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HomeMy WebLinkAboutBuilding Permit #224 - 672 MASSACHUSETTS AVENUE 9/23/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Y Date Received --�&� Date Issued: IMP RTANT'Ap' P icon' ist-complete all items on this page LOCATION _ rint PROPERTY OWNER l Print MAP NO PARCEI.O :5 ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne amiI Addition Two or more family Industrial eration No. of units: Commercial epair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed-District a er ew 7SCRIPTION OF WORK TO BE PERFORMED: Afi s �AAAA __II d-& fLd VIS Cc 2lMDV 4, -301 �h RC0 CAGn;f �, ►� lg� ec �`/er��, Identifi tion Plea a TYYPPE�or Print Clearly) OWNER: Name: ire j Foy- _rn n S i� u�_h o ri Phone: ,! a -coq -,I V-10 Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: °Home Improvement License: Exp. Date: 9 J ARCHITECT/ENGINEER 1 r *:e j n� C, Phone: S—6y3 Address: ; Reg. No. gG 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: $ 1 00 C) Check No.: .z. -9 7 Receipt No.: 22 �4 NOTE: Persons contracting with r isterea contractors do not have access to the gu anty fund Signature of Agent/Owner Signature of contractor i Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public SewerSwimming Poolsannngassageoy - Well FR 1 •p 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 Signature COMMENTS HEALTH Reviewed on Signature COMMENTS , Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes �--'" no Located at.124 Iain Street �, f _�! Fire Department signatureldate COMMENTS F: Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine f NOTES and DATA– For department use) ❑ Notified for pickup - Date + _.—......................_.....................-_...........—.--........-........_..__..................__...................-_._..-...__._........._.............................—.............--........................_...............__............._ _ ._.... -.—......._ Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit t 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 i ❑ 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) Li Mass check Energy Compliance Report (If Applicable) o 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 Q 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) o 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: Doc.Building Permit Revised 2008 I Location Co No. 2 DateOf y 140QT: TOWN OF NORTH ANDOVER + s Certificate of Occupancy $ Building/Frame Permit Fee $ ti Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # V� 224 oding Inspector Date. ". NORTH44, TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING SSACMU5' This certifies thatat � has permission to perform . . ./t-.f �. . �.��!��.�. . . l�'. . . . • • • • plumbing in the buildings of . . . . ... . . . . . . . . . . . . at . . . .6. 7) . . r . . . . . . . . .,North Andover, Mass. Fee.F),.' v. . .Lic. . . . . . . . IZ . . ... . . . . . . ,!�: PLUMBING INSPECTOR Check # Fyt'X~ 8 2 7 8 , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) ac. ,Mass. Date 1 l- 3 20o L_Permit# P 2 f _ Building Location 6�2�%( AjL� Owner's Name c" Owner Tel# Type of Occupancy New ❑ Renovation t/ Replacement .❑ Plan Submitted: Yes ❑ No ❑ FIXTURES z z V) z z > N a B o a z ] o 9 t~ o z z z a F w 3 X oZ .p c4 Q w a d w Z A a z Q rx G1 or, w w .< x 3 oz A x O 3 .� x ¢ w w x w w x = o a z o N H o U x 6 .N G Q x to `�' ¢ Q . ¢ 0 0 ¢ a Q O < F SUB-BSMT BASEMENT ' y 1'T FLOOR t l ( I 2ND FLOOR t, 2 t 3"D FLOOR 4T"FLOOR 5'n'FLOOR 6TH FLOOR 7TH FLOOR TH Installing Company Name__bCjj1A4 / i Check one: Certificate Address Dfdr aT' ( 7 o Corporation O, J ❑ Partnership Business Telephone# 1�— L q*,) ❑Firm/Co. Name of Licensed Plumber INSURANCE COVERAGE: I have a current li ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Q/ No ❑ If you have checked yes,please tcate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe it issu for this application will be in compliance with all, pertinent provisions of the Massachusetts.State Plumbing Code and Chapter 142 of the Ge r L By i Signature of ed Plumber Title Type of License:Master Journeyman ❑ City/Town (dam APPROVED(OFFICE USE ONLY) License Number Date. . . ... ... .. ,10RTN TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION Oq 9 'tl9SSACHUSE�� This certifies that . .C.�""� !`: .��� . . . � .r� has permission for gas installation t.