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HomeMy WebLinkAboutBuilding Permit #488-15 - 73 MAYFLOWER DRIVE 11/19/2014s BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: 4 a_0 Date Received ' Date Issued: I l©1 t4 IMPORTANT: Applicant must complete all items on this page. LOCATION 7�' %%fi�1�/��Ow�K �,Pi 1/� �o 16a Print PROPERTY OWNER Ked bete- 14r— Print 100 Year Structure yes MAP/ I 7 -.PARCEL: c�91� ZONING DISTRICT: 1�Historic District yes Machine Shop Village yes /pORTN\ o t.�yED '6* .1.0 6 o � H T Ct9'w.1'e TYPE OF IMPROVEMENT PROPOSED USE yx4 eirg<` Residential Non- Residential New Building P,6ne family 07-4-S0 _,t!- ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ S�RPtic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District Aater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: In f.'O.L mF S 3e b 9C1,0 wt Q:A 6 - 4A --+*W N,09142- WI T�1 I entification - Please Type or Print Clearly OWNER: Name: Keaq me_ TIG Phone: i7�-�83"31b� Address: "c �4 D ®vc-e__ A 4 paq. 11-1 Contractor Name:_:?jexLt�GeoiN,, Phone: Address: 19Q No Wtumg ee, yx4 eirg<` Supervisor's Construction License:G & 07-4-S0 _,t!- Exp. Date: 1.�L l�qlo1 f Home Improvement License: _ Exp. Date: ////, "0 o4V ARCH ITECT/ENGINEEF�fu4�imut - Aw!twe Phone: Address:G-- Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 3,�L94 00 d FEE: $ Check No.: &q � Receipt No.: Q EEoZ R NOTE: Persons contracting with unregistered contractors do not have access to e guaranty fund - - - -r. - - - Signature of Agent/Ow Signature of Plans Submitted Plans Waived ❑ Certified Plot Plan [7 p Stam ed Plans El 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 COMMENTS Signature_ CONSERVATION Reviewed on Sianature COMMENTS HEALTH Reviewed on Sianature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Water & Sewer Connection/Signature & DPW Town Engineer: Signature: Comments Comme /.� / nrivawav Parmit Locatea :st54 USgOoa Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location U iW�iL +' No. Date Check #rA-kz TOWN OF NORTH ANDOVER Certificate of Occupancy $ dU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee A $ TOTAL $441-9 ' Building Inspector O< 'ORT" 1ti O „ # Ja�cNuse CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 488-15 on 11/19/2014 Date: March 4, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED ON 73 Mayflower Drive 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: Buil ing Inspector Fee: Prepaid $100.00 Receipt: 28287 Check: 6968 a� 0 0 V d z Z • m M Z to O Z � U/ W Oc _W 0- x xLLJ O C Cl) GN/ I..f W a Z L: CLd C 02 m an ra I .v a O R �• M O . 0 0. L ® O 0 • N V LU LLI IA H _ LLI LL o WLU _� u Z N o ^, N LL, . Q ,M c� o m ci N N m c \ .. \ �_` �, Jje a 7 W J W �\ S LL - 1,• cu 'O O N LL N O •. O LL `L .0 �'L LA LL 00 to O cr LL j O d 1= C tL =1t0 O C d' LL C v O 7 H E CO Ln 0 0 V d z Z • m M Z to O Z � U/ W Oc _W 0- x xLLJ O C Cl) GN/ I..f W a Z L: CLd C 02 m an ra I .v a O R �• M O . 