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HomeMy WebLinkAboutBuilding Permit #546-2016 - 70 Main Street 5/1/2018 BUILDING PERMIT 06o Dr 6'�ti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION :T _ b Permit No#: Date Received AAO'°"`"` � R�reo�P •l5 SSACHus�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION t0 6aV"delr5 ( '4 PROPERTY OWNER ��C��l, �' {�drQ"l-,A&r, L�� Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential )(New Building ❑ One family ❑Addition XTwo or more family ❑ Industrial ❑ Alteration No. of units: 14 ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other mes �Me l . 41a INS DESCRIPTION OF WORK TO BE PERFORMED: co A�Tv 0414 trey` �eAa &-r L`,- 14 Iden ' ication- #lease,Type or Print Clearly OWNER: Name: Vit A.A S UA .?A-c S ULPhone: �rZ� ° ���1 •��� Address: I� , AAAA Ak 0) 5 d v Contractor Name: ��e�o CS' S Phone: 8 6 ?,� Email: w"IL E vvk co dest n Address: l ��►vi Qui1 ry Supervisor's Construction License: CG- (OS 181 Exp. Date: -7 It 17 Home Improvement License: h2' Exp. Date: ARCHITECT/ENGINEER �a CZrc�gS� S°�- l Phone: Address: I 51 hn 6avAxt kvxJw OA- 0*0 Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.0 PER S.F. r Total Project Cost: $ , FEE: $ r Check No.:&,q / ,� Receipt No.: NOTE: Persons contracting w't unregistered contractors do not have access to the guaranty fund arnT"w..4 5�`���.�'' +��` :�u F a + t ,+FAa.u,n� z 4t. ��,r$ng "+Sx." +: t.. .,. s.r� r..�-.w,....,,,.,...•mc: ..._._. ._. .___-c... .<..,, ..,..„ ..,.<,.....: .,..,.ter .......... _. ...._._- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On ((� `� Signature COMMENTS_ s Per 4494'-, dakd 1.6-201,5- 3, / CONSERVATION Reviewed on Signature' �. CO ENTS HEALTH Reviewed on D Z� ! Si nature /, . CO M�ENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Con nection/si nature& Date Z4 Driveway Permit DPW Town Engineer: Signature: Located t84 Osgood Street �FIRE DEPARTMEN,i "'T mp}Du fier onsite>,. yes. �I � n'b' a'`.,.f •,. e �xgi � 4 •t A A -i +1$l 'di to Y's —.1 '•. Located at124 P C, FirewDepa men signature/date r) 'r 1 f rel ai e',�S..d P, t r'+r •'S> r' i I��,� .AePxe - ,1 SP S ` a..lip wkt 2',i. ,5 �r d,�,. P'°.e,, r Fk,•. t ..^ _ tid t'ikky ' a�`f{3*I klwli COMMENTS: FORTH Town ofAndover . ... O �-�- w" 0 No. h vee, Mass, /��� Al coc"Ic MlWKK - S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ,J�..f4.� .. �'.� : �'.`:.2.!!�l`�f 'Z'�� BUILDING INSPECTOR 67 SaU yy C���-r`S' Foundation has permission to erect .......................... buildings on ..S.i.................................................................... . 1 7.... ........ ................................. .. �� Rough to be occupied as ........................... �`G.`. ......� CJI ... f.�.. 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS�CONSTRUCTION STARTS Rough \ Service ...........;. ..... � ............................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy.Buildin 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. ?.�. Wf.rh.f %`" >»�'fi Y .,t Uri✓+ 1 rr p' 7"2,�. L "'�)^1�?)>r�r 7_yy� ::.;kva�� .-f,;; �I=+� ♦4gJt 9' � f h'Y a u i a r'�,G� ,A rt N,ry�iy c:�'�F{r�q'+�' 1• i �m T�:a-^�M�>Y^1d k� S.NP r ��;, �r X�- i w,/,y`f:1,.W''�n+`7 yCixr`�}f...a,A�.7.' upY'�:j.n.f;iCx!"��rz$!`arO~.-=��1?-f w�.kl..x..;yt�.7;•I�,a.`nr?r?..+N;.xr�n'"4.-...8 1l"..f.°.�L', l.�,atFr.r'7'W. 7T . � 1+ Y .f. tixGase '..I1,kx.{dvh'.{Yr a.F�Jch.`l�ca„�I.�',a:.`i,:S..to'ti3"t'x5w�e`.,Rt1Jv'.•).wri a+9't?.'Y�'1]'(+f itnJa Wx1iV�nSk i,.'