�: G? <<`�i{`° in the buildings of . . .a-� �F<�.cf . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . , North Andover, Mass. o� Fee. . i . . . . Lic. No::/°. /GAS INSPECTOR/ Check#` / `7 7007 �7 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) T D2f� f�td1 I[ ,Mass. Date o-� 3 200 Permit# Building Location G 7 Z- marts dtAe Owner's Name fle4 firm Cc�•,.�i�' Owner Tel# Type of Occupancy �f New ❑ Renovation Replacement ❑ Plan Submitted: Yes ❑ No ❑ FIXTURES ¢ a W O x W E o 0 J W �1 FO h a, a dU) U `baa z Q w J Q z W > z ¢ > O U O F J F c°m� z o z 0 � cpcl 2 O Cr M w 3 A C7 a UO 9 > A a SUB-BSMT BASEMENT 1ST FLOOR I x 2ND FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 1. 7T"FLOOR 8T"FLOOR -H+f+4]T Installing Company Name e. 1' 4C Check one: Certificate Address P,6), AD 70 % ❑ Corporation p a ❑ Partnership Business Telephone# DY -3 ) q— ! ( 3 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 1001 {. ;'vvyLj INSURANCE COVERAGE: I have a current jability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yes No ❑ If you have checked Vis,please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued faf this pli ation will b in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene I aw BY T wof License: Plumber Sigf at a of Licensed Plumber or Gas Fitter Title •G s fitter Master License Number Cityrrown •-Journeyman APPROVED(OFFICE USE ONLY) ilk F� C',.., ' � s >M - now WE ►K j >y� I`•� REScheck Software Version 4.2.2 Compliance Certificate Energy Code: 2006 IECC Location: North Andover,Massachusetts Construction Type: Single Family Conditioned Floor Area: 1232 ft2 Glazing Area Percentage: 10% Heating Degree Days: 6322 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: 672 Mass.Ave North Andover,MA Compliance:0.0%.Better Than Code Maximum UA:134 Your UA:134 1232 38.0 0.0 37 Ceiling 1:Flat Ceiling or Scissor Truss 59 Wall 1:Wood Frame,16"o.c. 1088 19.0 0.0 Window 1:Vinyl Frame:Double Pane with Low-E 108 0.350 38 SHGC:0.70 0 Floor 1:All-Wood JoistlTruss:Over Unconditioned Space 10 38.0 0.0 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 20061ECC requirements in REScheck Version 4.2.2 and to comply with the mandatory requirements listed in the REScheck Ins `'on Cheddist. Sig ture Date Name-Title t Report date: 09/21/09 Project Title: Page 1 of 3 Data filename:C:\Documents and Settings\Mother\My Documents\2008\2009\rae9-09.rck REScheck Software Version 4.2.2 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-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 Comments: Note:Up to 15 sq.ft.of glazed fenestration per dwelling is exempt from U-factor and SHGC requirements. Floors: ❑ Floor 1:All-Wood Joist/Truss:Over Unconditioned Space,R-38.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. 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. Sunrooms: ❑ 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. Vapor Retarder: ❑ Vapor retarder is installed on the warm4n-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 and Installation: ❑ 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 dearly 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 or outside the building are insulated to at least R-8. ❑ Duds in floor trusses above unconditioned spaces or above the outdoors are insulated to at least R-6. Duct Construction: Air handlers filter boxes,and dud connections to flanges of air distribution system equipment or sheet metal fittings are sealed and Ai , ❑ 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. Report date: 09/21/09 Project Title: Page 2 of 3 Data filename:C:\Documents and Settings\Motter\My Documents\2008\2009\rae9-09.rck 1 2006 IECC [energy Efficiency Certificate �( ambn Ceiling/Roof 38.00 Wall 19.00 Floor/Foundation 38.00 Ductwork(unconditioned spaces): p... �• MOMW Window 0.35 0.70 Door Water Heater: Name: Date: Comments: ~` -,0 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 Cade. Temperature Controls: C] 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. Certificate: El 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: Report date: 09/21/09 Data filename:CADocuments and Settings\Mother\My Documents\2008\2009\rae9-09.rck Page 3 of 3 W - _ LpT2 `, �.{ -17- 4DaDt sT- LOT 3 ' =1 PORtli - - iry6� 1 x — 1 - 249'1 MASSACHUSETTS AVENUE ASN OF ML9 JOHN S. LAURETANI y # 34311 4 MORTGAGE LEWER USE ONLY plotplans.com Drs LAURIERS LOL coNsTt771TLON BLYD,ROBE B PRANXIM MA OEM -. ... - (BOO)✓'&'F-BOD PA%..