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HomeMy WebLinkAboutBuilding Permit #565-13 - 58 MOLLY TOWNE ROAD 2/19/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: v / Date Received Date Issued: l�' IMPORTANT:Applicant must complete all items on this page .LOCATION Le) I-_. .f PPROPERT�Y�OWNER ��t^-1-� t�Yld©Vey ��-�`1 C-0 r9: _ Print .100,16,.1 arkOld:Structure yes no; MAPFNO: PARCEL: ZONINGiDISTRIG tl-listoriclDistricf yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ew Building One family ❑Addition ❑Two or more family ❑ Industrial. ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic+ EI.Weli.:: ` a. f'Floodplain ❑Wetlands V1latershed Districf -Water/Sewer - DESCRIPTION OF WORK TO BE PERFORMED: � r ; Identification Please Type or Print Clearly) OWNER: Name: K>tAA (orQ Phone: TIE I /V 77,6 Address: CONTRACTOR Na-e: 1J Coc/�6. ( Phone: Z� .C/7�j ;2-2-7L ,odd gess; 2-1 Joknso n -. C i nc1 Q N- A 4oae- M a , n f e Y S LSupervisorrs,Construction,L'icense: 6350 3 Exp: 'Date: X,� Home ImprovementtLicense: Exp._ Date, ARCHITECT/ENGINEER L wre,►'i, Phone: 1' d 5Qa I Address: F—• IMA i N 5T Cm)rg'tovi n M cA Reg. No. 2-7:Z`1 LJ FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ � FEE: $ �(� s Check No.: ��V Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acc4Samped the guaranty fund rC � Signature of Agent/Ow .. _ Signature of contractor, Plans Submitted 11Plans Waived 0 Certified Plot Plan ❑ Plans Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPO Public Sewer 7 Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION Reviewed on I 3 Si nature Vu COMMENTS MA- UP—P Cf>� /a b0br'I�� ( '0 C� 6m n� w LA �a'l HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments---,- ____ 2 - 14-0 Water & Sewer Connection/Si nature Da:t7e :4W4- Driveway Permit DPW Towp_ Engineer: Signature: e7 Located .1 Os ood Street FIRE DEPARTMNT - Temp Dur�ister o e yes o Located .at;124 Main'Street- Fire Department signatureldate �G/U13 COMMENTS Dimension l q � Number of Stories: ZTotal square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: �� ` ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— (For department use El Notified for pickup - Date i E [ { Doc.Building Permit Revised 2010 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 o 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 9 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 o 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: Doc.Building Permit Revised 2012 Location �� � G //� / C7C(_//�f ✓'j No. ro Z Date /3 • ' TOWN OF NORTH ANDOVER � ��,x•�Lrrr 146` . • Certificate of Occupancy Building/Frame Permit Fee $ �C' 2_� D � Foundation Permit Fee $ /!JU Other Permit Fee $ TOTAL— Check#w 26157 iailding Inspector '► OMO eTN qry V O R SS4C HU5E CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 565-13 on 2/19/2013 Date: December 10, 2014 THIS CERTIFIES THAT THE BUILDING LOCATED ON 58 Molly Towne Road —Lot 12A MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: North Andover Realty Corp. 58 Molly Towne Road North Andover, MA 01845 Building Inspector Fee: PrePaid $100.00 Receipt: 26157 Check : 20500 i � NORTH own of A O - 0 No. ti r, h ver, Mass, O 4 E � cocw1c"�cnaw:cK 7.1'AOR'{TED "'v Cl) BOARD OF HEALTH ERM T LD Food/Kitchen Septic System p s BUILDING INSPECTOR THIS CERTIFIES THAT ..............:. ................. .................... ..... ...... :..:..f:. � .F::.................. Foundation oun ' has permission to erect .......... buildings on ................... . ... .....:........� ........ ................ Rough to be occupied as ............ ........:.�.. ........_ ....:... ...�... ..................... ..'_-...........'.`.....: ..... . ...... < _f` f "1 Chimney provided that the person accepting thispermit shall in every respect conform to the terms of the application Final !�"". leg 11 D 114 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. _ Finalg4sCI�- PERMIT EXPIRES IN 6 MONTHSELECTRIC�L IN ECTOR �i�,�'��„�i�� � '�� „ ''. •�<;�,' ter?, � UNLESS CONSTRUCTION STARTSRough I Service ...............................:.'