�uEh,--.z�';w_•FC`3�"a t''�ryr"9r`,:�.1��'��I.wi"�l 1tt�az r1����'Nr.j n�'f i�s'dil�-':�5a7�i--�r,.�5'-"f,f`.5'ir',��'!f.y5r F'n��1aS�,p�A.'a*,r�•1a3�rr'sv.�>.t:ly,�raa�:+;.y,Fry�ai.oe,k.�Sr5 7'�r�Aw^"sr.�en 4p5y,n..�rnth'A3��.-'hkFD.,,.�u�k'.m.{f.L�+,.0.r.."��;'"'iai"rG,-v,��.�r1s aw7r,ss�,+�'��ZMti&�"�,.\ r x F`aG w� ..... N?" J l a'w)`a��',•r:.J�y^.'':'.��hh AurJ�y R„';A���.L.`t�ert „IA'noF,,(xalVlll n >i . ,� "k L'/:+uh„�r r4�i�,lr --�.v., 4. ^r �' � ram � "� �^ a..rm'�. r �i '7".. �Y°,td �. »s^ Ir�n�;r y'�' 1!" e5�-a ri 3-�.� r(-d�'✓.:.a°7�1 NafF1',,.t }..j..�nr�' J+.r*p rrttkY il vi.�� �,°"�� �--, r 4r alf.:t+c' A 4,F�.r ")'✓ ...�.>y. F ��-;.d"1"" r '�z ti :(�S.r �{! r �ac�>���K � ;x 1 t 'i. i z.� � � 43�e r� � -�fjuhanna�4'E Hoch�RA-- . `S-rr'?dy��,�.$�5'^'t1,. �.,ti��,1,�!I��r'�e sdro :"7r��.�, r� yr s� F•y\!r .; 'ca .mss `r ��s �mf'.'a.`!��� :F��Y''� rA�ArF�����`I�{�'&'�''j s��tdP•(`�3.vy..r7yr 'j M t� x November 2, 2015 North Andover Board of Health North Andover Town Hall 1600 Osgood Street, North Andover, Ma 01845 Re: Bradstreet on Main Attn,Susan Sawyer, Please accept this memo as my Affidavit as an amendment to my Building Permit Architectural Affidavit given to the Building Department for the issuance of a Building Permit. I have never had to submit a special one to the Board of Health and do not have any special forms. The 15 DU building under construction shall comply with the requirements of the Department of Public Health Human Habitation Code MGL 105 CMR 410.000. Exception: When completed,the building will be in compliance with the occupancy requirements, however I cannot certify that the continued operational maintenance of the building under the habitation code will be continued. ���p ARCM, Signed: �� �o,Lacs o� S x N°'4A 53 W V" 4 o woMPco Joseph D LaGra e,AIA e FAL7H OF MP Joseph D LaGrasse and Associates, I 1 Elm Square, Andover, Massachusetts,01810 One Elm Square T 978.470.3675 1420 Celebration Blvd. Andover,MA 01810 F 978.470.3670 Celebration,FL 34747 AA26001333 www.lagrassearchitects.com NonTp I V ry ill ll.r 1'Ivn1 n t111Lv v r,n OFFICE OF BMDING DEPARTMENT 400 Osgood Street 4`R�;�o;;�� $ North Andover,Massachusetts 01845 a'sac►ausE D.Robert Nicetta, Telephone(978)688-95454 Building Commissioner Fax (978)688-9542 CONTROL CONSTRUCTION- SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01845 I, T614e- 0 fl� La6r"-s� ,HEREBY CERTIFY THAT I THE BUILDING CONSTRUCTED AT !;ay"Jef-5 ';+ DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: w�,�crer:�e-rr•� 44 AUTHORI SIG o I ' No.4153 �. ANDOVER DA to2 y i S } a MA :x REGIST 3 N: NOTE: ENGINEER"WET STAMP"MUST BE AFFIXED TO THIS FORM Control Construction Form revised It 15.2004 BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLAN"G 688-9535 Generated by REScheck-Web Software Compliance Certificate Project 39-67 Saunders St., N. Andover Energy Code: 2012 IECC Location: Essex County, Massachusetts Construction Type: Multi-family Project Type: New Construction Conditioned Floor Area: 15,408 ft2 Glazing Area 16% Climate Zone: 5 (6499 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: 39-67 Saunders St Willard Perkins Mark Yanowitz North Andover, Massachusetts Bradstreet Partners,LLC Verdeco Designs LLC 01845 28 Andover St 1 Elm Square Andover,Massachusetts 01845 Andover,Massachusetts 01810 (978)475-5400 978-409-2217 wperkins@hearthstonerealty.com mark@verdecodesigns.com . . Compliance: 16.6%Better Than Code Maximum UA: 1411 Your UA: 1177 The%Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. Envelope Assembiies Gross Area Cavity Cont. Ceiling: Flat or Scissor Truss 15,408 0.0 49.0 0.020 308 Wall:Wood Frame,16in,D.C. 7,830 20.0 5.0 0.044 287 Window:Vinyl Frame,2 Pane w/Low-E 1,215 0.300 365 Door:Solid 63 0.200 13 Door: Glass 21 0.300 6 Floor: Unheated Slab-On-Grade 290 10.0 0.684 198 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 2012 IECC requirements in REScheck Version 5.5.