro OM VtiO EXISTiA.M Mov58 NOT£t. {>Rc.SuR� T'Re—zo f��OGef� carrµ CONTRaG-('oF{ TO ' r�'I 2 Rows 9✓8 A'cGURATM'Ll( LOWEt S.IMPeoN eco. a=pR 6<F PD'>r i S"EE FP_ 4M►e3G p�•Aiv G P/vase OCA. IRaR 4+4- Posy wASreN Ma�TLR OT--,P5 To 'leve VRP, 1tN Of 4 L oueR Lo i< L.eroat:a Lo K'',l Nsr04"Ano�J # Pf/r 6/epoon AG cow Cr\RDdR ,4`r 0G. An Ori-TILFLE D ON i` 8!R �tnnP90/v JOtsi'NAM1JGL'R LV$L1035 Loxds+',nea 5'Tvp$ � '•SCE � 6)f 6 'Pc6 PIAN P{\\R OF S,mPsnN j AC.4 oa pG6 4' C-4-PS F OK ix& P*$T o /+eb ASV64 BASF spa a4 _— Ata,OVAce 4- eAPs PoR 4w4 po.sr tvollL t• CAREFULLY •o y Cott 1-P 4 0- GSA P`S 6•GPosr Np-rnPy swe-weEa 6lf7R� PRocceo,n/G CS RF' ii 6,NPcoiv Av.v 64 Po4 6.G Po1r • , . t� s•.tts vE�'au �aN n+D"e' q a OMR EN6 P/r4V dglMI „ r. AccaMpc lSNeP /}5 Si{pW}� 1`3/ggW .w BOLT ''• '`�.e�q p �+ 4 yy zR Ivp Er—A L. 5c�ctIyn A RDoT ;, � N,P. p �'pR 'R C:T': 4 + �.or t6 o Z 13 oxf2=0 STA et r .. uNotslvRea,7! 19 T NQ"re5,, NoptTa. R+uDov CR Mq s c. CEO ► ' 't V;.kA.011833 ' egNA U �1 9'1$+3 2-8 8;ge11998• 02.5921 opt e e-r. L-V MS A IL D NORTH T � E o w n o � ._ : :_ ���. , Andover No. ver, Mass, d ao4 1212-01 T O LAN! COC NIC MI M.KN ` 7S U BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System .X" ..T �4 ,., BUILDING INSPECTOR THIS CERTIFIES THAT ................ ... ..... ......................... ........................ ....[�� . .. � r Foundation has permission to erect .......................... buildings on .�L �. "���,,,///1��K// �. ......................... � � Rough to be occupied as .......... .. .. ........ .. !.... . ....... ...................................:.............................. Chimney provided that the person acceptin his r it shall in every respect conform to the terms of the 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 CONSTRUCTION TARTS Rough Service �' "641rflb� ...................... Final BUILDING 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. Ll LfP Jfl C? Property HERS Unknown Rating Type: Projected Rating Certified Energy Rater: Eric Wilder Lot 1 540 Boxford St. Rating Date: 5/5/2015 Rating Number: North Andover,MA 01845 Registry ID: Projected Rating: Based on Plans- Field Confirmation Required. Estimated Annual Energy Cost Use MMBtu cost Percent HERS Index: 53 Heating 32.8 $1485 49% General information Cooling 6.3 $89 3% Conditioned Area 2537 sq.ft. House Type Single-family detached Hot Water 8.1 $432 14% Conditioned Volume 20352 cubic ft. Foundation Unconditioned basement Lights/Appliances 22.5 $885 29% Bedrooms 4 Photovoltaics -0.0 $-0 -0% Service Charges $136 4% Mechanical Systems Features Total 69.7 $3026 100% Heating: Fuel-fired air distribution,Propane,96.0AFUE. Cooling: Air conditioner,Electric,13.0 SEER. Criteria Water Heating: Instant water heater,Propane,0.82 EF,0.0 Gal. This home meets or exceeds the minimum criteria for the following: Duct Leakage to Outside 98.00 CFM25. Ventilation System Exhaust Only:55 cfm,21.0 watts. Programmable Thermostat Heat=Yes;Coot=Yes Building Shell Features Ceiling Flat R-50.0 Slab None Seated Attic NA Exposed Floor R-30.0 Vaulted Ceiling NA Window Type U-Value:0.320,SHGC:0.300 Above Grade Waits R-21.0 Infiltration Rate Htg:3.00 Clg:3.00 ACH50 Foundation Walls R-0.0 Method Blower door test Eric Wilder Conservation Services Group Lights and Appliance Features 50 Washington St. Percent Interior Lighting 100.00 Range/Oven Fuel Propane Westborough,MA 01581 Percent Garage Lighting 100.00 Clothes Dryer Fuel Electric 5D8-836-9500 Refrigerator(kWh/yr) 550 Clothes Dryer EF 3.01 2003-017 Dishwasher(kWh/yr) 256 Ceiling Fan(cfm/Watt) 0.00 9901142 REM/Rate-Residential Energy Analysis and Rating Software v14.6.1 This information does not constitute any warranty of energy cost or savings.0 1985-2015 Noresco,Boulder,Colorado. The Home Energy Rating Standard Disclosure for this home is available from the rating provider. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): sw, .•Awes' &jiC Address: AI W&- 5 6 j( Ave U m l f`�7/ City/State/Zip: ` Q gf 7 Phone 4: Lre you an employer?Check the appropriate box: Type of project(required): ❑ I am a employer with 4. ❑I am a general contractor and I have hired the sub-contractors 6. 1ew construction employees(full and/or part-time).'* ❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. VkWe are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp,insurance required.] ty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. w irn employer that is providing workers'compensation insurance for my employees. Below is the policy and job site grmation. urance Company Name: icy#or Self-ins.Lic.#: Expiration Date: Site Address: City/State/Zip: ach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 tp to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of ,stigations of the DIA for insurance coverage verification. 111 areby certify under the pains and enalties ofperjury that the information provided above is true and correct. i - iatur / p Date: ne#: )fficial use only. Do not write in this area,to be completed by city or town official. :ity or Town: Permit/License# ssuing Authority(circle one): .Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector .Other `.nntartPprenn- Phnnaif- 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 be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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-contractor(s)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 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"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, .3lease do not hesitate to give us a call. he Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Jndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fav A 617..777_77d9 fes! Massachusetts-Department of Public Safety f Board of Building Regulations and Standards Construction Superisor .. License:CS-076124 cE TS William H Lumbars ,•;. 14 Bemis Circle IMMIF ' Tewksbury MA 6187 71W Expiration Commissioner 02/1812017