0 0. L ® O 0 • N V CD O c 0 V d z Z • m M Z to O Z � U/ W Oc _W 0- x xLLJ O C Cl) GN/ I..f W a Z L: CLd C 02 m an ra I i ,zo / leo, rzrtcs_ 0i77J- ' E Off' COMPLIANCE M.G.Q.. CHAPTtR 148, tel; t IONS 266, 26f'/a cltylar To�nrn Thk Cemes that the property laced ed ^ * hey been etgpped v(#h eppraved smoke det-Ctars, and carbon monaAde dagm and oras fated to be In COMpliance w1tFr Massachusetts General Law, Chapter 149 veatiam 261� 2GFx. and, et lnspecUa VTbsiinn car tplefad on: Ey: Fee Paid: L• Head ai Firs aepaftenf AV i. Nota: This ceNcate expires --- � . . shay {sQy days .fir dek of issue. 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Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 350,000.00 m $ - $ 4,200.00 Plumbing Fee $ 525.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 525.00 Total fees collected $ 5,350.00 73 Mayflower Drive 488-15 on 12/2/2014 Single Family Home 3 0 H E7 n M G� i s= �- O O �• 0 O: �aT rL aD =� C („f 0 Q r C-EcL v) Z. m E CD _O _ i Q : ca o O o CD CL J t/1 , m O � O O � O N 0,0 y E-. c CL W r I) O a c o0 CL d i (D t6O`n i—tj 0_� L L cc CD CL N m W C -a +'_+ Ouj O LLL. .N d .y _ -0 t O LU E 0-0 CLoU 2 Z m Z W w CLX LLJ _H W CL O W CL U) CD 0 CO 0=0 z Q V I.L. z U U) Cl) Z �V .ti w L: 0 N = O 0 0O oc z u W a O W uj 2 Z W LL Z Z u Z D z Z W cr co CA Q W 0 ix m E > > U W aU m c 0.u. 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TV m rn c >.wW c o W o v m R ct d O Q avv N C O d N Ern d1 _O r w l6 c It L W w The following table identifies and ranks energy use and cost by building component A maximum of six components are shown. Current mechanical equipment is assumed for this analysis. To determine the impact of varying the equipment ACTION REPORT the equipment specified in the building file and perform the energy calculations again. Date: March 02, 2015 Rating No.: ABA5303-12-7 Building Name: 73 Mayflower Drive, lot 16 Rating Org.: Advanced Building Analysis LLC Owner's Name: Key Lime, Inc - Ben Osgood Phone No.: 978-270-3911 Property: 73 Mayflower Dr Rater's Name: Steve Weglarz Address: North Andover, MA01845 Raters No.: 1225336 Builders Name: Key Lime, Inc- Ben Osgood Windows/Skylights 11.2 Weather Site: North Andover, MA Rating Type: Confirmed File Name: ABA5303-12-7.blg Rating Date: 3/2/2015 The following table identifies and ranks energy use and cost by building component A maximum of six components are shown. Current mechanical equipment is assumed for this analysis. To determine the impact of varying the equipment efficiency, change the equipment specified in the building file and perform the energy calculations again. COOLING Internal Gains 3.0 $ ANNUAL ENERGY PROFILE Windows/Skylights 1.1 $ Energy End -Use Component Consumption Ducts Cost $ (MMBtutyr) Other ($/yr) HEATING Above Grade Walls 20.3 $ 683 Ducts 11.2 $ 377 Windows/Skylights 11.2 $ 376 Mechanical Ventilation 9.9 $ 331 Infiltration 8.3 $ 280 Crawl Space/Unht Bsmt 6.4 $ 216 Other -3.7 $ -125 Total 63.6 $ 2139 COOLING Internal Gains 3.0 $ 153 Windows/Skylights 1.1 $ 59 Ducts 0.5 $ 26 Other -2.3 $ -118 Total 2.3 $ 121 WATER HEATING Water Heater 17.9 $ 587 LIGHTS&APPLIANCES Lights&Appliances 19.7 $ 964 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 This information does not constitute any warranty of energy cost or savings. ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Date: March 02, 2015 Building Name: 73 Mayflower Drive, lot 16 Owners Name: Key Lime, Inc- Ben Osgood Property: 73 Mayflower Dr Address: North Andover, MA 01845 Builder's Name: Key Lime, Inc- Ben Osgood Weather Site: North Andover, MA File Name: ABA5303-12-7.blg Whole House Infiltration Duct Leakage Ventilation AIR LEAKAGE REPORT Rating No.: ABA5303-12-7 Rating Org.: Advanced Building Analysis LLC Phone No.: 978-270-3911 Rater's Name: Steve Weglarz Raters No.: 1225336 Rating Type: Confirmed Rating Date: 3/2/2015 Leakage to Outside Units Blower door test CFM @ 25 Pascals: Heating Cooling Natural ACH: 0.25 0.22 ACH @ 50 Pascals: 2.96 2.96 CFM @ 25 Pascals: 637 637 CFM @ 50 Pascals: 1000 1000 Eff. Leakage Area: [sq.in] 54.9 54.9 Specific Leakage Area: 0.00016 0.00016 ELAM 00 sf shell: [sq.in] 0.94 0.94 Leakage to Outside Units ducts CFM @ 25 Pascals: 86 CFM25 / CFMfan: 0.0515 CFM25 / CFA: 0.0356 CFM per Std 152: N/A CFM per Std 152 / CFA: N/A CFM @ 50 Pascals: 135 Eff. Leakage Area: [sq.in] 7.41 Thermal Efficiency: N/A Total Duct Leakage Units CFM25/CFA Total Duct Leakage: 0.0393 Mechanical: Exhaust Only Sensible Recovery Eff. (%): 0.0 Total Recovery Eff. (%): 0.0 Rate (cfm): 54 Hours/Day: 24.0 Fan Watts: 9.0 Cooling Ventilation: Natural Ventilation ASHRAE 62.2 - 2010 Ventilation Requirements For this home to comply with ASHRAE Standard 62.2 - 2010 Ventilation and Acceptable IndoorAir Quality in Low -Rise Residential Buildings, a minimum of 54 cfm of mechanical ventilation must be provided continuously, 24 hours per day. Alternatively, an intermittently operating mechanical ventilation system may be used if the ventilation rate is adjusted accordingly For example, a 108 cfm mechanical ventilation system would need to operate 12 hours per day, as long as the system operates to provide required average ventilation once each hour. REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 This information does not constitute any warranty of energy cost or savings. ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT File Name: ABA5303-12-7.blg 1 Date: March 02, 2015 Property/Builder: Name Rating Unins FndAmb 1/2 Building Name: 73 Mayflower Drive, lot 16 Org. Name: Advanced Building Analysis LLC Owner's Name: Key Lime, Inc - Ben Osgood Address: 2 Woodlawn Street Property Address: 73 Mayflower Dr City, St, Zip: Amesbury, MA 01913 City, St, Zip: North Andover, MA 01845 Phone No: 978-270-3911 Phone No: 508-328-4630 Website: www.advancedbuildinganalysis.com Builder's Name: Key Lime, Inc- Ben Osgood Rater's Name: Steve Weglarz Phone No: 978-683-3163 Rater's Email: steve@advancedbuildinganalysis.com Email Address: bennyo@comcastnet Rater's ID: 1225336 Model: H Model unfinished basement Provider ID: Development: Old Salem Village Sample Set ID: Permit Date/Number: 11.19.2014/488-15 Rating Date: 3/2/2015 Rating Type: Confirmed Reason: New Home Rating No.: ABA5303-12-7 Registry ID: 469779324 General Building Information Area of Cond. Space(sq ft): Volume of Cond. Space: Year Built Housing Type: Level Type(Apartments Only): Floors on orAbove-Grade: Number of Bedrooms: Foundation Type: Enclosed Crawl Space Type: Thermal Boundary