...:.........:.................................. inal �, 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 DEPART ENT Until Inspected and Approved by the Building Inspector. Burner Street No. Ifx;_�,�— Smoke Det. SEE REVERSE SIDE GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip- Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. Girls-solid brick or steel plate bearing at foundations '/"air space at sides in foundation pockets. C Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. of required glazing shall be openable. Bedrooms required min.20x24 egress window or door. Vent"attic spaces-"proper vent", soffit and required ridge vents. ;v="Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish Smooth parging, clean joints, 8"solid @ combust. _ DECKS: Lag to house, provide flashing. + Rails min. 36" high, Baluster max space 4"on center. At Over 8'above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. t FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. 4 Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee- $30.00(Be Ready). Certificate of occupancy required prior to occupying structure t NvR TFi Town Of ... . r to No. * -T iq verMass,Zh � COC NIC N[WICK � �d AOR�7E0 P'QP,`�5 s � BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..... ` l . ........................................... BUILDING INSPECTOR � Foundation has permission to erect .......................... buildings on :.::'..... C?//, ........... ..... :.?!Y.f.............................. � f Rough to be occupied as ............. .�1.,?:I.�.�.� �....� .�' f.:'.'s:::: ................................................................... Chimney provided that the person accepting this permit 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 Rough VIOLATION of.the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service J .......�. .. 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 D/et.� Ogden Engineering 978-352-2858 p.1 LAWRENCE H. OGDEN,P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978 352-2858 cell: 978-502-5921 June 11,2014 Mr. James Carroll North Andover Reality Trust 66 Spring Hill Rd. North Andover, Ma. 01845 RE: Lot 12 ## 58 Molly Towne Rd,North Andover Dear Mr.Carroll As you requested I conducted a site visit 6/9/14 to re-7ew 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 by G. Brubo Associates dated 3/14/13 with the framing plans sheets A- 6 and A-7 certified by me 10/31/13.at the time of this visit the house was framed,the roofing, siding, and garage door trim were in place. Based on the above site visit and based on what I could visibly see. I can certify that to the best of my knowledge the LVLs members and 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, provided the following minor work is performed. All other framing requirements of the drawings and code,including but not limited to materials; nailing schedules,blocking,connections, manufacturers installation requirements and other details are the responsibility-of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call, Yours truly, Id_� SOF rence H. Ogden P.E.Structural 27765 �4- y � Qras o ANAL EN�'� Enter construction cost for fee cal - North Andover Fee CalCulatlon Construction Cost $ 562,500.00 m $ - $ 6,750.00 Plumbing Fee $ 843.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 843.75 Total fees collected $ 8,537.50 58 Molly Towne Road 565-13 on 2/21/12 New SFH NORTH oven of _E ndover nw ver, Mass, COCMIC MIWIC/t S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System N���� n �d��� BUILDING INSPECTOR THIS CERTIFIES THAT ......... .. y ` Foundation has permission to erect .......................... buildings on ... ...... Rough to be occupied as ........... �L(:S.y. i ...,1 .r. ... ........... .z1f....�.�.:. ........ ....... Chimney provided that the person accepting this permit shall in every respect conform ifthe terms of the appli tion 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 CONSTRUCT RRTS Rough Service ............. ..... .�'Ir�r. ... ......�..t:�................. 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. SEE REVERSE SIDE CREScheck Software Version 4.4.0 NJ( Compliance Certificate Project Title: COLONIAL HOUSE Energy Code: 2009 IECC Location: North Andover,Massachusetts Construction Type: Single Family Glazing Area Percentage: 18% Heating Degree Days: 6322 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: 12 MOLLY TOWN N.ANDOVER 0184 Compliance:29.3%Better Than Code Maximum UA:570 Your UA.403 The%Better or Worse Than Code index reflects how close to compliance the house is based on code tradeoff rules. It DOES NOT provide an estimate of energy use or cost relat ve to a minimum-code home. Assembly Gross Cavity Cont. Glazing UA Area or or D•• Perimeter Ul-Factor Ceiling 1:Flat Ceiling or Scissor Truss 2288 38.0 0.0 Wall 1:Wood Frame, 16"o.c. 69 3298 21.0 0.0 153 Window 1:Vinyl Frame:Double Pane with Low-E 525 0.030 16 Door 1:Glass 84 Basement Wall 1:Solid Concrete or Mason 0.030 3 rY 2288 30.0 0.0 162 Wall height:8.0' Depth below grade:7.0' Insulation depth:4.0' Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other calculations submitted with the permit application.The proposed building has been designed to meet the 2009 IECC requirements in REScheck Version 4.4.