{fi0R)628-4011 MORTGAGE INSPECTION PLAN THERE ARE NO DEEDED EASEMENTS IN THE ABOVE REFERENCED DEED OR ADDRESS:672 MASSACHUSETTS AVENUE.NORTH ANDOVER,IIA ENCROACHMENTS%7TH RESPECT To LENDER;MRTHMARK MW EXCEPT AS STATED ON THE DEED OF RECORD SHOWN. ( ATTORNEY:MCELHINEY AND MATSON 09-426 OWNER:FIRST MORTGAGE STRATEGIES CROUP.INC. THE LOCATION OF THE DWEUNG AS APPLICANT,5ELFORD CONSTRUCTION. INC. SHOWN HEREON W IIH THE LOCAL IN DATE:9L2-212-009 SCALE: BY-LAWS IN EFFECT WHEN 1'=60' couNTY:ESSU NORTH CONSTRUCTED(PATH RESPECT 70 STRUCTURAL SETBACK REOUREUENTS _-- UNREGISTERED LAND DNLY>_OR IS EXEMPT FROM VIOLATION �LOOD HAZARD INFO:. DEED BOOK:11560 PAGE:192 ENFORCEMENT ACTION UNDER MASS.G.L :ONE- C DATED:VV1993 PLAN BOOK PAGe LOT(5):1 6:2 :OFAMUNITY PANEL'150Coe cm PLAN NUMBER:2286 OF NE LOCATION OF THE DWFJLING SHOWN REGISTERED LAND CERTIFICATE OF TITLE: )DES NOT FALL WDWN A SPECIALREGISTRATION BOOK: PAGE ASSESSORS MAP: WOO HAZARD ZONE,EXCEPT AS MAY IE INDICATED. I PLAN NUMBER: LOT(S): BLOCK: LOT: ENERAL NUIM-(1)THE DECLARATIONS MADE ABOVE ARE ON THE BASIS OF MY KNOWLEDGE,INFORMATION,AND BELIEF AS THE RESULT OF A MORTGAGE INSPECTION TAPE JRVEY,NOT 114E RESULT OF AN INSTRUMENT SURVEY MADE TO THE NORMAL STANDARD OF CARE OF REGISTERED LAND SURVEYORS PRACTICING IN MASSACHUSETTS.(2) ECLARATIONS ARE MADE TO THE ABOVE NAMED CLIENT ONLY AS OF THOS DALE(3)THIS PLAN WAS NOT MADE FOR RELO.4ONG PURPOSES,FOR USE IN PREPARING DEED ESCRIPILO7S OR FOR CONSTRUCTION.(4)VERIFICATIONS OF PROPERTY LINE DNMENSONS,BUILDING OFFSETS,FENCES,OR LOT DoNSWRARON MAY BE ACCOMPLISHED BY AN CCURATE INSTRUMENT SURVEY.(S)NO RESPONSIBILITY 15 ASSUMED HEREIN TD THE LAND OWNER OR OCCUPANT. r�rcars ��✓e� a�c�cfur t Board of Bneldin9 Kegittatio , and tants i Gonstructibn Supervisor License GS ' '. '- 14197 a � �a a EX13sretie�ti ;N/2010 T€# 2088' i A MARK FE, z a# 85 JOHNSON ST a � *�%, - � ✓ r: f NO AN©OVER,.MA 0?845-� Commissioner u ACCOR 0 CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 9/23/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION M.P. Roberts Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1060 Osgood Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR North Andover, MA 01845 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURED INSURERS AFFORDING COVERAGE NAIC# INSURER A: LLOYD'S LONDON BELFORD CONSTRUCTION, INC. INSURER B: 85 JOHNSON STREET INSURER C: NORTH ANDOVER, MA 01845 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAIDCLAIMS. 1NSR_ADD' LTR INS TYPE OF INSURANCE POUCY EFFECTIVE POUCY EXPIRATION POLICY NUMBER .-DATE(MM/DD(YYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY TBA 9/23/09 TO RENTED 9/23/09 9/23/10 PREMISES(E.occurrence) $ 100,000 CLAIMS MADE Fx_]OCCUR MED EXP(Arty one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENTAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY PRO LOC AUTOMOBILE LIAR UTY COMBINED SINGLE LIMIT ANYAUTO (Eaaccident) $ ALL 0 W NE D AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTNE OFFICERAVIEMBER EXCLUDED? E.L.EACH ACCIDENT $ (Mandatory in If yes,describe under aE.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.DISEASE-POLICYLIMTT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OFT HE ABOVE DESCRIBED POLICIES BECANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN TOWN OF NORTH ANDOVER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL MAIN STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR NORTH ANDOVER, MA 01845 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2009/01) -94, ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD.name and logo are registered marks of ACORD T i 1 * j �l. FORA 153 The Commonwealth of Massachusetts Department of Industrial Accidents FSEP 18 2009 Office of Investigations-Dept. 153 600 Washington Street-7th Morar,Boston,Massachusetts 02111 11, http://wivw.mass.govtdia 1 .' ! 1 §'TRIAL A4' S F DAVLT OF EXEMPT. MR CERITAIN C0RrQflA_TL Iss OFFICERS OR DIRECTORS Chapter 169 cif the Acts of 2002 amended M.G.L. c. 152, §1(4) by adding the following paragraph: "l leis chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation.Notwithstanding section 46,these provisions shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set forth in section 25C." Pursuant to M.G.L. c. 152, §1.