Location: 2415 20263 2015 Single-family detached None 2 3 Unconditioned basement N/A REM Default Foundation Wall Info: 1 2 3 Name Unins Fnd Amb Unins FndAmb 1/2 Unins Fnd Garage Library Type R0,10" R0,10" R0,10" Length(ft) 38.0 65.0 27.5 Total Height(ft) 8.5 4.0 8.5 Depth Below Grade(ft) 7.0 3.0 7.5 HeightAbove Grade(ft) 1.5 1.0 1.0 Location Uncond bsmt->amb/grnd Uncond bsmt->amb/grnd Uncond bsmt->garage/grnd Uo Value (wall, airfilm, & soil) 0.222 0.316 0.192 Uo Value (wall assembly only) 1.205 1.205 1.205 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 @ 1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 2 Foundation Wall: R0,10" Type: Solid concrete or stone Thickness(in): 10.0 Studs: None Interior Insulation: Continuous R -Value: 0.0 Frame Cavity R -Value: 0.0 Cavity Insulation Grade: 1 Ins top: 0.0 ft from top of wall Ins Bottom: 0.0 ft from top of wall Exterior Insulation: R -Value: 0.0 Ins top: 0.0 ft from top of wall Ins bottom: 0.0 ft from top of wall Note: Floor Info: 1 2 3 Name Gond/unc bsmt stairs/unc bsmt over garage Library Type R30,FG2,X-16 R15,FG2,X-16 R30,FG1,X-16 Area (sq ft) 943 58 570 Location Btwn cond & uncond bsmt Btwn cond & uncond bsmt Btwn cond & garage Uo Value 0.040 0.069 0.035 Floor Info: 4 Name Cantilever Library Type R30,FG3,X-16 Area (sq ft) 6 Location Btwn cond & ambient Uo Value 0.048 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 0198E-2014Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 3 Floor: R30,FG2,X-16 Information From Quick Fill Screen Continous Insulation R -Value 0.0 Cavity Insulation R -Value 30.0 Cavity Insulation Thickness (in.) 9.0 Cavity Insulation Grade 2.0 Joist Size (w x h, in) 1.5 x 9.3 Joist Spacing (in oc) 16.0 Framing Factor- (default) 0.1300 Floor Covering HARDWOOD Note: Updated Grade 2AP 11/1/05 Layers Paths Cavity Framing Grade Inside Air Film 0.920 0.920 0.920 Floor covering 0.680 0.680 0.680 Subfloor 0.820 0.820 0.820 Cavity ins 30.000 0.000 0.000 Continuous ins 0.000 0.000 0.000 Framing 0.000 11.250 0.000 0.000 0.000 0.000 Outside Air Film 0.920 0.920 0.920 Total R -Value 33.340 14.590 3.340 U -Value 0.030 0.069 0.299 Relative Area 0.850 0.130 0.020 UA 0.025 0.009 0.006 Total Component UA: 0.040 Total Component Area: 1.0 Component Uo: 0.040 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 4 Floor: R15,FG2,X-16 Information From Quick Fill Screen Continous Insulation R -Value 0.0 Cavity Insulation R -Value 15.0 Cavity Insulation Thickness (in.) 3.5 Cavity Insulation Grade 2.0 Joist Size (w x h, in) 1.5 x 9.3 Joist Spacing (in oc) 16.0 Framing Factor- (default) 0.1300 Floor Covering HARDWOOD Note: Updated Grade 2 AP 11 /14/05 Layers Paths Cavity Framing Grade Inside Air Film 0.920 0.920 0.920 Floor covering 0.680 0.680 0.680 Subfloor 0.820 0.820 0.820 Cavity ins 15.000 0.000 0.000 Continuous ins 0.000 0.000 0.000 Framing 0.000 4.375 0.000 0.000 0.000 0.000 Outside Air Film 0.920 0.920 0.920 Total R -Value 18.340 7.715 3.340 U -Value 0.055 0.130 0.299 Relative Area 0.850 0.130 0.020 UA 0.046 0.017 0.006 Total Component UA: 0.069 Total ComponentArea: 1.0 Component Uo: 0.069 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 