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. Name-Title Signature Date Project Title: COLONIAL HOUSE M' Data filename:C:\Users\JERRY\Documents\REScheck\jim carroll.rck Report date: 02/17/13 Page 1 of 4 CREScheck Software Version 4.4.0 NJ( Inspection Checklist Ceilings: ❑ Ceiling 1:Flat Ceiling or Scissor Truss,R-38.0 cavity insulation Comments: Above-Grade Walls: ❑ Wall 1:Wood Frame, 16"o.c.,R-21.0 cavity insulation Comments: Basement Walls: ❑ Basement Wall 1:Solid Concrete or Masonry,8.0'ht/7.0'bg/4.0'insul,R-30.0 cavity insulation Comments: Windows: ❑ Window 1:Vinyl Frame:Double Pane with Low-E,U-factor:0.030 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: Doors: ❑ Door 1:Glass,U-factor:0.030 Comments: Air Leakage: ❑ Joints(including rim joist junctions),attic access openings,penetrations,and all other such openings in the building envelope that are sources of air leakage are sealed with caulk,gasketed,weatherstripped or otherwise sealed with an air barrier material,suitable film or solid material. ❑ Air barrier and sealing exists on common walls between dwelling units,on exterior walls behind tubs/showers,and in openings between window/doorjambs and framing. ❑ Recessed lights in the building thermal envelope are 1)type IC rated and ASTM E283 labeled and 2)sealed with a gasket or caulk between the housing and the interior wall or ceiling covering. ❑ Access doors separating conditioned from unconditioned space are weather-stripped and insulated(without insulation compression or damage)to at least the level of insulation on the surrounding surfaces.Where loose fill insulation exists,a baffle or retainer is installed to maintain insulation application. ❑ Wood-burning fireplaces have gasketed doors and outdoor combustion air. Air Sealing and Insulation: ❑ Building envelope air tightness and insulation installation complies by either 1)a post rough-in blower door test result of less than 7 ACH at 33.5 psf OR 2)the following items have been satisfied: (a)Air barriers and thermal barrier:Installed on outside of air-permeable insulation and breaks or joints in the air barrier are filled or repaired. (b)Ceiling/attic:Air barrier in any dropped ceiling/soffit is substantially aligned with insulation and any9 P a s are sealed. (c)Above-grade walls:Insulation is installed in substantial contact and continuous alignment with the building envelope air barrier. (d)Floors:Air barrier is installed at any exposed edge of insulation. (e)Plumbing and wiring:Insulation is placed between outside and pipes.Batt insulation is cut to fit around wirin and lumbin r sprayed/blown insulation extends behind piping and wiring. 9 P g'° (9 Comers,headers,narrow framing cavities,and rim joists are insulated. (9)Shower/tub on exterior wall:Insulation exists between showers/tubs and exterior wall. Sunrooms: Project Title: COLONIAL HOUSE Data filename:C:\Users\JERRY\Documents\REScheck\jim carroll.rck Report date:02/17/13 Page 2 of 4 0 Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U-factor of 0.50 and the maximum skylight U-factor of 0.75.New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Materials Identification and Installation: F1 Materials and equipment are installed in accordance with the manufacturer's installation instructions. F-1 Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R-value. ❑ 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 and glazing U-factors are clearly marked on the building plans or specifications. Duct Insulation: Supply ducts in attics are insulated to a minimum of R-8.All other ducts in unconditioned spaces or outside the building envelope are insulated to at least R-6. Duct Construction and Testing: LI Building framing cavities are not used as supply ducts. Ll All joints and seams of air ducts,air handlers,filter boxes,and building cavities used as