(4) as amended, I/We the undersigned officers of: arA I LL (Name of Corporation and Address) each holding at least 25%of the issued and outstanding stock in said corporation, do hereby invoke the right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s) or director(s). ]/We the undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further, I/we the undersigned do understand that, should the above-named corporation hire or have in its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said corporation is required to obtain workers' compensation coverage for the employees) as prescribed by M.G.L. c. 152, §25A. I/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checked the appropriate box below my/our name(s) indicating my/our desire to be exempt or not to be exempt fro he provisions of M.G.L. c. 152. Signeder t 1 ins dand penalties of erjury: / 1 ig ature Print Name&Title Date(nam/drUyyyy) 1 wish to exercise my right of exemption or El I wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/yyyy I wish to exercise my right of exemption or ❑ 1 wish NOT to exercise my right of exemption -" n/,,dl m /yyyy�--j ' Signature Print Name&Title Date( _ ..... ❑ I wish to exercise my right of exemption or I wish NOT to exercise my right of exemption r Signature Print Name&Title Date(mm/M/yyyy- ❑ I wish to exercise my right of exemption or I wish NOT to exercise my right orexemption Note:AU ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. Instructions on back. Form 153-10-28-02 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 I Please Print Legibly Name(Business/Organization/Individual): C Address: 0109 14 A,, City/State/Zip: t�f c Xfr.(C%j VW6 Phone#: S O'S -S O Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. 1 7. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 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.❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] p—applicant that checks box.#1 must also fill out the section below showing their workers' onpoIicym-forma-tion. nformati^ t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u e pain d ties ofperjury that the information provided above 's tru and correct Signature:, Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• AORTH Town Of over No. Z Z y over, Mass., O � -LAKE COC MIC ME WICK y�. ADRATED PPat-`y l`S ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System // BUILDING INSPECTOR THIS CERTIFIES THAT � L.., �d CG�lS� uc:;;p ............4 .........t-.. ... . ................................. Foundation has permission to erect............................... buildings on .....��. ...... .. .. q,5. .� ..,......................... Rough p ,,D to be occupied as.............c o ... ......:.....��...�!/... ........ 451;. �/..........,,---- ........., ..1 .. ...... Chimney provided that the person accepting this permit sham every respect conform to the tefms 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 EXPMES 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 DEPARTMENT' Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. 6chna5 Structural Phone 978.465.6436 Daniel L. Gelinas, P.E. Fax 978.465.5160 579A North End Blvd. Email danl elg inas@comeast.net Salisbury, MA 01952-1738 October 26, 2009 Mark Rae, Belford Construction Inc 283 Washington St cell 508.509.9430 Groveland MA 01834-1008 Subject: 6��M North Andover MA -, Dear Mr. Rae; Per your request on 10.21.09 Gelinas Structural Engineering LLC (GSE) met you on site to observe the modified framing at 672 Mass Ave. Our comments are as follows: 1. Change 2- 2x12 first floor header spanning 8'-4"to two 1 3/4x 9 '/4 LVL's. Location is 1"floor ceiling at kitchen, actually 2nd floor framing 1 1"floor center line steel beam, keep maximum span 20 feet. It appears two locations will require footings/posts. Pervious drawings indicated add one footing only. Final room layout with wall removed reveals one post/footing currently is in place and span is greater than 20 feet on two sides Provided these items are completed the framing observed satisfied the structural requirements of the Structural Design drawings and the Massachusetts State Building Code 7th Edition One &Two Family Dwellings. JVk OF DANIEL L. �. QAC c� Very Truly Yours, 1=L►Ns STRUCTURAL � No.33994 VDaL. G linas, P.E. ry � Q framing observed 10-21-09 job 09124.doc