5 Floor: R30,FG1,X-16 Information From Quick Fill Screen Continous Insulation R -Value 0.0 Cavity Insulation R -Value 30.0 Cavity Insulation Thickness (in.) 9.0 Cavity Insulation Grade 1.0 Joist Size (w x h, in) 1.5 x 9.3 Joist Spacing (in oc) 16.0 Framing Factor- (default) 0.1300 Floor Covering HARDWOOD Note: Updated Grade IAP 11/1/05 Layers Paths Total Component UA: 0.035 Total ComponentArea: 1.0 Component Uo: 0.035 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Cavity Framing Grade Inside Air Film 0.920 0.920 0.920 Floor covering 0.680 0.680 0.680 Subfloor 0.820 0.820 0.820 Cavity ins 30.000 0.000 0.000 Continuous ins 0.000 0.000 0.000 Framing 0.000 11.250 0.000 0.000 0.000 0.000 Outside Air Film 0.920 0.920 0.920 Total R -Value 33.340 14.590 3.340 U -Value 0.030 0.069 0.299 Relative Area 0.870 0.130 0.000 UA 0.026 0.009 0.000 Total Component UA: 0.035 Total ComponentArea: 1.0 Component Uo: 0.035 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Floor: R30,FG3,X-16 0.920 0.920 0.920 Information From Quick Fill Screen: 33.340 14.590 3.340 Continous Insulation R -Value 0.030 0.069 0.299 Cavity Insulation R -Value 0.820 0.130 0.050 Cavity Insulation Thickness (in.) 0.025 0.009 0.015 Cavity Insulation Grade Joist Size (w x h, in) Joist Spacing (in oc) Framing Factor- (default) Floor Covering Note: Updated Grade 3AP 11/1/05 Layers Paths Cavity Framing Grade Inside Air Film 0.920 0.920 0.920 Floor covering 0.680 0.680 0.680 Subfloor 0.820 0.820 0.820 Cavity ins 30.000 0.000 0.000 Continuous ins 0.000 0.000 0.000 Framing 0.000 11.250 0.000 0.000 0.000 0.000 Outside Air Film 0.920 0.920 0.920 Total R -Value 33.340 14.590 3.340 U -Value 0.030 0.069 0.299 Relative Area 0.820 0.130 0.050 UA 0.025 0.009 0.015 Total Component UA: 0.048 Total ComponentArea: 1.0 Component Uo: 0.048 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 6 0.0 30.0 9.0 3.0 1.5 x 9.3 16.0 0.1300 HARDWOOD BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 7 Above -Grade Wall: 1 2 Rim and Sand Joist: 1 2 Name `band Gond amb band cond garage Area(sq ft) 107.7 49.0 Continuous Ins 0.0 0.0 Framed Cavity Ins 21.0 21.0 Cavity Ins Thk(in) 5.5 5.5 Joist Spacing 16.0 16.0 Insulation Grade 1 1 Location Cond -> ambient Cond -> garage Uo Value 0.047 0.047 Above -Grade Wall: 1 2 3 Name cond/amb unc bsmt/amb cond/gar Library Type R21,FG1,6-16 R21,FG1,6-16 R21,FG1,6-16 GrossArea(sq ft) 2380.00 355.00 190.00 Exterior Color Medium Medium Medium Location Cond -> ambient Uncond bsmt-> ambient Cond -> garage Uo Value 0.058 0.058 0.058 Above -Grade Wall: 4 Name cond to uncond bsmt Library Type R13,FG2,4-160 GrossArea(sq ft) 93.00 Exterior Color Medium Location Cond -> uncond bsmt Uo Value 0.090 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Above -Grade Wall: R21,FG1,6-16 Information From Quick Fill Screen: Standard Wood Frame Continuous Insulation (R -Value) Frame Cavity Insulation (R -Value) Frame Cavity Insulation Thickness (in) Frame Cavity Insulation Grade Stud Size (w x d, in) Stud Spacing (in o.c.) Framing Factor- (default) Gypsum Thickness (in) Note: Updated Grade I BH 10/24/05 Layers Paths Total Component UA: 0.058 Total