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. - i& z-7 }6, Name-TitleSi a u Dat Project Title: 39-67 Saunders St., N.Andover Report date: 10/28/15 Data filename: Pagel of 8 REScheck Software Version 5.5.0 Inspection Checklist Energy Code: 2012 IECC Requirements: 100.0% were addressed directly in the REScheck software Text in the "Comments/Assumptions" column is provided by the user in the REScheck Requirements screen. For each requirement, the user certifies that a code requirement will be met and how that is documented, or that an exception is being claimed. Where compliance is itemized in a separate table, a reference to that table is provided. Section Plans Verified Field Verified # Pre-Inspection/Plan Review Value Value Complies? Comments/Assumptions & Req.ID 103.1, Construction drawings and ❑Complies Requirement will be met. 103.2 documentation demonstrate []Does Not [PR111 energy code compliance for the ❑Not Observable 0 building envelope. []Not Applicable 103.1, Construction drawings and ❑Complies Requirement will be met. 103.2, documentation demonstrate ❑Does Not 403.7 energy code compliance for ❑Not Observable [PR3)1 lighting and mechanical systems. []Not Applicable 141 Systems serving multiple dwelling units must demonstrate compliance with the IECC Commercial Provisions. 30..2.1, Heating and cooling equipment is Heating: Heating: ❑Complies Requirement will be met. 403:6 sized per ACCA Manual S based Btu/hr_ Btu/hr ❑Does Not jPR:2jz on loads calculated per ACCA Cooling: Cooling: ❑Not Observable Manual J or other methods Btu/hr Btu/hr approved by the code official. ❑Not Applicable Additional Comments/Assumptions: 11 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N. Andover Report date: 10/28/15 Data filename: Page 2 of 8 Section Plans Verified Field Verified # Foundation Inspection Value Value Complies? Comments/Assumptions & Req.ID 402.1.1 Slab edge insulation R-value. R- R-_ ❑Complies See the Envelope assemblies [1`01)1 ❑ Unheated ❑ Unheated ❑Does Not table for values. ❑ Heated ❑ Heated ❑Not Observable ❑Not Applicable 303.2, Slab edge insulation installed per ❑Complies Requirement will be met. 402.2.9 manufacturer's instructions. ❑Does Not (F02)1 ❑Not Observable ❑Not Applicable 402.1.1 Slab edge insulation ft _ft ❑Complies table for Envelope nvelvaluo a Assemblies [F03)1 depth/length. ❑Does Not ❑Not Observable ❑Not Applicable 3..0 ❑Comlies Requirement will be met,3 Z.1 A protective covering is installed P• q [FOiI] to protect exposed exterior ❑Does Not insulation and extends a ❑Not Observable minimum of 6 in.below grade. ❑Not Applicable 404.8: Snow-and ice-melting system ❑Complies Exception:null. [F01.2] controls installed. ❑Does Not ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: 11 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N.Andover Report date: 10/28/15 Data filenarne: Page 3 of 8 Section Plans Verified Field Verified # Framing/Rough-In Inspection Value Value Complies? Comments/Assumptions & Req.ID 402.1.1, Door U-factor. U-_ U-_ ❑Complies See the Envelope Assemblies 402.3.4 ❑Does Not table for values. [FR1]1 []Not Observable ' ❑Not Applicable 402.1.1, Glazing U-factor(area-weighted U-_ U-_ ❑Complies See the Envelope Assemblies 402.3.1, average). []Does Not table for values. 