return ducts are substantially airtight by means of tapes,mastics,liquid sealants,gasketing or other approved closure systems.Tapes,mastics,and fasteners are rated UL 181A or UL 181 B and are labeled according to the duct construction.Metal duct connections with equipment and/or fittings are mechanically fastened.Crimp joints for round metal ducts have a contact lap of at least 1 1/2 inches and are fastened with a minimum of three equally spaced sheet-metal screws. Exceptions: Joint and seams covered with spray polyurethane foam. Where a partially inaccessible duct connection exists,mechanical fasteners can be equally spaced on the exposed portion of the joint so as to prevent a hinge effect. Continuously welded and locking-type longitudinal joints and seams on ducts operating at less than 2 in.w.g.(500 Pa). Duct tightness test has been performed and meets one of the following test criteria: (1)Postconstruction leakage to outdoors test:Less than or equal to 8 cfm per 100 ft2 of conditioned floor area. (2)Postconstruction total leakage test(including air handler enclosure):Less than or equal to 12 cfm per 100 ft2 pressure differential of 0.1 inches w.g. (3)Rough-in total leakage test with air handler installed:Less than or equal to 6 cfm per 100 ft2 of conditioned floor area when tested at a pressure differential of 0.1 inches w.g. (4)Rough-in total leakage test without air handler installed:Less than or equal to 4 cfm per 100 ft2 of conditioned floor area. Heating and Cooling Equipment Sizing: Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code. For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2009 IECC Commercial Building Mechanical and/or Service Water Heating(Sections 503 and 504). Circulating Service Hot Water Systems: Circulating service hot water pipes are insulated to R-2. Circulating service hot water systems include an automatic or accessible manual switch to tum off the circulating pump when the system is not in use. Heating and Cooling Piping Insulation: C] HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-3. Swimming Pools: ❑ Heated swimming pools have an on/off heater switch. Pool heaters operating on natural gas or LPG have an electronic pilot light. Timer switches on pool heaters and pumps are present. Exceptions: Where public health standards require continuous pump operation. Where pumps operate within solar-and/or waste-heat-recovery systems. Heated swimming pools have a cover on or at the water surface.For pools heated over 90 degrees F(32 degrees C)the cover has a minimum insulation value of R-12. Exceptions: Covers are not required when 60%of the heating energy is from site-recovered energy or solar energy source. Lighting Requirements: Project Title:COLONIAL HOUSE Report date: 02/17/13 Data filename:C:\Users\JERRY\Documents\REScheck\jim carroll.rck Page 3 of 4 • 4 ri A minimum of 50 percent of the lamps in permanently installed lighting fixtures can be categorized as one of the following: (a)Compact fluorescent (b)T-8 or smaller diameter linear fluorescent (c)40 lumens per watt for lamp wattage—15 (d)50 lumens per watt for lamp wattage>15 and—40 (e)60 lumens per watt for lamp wattage>40 Other Requirements: Ll Snow-and ice-melting systems with energy supplied from the service to a building shall include automatic controls capable of shutting off the system when a)the pavement temperature is above 50 degrees F,b)no precipitation is falling,and c)the outdoor temperature is above 40 degrees F(a manual shutoff control is also permitted to satisfy requirement V). Certificate: Lj 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.The certificate does not cover or obstruct the visibility of the circuit directory label,service disconnect label or other required labels. NOTES TO FIELD:(Building Department Use Only) Project Title:COLONIAL HOUSE � � � Report date: 02/17/13 Data filename:C:\Users\JERRY\Documents\REScheck\jim carroll.rck Page 4 of 4 t �J( 2009 IECC Energy Efficiency Certificate Ceiling/Roof 38.00 Wall 21.00 Floor/Foundation 30.00 Ductwork(unconditioned spaces): �.• „ Window 0.03 Door 0.03 NA Heating System: Cooling System: Water Heater: Name: Date: Comments: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information PleasePrint Leizibly Name (Business/Organization/Individual): N04�1 ✓�OV e 1 `eo,f 4•• COT Address:_�(o S�('l ✓t� �I QC� 1�n Cr c'�ll P�� City/State/Zip: AJow r (Vl rA 01G14-'I Phone#:_ 1 )a J58 QbS7 Lre u an employer?Check the appropriate box: Type of ect(required): I am a employer with�_ 4. ❑ I am a general contractor and I 6. ErNew construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet.# ? ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• rl Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 1311 Other 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 a new 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 an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 9rmation. urance Company Name: A-55X_ 1a4J �E Q l V V_r s lw s (IO icy#or Self-ins.Lid.#: AyJCC-301 oZ 3 LJO i o* (V)2: Expiration Date: 3 13 }q Site Address:_ 4�2, City/State/Zip: w•P`yi&oft_C r,4>9 O)g f J 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 Lp to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of estigations of the DIA for insurance coverage verification. P hereb cert alder the pains and penalties of perjury that the information provided above is true and correct. iatur G^- " Date: ) 3 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Other '.nntart Pvrenn• PhnnP#- 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, )lease do not hesitate to give us a call. he Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727.4900 ext 406 or 1-,877-MASSAFE Rasr�f M 7-777..7749 02/11/2013 13:48 9786833147 PAGE 01/01 DATE(MMIDDNYYY) AE' CERTIFICATE OF LIABILITY INSURANCE 2/x,1/2013 THIS CERTIFICATE IS ISSUED A9 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,' EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), RIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT. If the es'rtifloate holder IB an ADDITIONAL INSURED,the P0111CAIe8)must be entloraed. If SUBROGATION IS WAIVED,aubJect to the torms and condltiotts of the policy,cortaln pollclos may require an endorsement. A statement on this cortlflcate does not confer rights to the certificate holder In Ilea ofsuch endorsement(s). PRODUCER NAME: FAA M P ROBERTS INS AGCY INC NE E,L. (978? 683-8073 AIGNo:(978J 683-3147 1060 Osgood Street ADOREss:sandi robertsinsurance.00m North Andover, MA 01845 INSURER(S1 AFFORDING COVERAOB NAIca INSURER A;ASSOCIATED EMPLOYERS I CO INSURED NORTH AND OVER REALTY CORP. INSURER s INSURER C. 66 S01ING HILL ROAD INSURER D: NORTH ANDOVER, MA 01845 INSURER E INS RER F; COVERAGES _ CERTIFICATE NUMBER: REVISION NUMBER: THIS I$TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWIT14STANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY Bre ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INBR POLICY NUMBER 7DDIYYYV M IYYYY LTR INa LIMITS TYPE OF INSURANCE GENERAL LIABILITY t ACH OCCURRENCE $ COMMERCIAL 0=-NERAL LIABILITY PREMISESs occurwan $ CLAIMS-MADE El OCCUR MED EXP(Any one parson) $ PERSONAL&ADVINJURY S GENERAL AGGREGATE $ FOGN 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ PRO• $ POLICY LOCINGLE LIMIT AUTOMOBILE LIABILITY EA aecitlent S BODILY INJURY(Per p0mon) A ANYAUTO ALL OWNEDSCHEDULED BODILY INJURY IFer aacldwL) S AUTOS UAMAGE NON-OWNED Per accldant $ HIRED AUTOS AUTOS S UMBRELLA LIAR OCCUR EACH OGGURRENOE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ 9 DED RETENTION$ STAT U- OTN- WORKERS COMPENSATION YLIMrr ER AND EMPLOYERS'LIABILITY YIN WCC5010734012012 03/13/12 03/13/13 E.L.EACH ACCIDENT $ 500,0001 ANY PROPRIETORIPAFTNERIEXECUTIVF. ❑ NIA OFFICIMMEMBER EX(:LWFD? INmnduWN in NHl E.L.DISEASE-EA EMPLOYEE$ 500.00 It Yea,dasaribeunder E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF O'ERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,0 morn space iB requlfmd) F*AX: 976-655-4760 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORT)B AMOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 OSGOOD STMT ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01645 AUTHORIZED REPRES T p euokw 01989-2010 ACORD CORPORATION. All rights reserved, ACORD25(2010105) The ACORD name and logo are registered marks of ACORD �It••.t�hu,rth - DC;wrtlilt.fit „f Ntihlic `,.ti'et% Bn,tr•tl of Builtlinv, FRct�ul.ttinrt. .tnd `+tanu.trth Construction Supervisor License CS 63503 JAMES V CARROLL 21 JOHNSON CIRCLE ,r NO ANDOVER, MA 01845 Exprrahr-n. 7/19/2013 ( mnu„i nn r Tr'= 687 Office 4Mn�mer .tf Toru r�y�¢ JHOME IMPROVEMENT CONTRACT Regulation t+ '*a- -Registration: 171245 1'1''Expiration: 3/1/2014Type' Individual CARROLL V.JAMES CARROLL JAMES 21 JOHNSON CIRCLE NO.ANDOVER, MA 01845 — Undersecretary