Component Area: 1.0 Component Uo: 0.058 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 8 0.0 21.0 5.5 1 1.5 x 5.5 16.0 0.2300 0.5 Cavity Framing Grade Inside Air Film 0.680 0.680 0.680 Gyp board 0.450 0.450 0.450 Air Gap/Fret 0.000 0.000 0.000 Cavity ins/Frm 21.000 6.875 1.030 Continuous ins 0.000 0.000 0.000 Ext Finish 0.940 0.940 0.940 0.000 0.000 0.000 Outside Air Film 0.170 0.170 0.170 Total R -Value 23.240 9.115 3.270 U -Value 0.043 0.110 0.306 Relative Area 0.770 0.230 0.000 UA 0.033 0.025 0.000 Total Component UA: 0.058 Total Component Area: 1.0 Component Uo: 0.058 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 8 0.0 21.0 5.5 1 1.5 x 5.5 16.0 0.2300 0.5 BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Above -Grade Wall: R13,FG2,4-160 Information From Quick Fill Screen: Standard Wood Frame Continuous Insulation (R -Value) Frame Cavity Insulation (R -Value) Frame Cavity Insulation Thickness (in) Frame Cavity Insulation Grade Stud Size (w x d, in) Stud Spacing (in o.c.) Framing Factor- (default) Gypsum Thickness (in) Note: Updated Grade II BH 10/24/05 Layers Paths Total Component UA: 0.090 Total ComponentArea: 1.0 Component Uo: 0.090 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 9 0.0 13.0 3.5 2 1.5 x 3.5 16.0 0.2300 0.5 Cavity Framing Grade Inside Air Film 0.680 0.680 0.680 Gyp board 0.450 0.450 0.450 Air Gap/Frm 0.000 0.000 0.000 Cavity ins/Frm 13.000 4.375 1.030 Continuous ins 0.000 0.000 0.000 Ext Finish 0.940 0.940 0.940 0.000 0.000 0.000 Outside Air Film 0.170 0.170 0.170 Total R -Value 15.240 6.615 3.270 U -Value 0.066 0.151 0.306 Relative Area 0.750 0.230 0.020 UA 0.049 0.035 0.006 Total Component UA: 0.090 Total ComponentArea: 1.0 Component Uo: 0.090 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 9 0.0 13.0 3.5 2 1.5 x 3.5 16.0 0.2300 0.5 BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 10 k Window Information: I 1 I 2 ( 3 Name Front unsh Front shaded Left Library Type 1-1:0.30, SHGC:0.29 U:0.30, SHGC:0.29 U:0.30, SHGC:0.29 U -Value 0.300 0.300 0.300 SHGC 0.290 0.290 0.290 Area(sq ft) 74.00 48.20 77.00 Orientation South South West Overhang Depth 0.0 6.0 0.0 Overhang To Top 0.0 1.0 0.0 Overhang To Bottom 0.0 6.0 0.0 Interior Winter Shading 0.85 0.85 0.85 Interior Summer Shading 0.70 0.70 0.70 Adjacent Winter Shading None None None Adjacent Summer Shading None None None Wall Assignment AGWall 1 AGWall 1 AGWall 1 Window Information: 1 4 1- 5 Name Rear Right Library Type U:0.30, SHGC:0.29 U:0.30, SHGC:0.29 U -Value 0.300 0.300 SHGC 0.290 0.290 Area(sq ft) 115.00 58.00 Orientation North East Overhang Depth 0.0 0.0 Overhang To Top 0.0 0.0 Overhang To Bottom 0.0 0.0 Interior Winter Shading 0.85 0.85 Interior Summer Shading 0.70 0.70 Adjacent Winter Shading None None Adjacent Summer Shading Most None Wall Assignment AGWall 1 AGWall 1 Window: U:0.30, SHGC:0.29 U -Value: 0.300 Solar Heat Gain Coefficient 0.290 Note: Door Information: 1 2 3 Name main entry garage basement Opaque Area(sq ft) 21.6 21.6 20.5 Library Type Steel-urth w/brk Steel-urth w/brk Wood Wall Assignment AGWall 1 AGWall 2 AGWall 3 Uo Value 0.187 0.187 0.341 REM/Rate - Residential Energy Analysis and Rating Software 04.