402.3.3, ❑Not Observable 402.3.6, ❑Not Applicable 402.5 [FR2]1 -10, 303.1.3 U-factors of fenestration products ❑Complies Requirement will be met. [FR4]1 are determined in accordance ❑Does Not with the NFRC test procedure or ❑Not Observable taken from the default table. ❑Not Applicable 402.4.1.1 Air barrier and thermal barrier ❑Complies Requirement will be met. [FR23]1 installed per manufacturer's [-]Does Not instructions. ❑Not Observable ❑Not Applicable 402.4.3 Fenestration that is not site built ❑Complies Requirement will be met. [FR20]1 is listed and labeled as meeting ❑Does Not AAMA/WDMA/CSA 101/I.S.2/A440 ❑Not Observable or has Infiltration rates per NFRC ❑Not Applicable 400 that do not exceed code limits. 402;4,4 IC-rated recessed lighting fixtures ❑Complies Requirement will be met. [FR16:]2 sealed at housinglinterior finish ❑Does Not and labeled to indicate s2.0 cfm ❑Not Observable leakage at 75 Pa. ❑Not Applicable 403.2.1 Supply ducts in attics are R- R- ❑Complies Exception: null. [FR12]1 insulated to >_R-8.All other ducts R- R- in unconditioned spaces or ❑Not Observable outside the building envelope are ❑Not Applicable insulated to>_R-6. 403.2.2 All joints and seams of air ducts, ❑Complies Requirement will be met. [FR13]1 air handlers,and filter boxes are ❑Does Not sealed. ❑Not Observable ❑Not Applicable 403.2.3 Building cavities are not used as ❑Complies Requirement will be met. [FR15]3 ducts or plenums. ❑Does Not ❑Not Observable ❑Not Applicable 403:3 HVAC piping conveying fluids R- R- ❑Complies Requirement will be met. [FFt17]2. above 105°F or chilled fluids ❑Does Not below 55°F are insulated to>_R- ❑Not Observable 3. ❑Not Applicable 403.3.1 Protection of insulation on HVAC ❑Complies Requirement will be met. [FR24]1 piping. ❑Does Not ❑Not Observable ❑Not Applicable 403A.2 Hot water pipes are insulated to R- R-_ ❑Complies Requirement will be met. [FR18j2 zR-3. ❑Does Not ❑Not Observable ❑Not Applicable 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 1 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N.Andover Report date: 10/28/15 Data filename: Page 4 of 8 Section Plans Verified Field Verified # Framing/Rough-in Inspection Value ValueComplies? Comments/Assumptions & Req.ID 403.5_ Automatic or gravity dampers are ❑Complies Requirement will be met. [fR191Z. installed on all outdoor air ❑Does Not intakes and exhausts. i ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: i i 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N. Andover Report date: 10/28/15 Data filename: Page 5 of 8 Section Plans Verified Field Verified # Insulation Inspection Value Value Complies? Comments/Assumptions & Reci.ID 303.1.. All installed insulation is labeled ❑Complies Requirement will be met. jIN13jz: or the installed R-values ❑Does Not provided. j ❑Not Observable ❑Not Applicable 402.1.1, Wall insulation R-value.If this is a R- R- ❑Complies See the Envelope Assemblies 402.2.5, mass wall with at least 1/i of the ❑ Wood ❑ Wood ❑Does Not table for values. 402.2.6 wall insulation on the wall ❑ Mass ❑ Mass ❑Not Observable [IN3]1 exterior,the exterior insulation ❑ Steel ❑ Steel ❑Not Applicable v requirement applies(FR10). 303.2 Wall insulation is Installed per ❑Complies Requirement will be met. [IN4]1 manufacturer's instructions. ❑Does Not ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N.Andover Report date: 10/28/15 Page 6 of 8 Data filename: Section Plans Verified Field Verified # Final Inspection Provisions Value Value Complies? Comments/Assumptions & Req.ID 402.1.1, Ceiling insulation R-value. R- R- ❑Complies See the Envelope Assemblies 402.2.1, ❑ Wood ❑ Wood []Does Not table for values. 402.2.2, ❑ Steel ❑ Steel ❑Not Observable ' 6 [Fill ❑Not Applicable FI1] Q 303.1.1.1, Ceiling insulation installed per ❑Complies Requirement will be met. 303.2 manufacturer's instructions. ❑Does Not [FI2]1 Blown insulation marked every 300 ft2. [--]Not Observable ❑Not Applicable 4;02.2,3 Vented attics with air permeable ❑Complies Requirement will be met. tF12212 insulation include baffle adjacent ❑Does Not to soffit and eave vents that extends over insulation. ❑Not Observable ❑Not Applicable 402.2.4 Attic access hatch and door R- R-_ ❑Complies Requirement will be met. [F13]1 insulation >_R-value of the ❑Does Not adjacent assembly. []Not Observable ❑Not Applicable 402.4.1.2 Blower door test @ 50 Pa.<=5 ACH 50= ACH 50= ❑Complies Requirement will be met. [FI17]1 ach in Climate Zones 1-2,and ❑Does Not <=3 ach in Climate Zones 3-8. ❑Not Observable ❑Not Applicable 403.2.2 Duct tightness test result of<=4 cfm/100 cfm/100 ❑Complies Requirement will be met. [FI4]1 cfm/100 ft2 across the system or ft2 ft2 ❑Does Not <=3 cfm/100 ft2 without air ❑Not Observable handler @ 25 Pa.For rough-in tests,verification may need to ❑Not Applicable occur during Framing Inspection. 403.2.2.1 Air handler leakage designated ❑Complies Requirement will be met. [FI24]1 by manufacturer at<=2%of ❑Does Not design air flow. ❑Not Observable ❑Not Applicable 403,1::1 Programmable thermostats ❑Complies Exception: null. :[Fis]2 installed on forced air furnaces. ❑Does Not ❑Not Observable ❑Not Applicable 4.03;1,2 . Heat pump thermostat installed ❑Complies Requirement will be met. [.Flld]2 on heat pumps. []Does Not ❑Not Observable ❑Not Applicable 403.4.1 Circulating service hot water ❑Complies Exception: null. [FI1112 systems have automatic or ❑Does Not accessible manual controls. ❑Not Observable ❑Not Applicable 403.5.;1. All mechanical ventilation system ❑Complies Requirement will be met. [F1251? fans not part of tested and listed ❑Does Not HVAC equipment meet efficacy and air flow limits. ❑Not Observable ❑Not Applicable 404.1 75%of lamps in permanent ❑Complies Requirement will be met. [FI611 fixtures or 75%of permanent ❑Does Not fixtures have high efficacy lamps. ❑Not Observable Does not apply to low-voltage lighting. ❑Not Applicable 11 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N. Andover Report date: 10/28/15 Data filename: Page 7 of 8 Section Plans Verified Field Verified # Final Inspection Provisions Value Value Complies? Comments/Assumptions & Req.ID 404.1.1 Fuel gas lighting systems have []Complies Exception: null. [FI23]3 no continuous pilot light. ❑Does Not ❑Not Observable ❑Not Applicable 401.3 Compliance certificate posted. ❑Complies Requirement will be met. [FI7]2 ❑Does Not ❑Not Observable []Not Applicable 303.3 Manufacturer manuals for ❑Complies Requirement will be met. [FI18]3 mechanical and water heating ❑Does Not systems have been provided. �- ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: I 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N. Andover Report date: 10/28/15 Data filename: Page 8 of 8 2012 iECC Energy Efficiency Certificate Above-Grade Wall 25.00 Below-Grade Wall 0.00 Floor 10.00 Ceiling/ Roof 49.00 Ductwork (unconditioned spaces): b•. Window 0.30 Door 0.20 .. Heating System: Vai l*-, Pvt+fcSS Cooling System: V�"W'. 5e1:4s � Water Heater: °° ' *PTu-S° Name: P{c% awtizv Date: VO 2? ) Comments ti The Commonwealth of 1Mlassachusetts z . Department of IndlustrialAccidents X Congress Street, Suite 100 Boston,MA 02114-2017 , www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeLyibl Name(Business/Organization/lndividual): Address: �{ � 46 ywt City/State/Zip: 1.Acyt M Pr Phone#: 0151-0 Areyou an employer?Check the appropriate box: Type of project(r}equired): 1.❑I am a employerwith : employees(full and/or part-time).* 7. KNew construction 2.[]I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition I❑I am a homeowner doing all work myself,[No workers'comp,insurance required.]t 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 F1 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no employees. 12.' Plumbing repairs or additions [] 5.� 'I am a general contragtor and I have hired the sub contractors listed on the attached sheet. 13.[�Roof repairs • These sub-contractors liave employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14• Other 152,§1(4),and we have nct.employees.[No workers'comp.insurance required.] ;Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit#his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have . employees. If the sub-contractors liave employees,biey,must provide their workeis'comp.policy number. .tam an employer that 1s pi'6vid1hg workers'compensation insurance for my employees.'Below is the policy and job site information. � A Insurance Company Name: � ��' •�_Q� Policy#or Self-ins,Lic.#: we V d 0 q 5 ,3 o Expiration Date: 3 `t 16 Job Site Address: �4-0 S�`'�a '"s City/State/Zip: P4" b t 5 4 Sr Attach a copy of the workers'compepsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA,for insurance coverage verification. I do hereby certify under the pains and penalties ofpei jury that the information provided above is true and correct. Signature: Date: Phone#• Official use only. Do not write in this area,to he 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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: m verdeco DESIGNS One Elm Square, Andover, MA 01810 • 978-409-2217 www.verdecodesigns.com November 2, 2015 TO: Gerry Brown, Town of North Andover Building Department RE: Building permit application for 39-67 Saunders Street This memo is to acknowledge that we are proceeding on a design-build basis for certain systems related to work defined in the above permit application and will provide additional design information and affidavits for the following: • Plumbing systems • Mechanical systems • Electrical systems • Fire Sprinkler & Protection systems • Health Department requirements including resident intercom system �rkYanovvitz Managing Partner Verdeco Designs, LLC DATE(MM/DD/YYY`) ACC>R V CERTIFICATE OF LIABILITY INSURANCE 9/8/2015 THIS CERTIFICATE IS ISSUED AS 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONAME:NTACT Lisa London HON MTM Insurance Associates PE (978)681-5700 aC o:(978)681-5777 1320 Osgood Street EMDRess:lisal@mtminsure.com INSURERS AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURERAAtain Specialty Insurance INSURED INSURERB:Safety Insurance Company 39454 Verdeco Designs INSURERC: 1 Elm Square INSURER D: INSURER E Andover MA 01810 INSURERF: COVERAGES CERTIFICATE NUMBER:15-16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLITYPE OF INSURANCE INSR SUER POLICY NUMBER MM/DDY EFF IPS IDCD EXP LIMITS LTRWVD GENERAL LIABILITY _ EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ r A CLAIMS-MADE nXOCCUR CIP159979002 /17/2015 /17/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY EOMaBBIINED Wdent)SINGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNEDSCHEDULED 057753 /17/2015 /17/2016 AUTOS AUTOS BODILY INJURY(Par accident) $ X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WCSTATU I OTH- AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 1600 Osgood St. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE f- M Laorenza/STEPH ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS1195 t9ninnsr m Th.AC non ..A I.—ern—;.#--A—Ie.of At'n Pin CERTIFICATE OF LIABILITY INSURANCE 7/15/2015 - THIS CERTIFICATE IS ISSUED ASA 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(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this c artificate does not confer rights to the certificate holder In lieu of such endorsements(s) CONTACT PRODUCER NAM MTM Insurance Associates,LLC (tic No Ext): (978)681-5700 FAX MTM 1320 Osgood Street D RIESS: North Andover,MA 01845 PRODUCER CUSTOMER IDA: INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Atlantic Charter Insurance Company VDAC 44326 Verdeco Designs,LLC INSURER B: INSURER C: One Elm Square INSURER D: Andover,MA 01810 INSURER E: INSURER F: COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL sUBR POLICY NUMBER POLICY EFFECTNE POLICY EXPIRATION LIMITS LTR INSR WVD DATE(MWDDffY) DATE(MMR)DIYY) (In Thousand) GENERAL LIABILITY EACH OCCURRENCE $ til LIABILITY DAMAGETO RENTEDPREMISES $ COMMERCIAL GENERAL BILITY . rre occunce) CLAIMS MADE F_] OCCUR ❑❑ MEDEXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ POLICY ❑PROJECT ❑LOC COMBINED SINGLE LIMB AUTOMOBILE LIABILITY (Ea Accident) $ ANY AUTO BODILY INJURY $ ALL OWNED AUTOS (Per person) SCHEDULED AUTOS F-10 BODILY INJURY $ (Es Accident) HIRED AUTOS PROPERTY DAMAGE $ NO"WNDEDAUTOS (Ea Accident) IUMBRELLA ❑ OCCUR EACH OCCURRENCE $ LIABILITY EXCESS LIAB❑ CLAIMS MADEAGGREGATE $ DEDUCTIBLE $ El❑ $ RETENTION $ WORKERS COMPENSATION AND WCV00951304 03/04/2015 03/04/2016X STATUTORY OTHER A EMPLOYERS•LIABILITY LIMITS ANY PROPRIETOR/PARTNEWEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? `T WA Policy Coverage State:MA EACH ACCIDENT $ 1,000,00 Mandatoryin NH 1 Ifyes,describe under SPECIAL PROVISIONS below DISEASE-POLICY LIMIT $ 1,000,000 DISEASE-EACH EMPLOYEE $ 1,000,000 OTHER ❑❑ DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of North Andover EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 1600 Osgood Street 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. g BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY North Andover,MA 01845 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. UTHORD:ED REPRESENTATIVE /�\��, tr/�7 ACORD 25(2009109) �'vvl71^1LLI^www/•" �i/(1/(1— Page I of 1 CERTIFICATE HOLDER COPY ©1988.2009 ACORD CORPORATION.All rights reserved. r - j Massachusetts department of Public Safety Board of Building Regulations and Standards License: CS-105187 Construction Supervisor ' .x.11• MARK J YANOWITZZ ;H ONE ELM SQUARE µ ANDOVER MA 61810 l� Expiration: Commissioner 07/11/2017 Commonwealth bf Massachusetts Department of Public Safety Sprinkler crintract.'rr License:SC-000463 RICHARD S EBA� "r 40 PORTSMOU* :� AMESBURY M* 0 Expiration: Commissioner 07/09/2097 r a