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 11 Door: Steel-urth w/brk R -Value of Opaque Area: 4.4 Storm Door: No Note: Door: Wood R -Value of Opaque Area: 2.0 Storm Door. No Note: Roof Information: 1 I 2 3 Name flat main flat hatch fp bump out Library Type R40,BFG16",10-16 Attic Hatch R10 R38,HDF1,10-16 Ceiling Area(sq ft) 1461.00 4.00 6.00 RoofArea(sq ft) 1826.00 8.00 7.50 Color Medium Medium Medium Radiant Barrier No No No Type(Attic) Attic Attic Attic Uo Value 0.025 0.089 0.036 Clay or Cement Tiles: No No No Sub Roof Ventilation: No No No REM/Rate - Residential Energy Analysis and Rating Software v14.6.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Ceiling: R40,BFG16",10-16 0.858 0.858 0.858 Information From Quick Fill Screen: 30.591 42.266 18.966 Continous Insulation (R -Value) 0.033 0.024 0.053 Cavity Insulation (R -Value) 0.141 0.859 0.000 Cavity Insulation Thickness (in) 0.005 0.020 0.000 Cavity Insulation Grade Gypsum Thickness (in) Bottom Chord/Rafter Size(w x h, in) Bottom Chord/Rafter Spacing (in o.c.) Framing Factor- (default) Ceiling Type Note: quick fill by SW 8/12/14 Layers Paths Framing Cavity Grade Inside Air Film 0.858 0.858 0.858 Gyp board 0.450 0.450 0.450 Cavity Ins/Frm 11.625 23.300 0.000 Continuous ins 16.800 16.800 16.800 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 Outside Air Film 0.858 0.858 0.858 Total R -Value 30.591 42.266 18.966 LI -Value 0.033 0.024 0.053 Relative Area 0.141 0.859 0.000 UA 0.005 0.020 0.000 Total Component UA: 0.025 Total ComponentArea: 1.0 Component Uo: 0.025 REM/Rate - Residential Energy Analysis and Rating Software v14.6.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 12 16.8 23.3 9.3 1 0.500 1.5 x 9.3 16.0 0.1412 Attic BUILDING FILE REPORT Paths 73 Mayflower Drive, lot 16 Page 13 Ceiling: Attic Hatch R10 Cavity Information From Quick Fill Screen: 0.610 Continous Insulation (R -Value) 10.0 Cavity Insulation (R -Value) 0.0 Cavity Insulation Thickness (in) 0.0 Cavity Insulation Grade 1 Gypsum Thickness (in) 0.000 Bottom Chord/Rafter Size(w x h, in) 0.0 x 11.3 Bottom Chord/Rafter Spacing (in o.c.) 10.0 Framing Factor- (defined) 0.0020 Ceiling Type Attic Note Layers Paths Framing Cavity Inside Air Film 0.610 0.610 Gyp board 0.000 0.000 Cavity Ins/Frm 0.000 0.000 Continuous ins 10.000 10.000 0.000 0.000 0.000 0.000 0.000 0.000 Outside Air Film 0.610 0.610 Total R -Value 11.220 11.220 U -Value 0.089 0.089 Relative Area 0.000 1.000 UA 0.000 0.089 Total Component UA: 0.089 Total ComponentArea: 1.0 Component Uo: 0.089 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT Paths 73 Mayflower Drive, lot 16 Page 14 Ceiling: R38,HDF1,10-16 Framing Information From Quick Fill Screen: 0.000 Continous Insulation (R -Value) 0.0 Cavity Insulation (R -Value) 38.0 Cavity Insulation Thickness (in) 6.3 Cavity Insulation Grade 1 Gypsum Thickness (in) 0.500 Bottom Chord/Rafter Size(w x h, in) 1.5 x 9.3 Bottom Chord/Rafter Spacing (in o.c.) 16.0 Framing Factor- (default) 0.1412 Ceiling Type Attic Layers Paths 0.000 0.000 0.000 Framing Cavity Grade 0.000 Inside Air Film 0.610 0.610 0.610 Gyp board 0.450 0.450 0.450 Cavity Ins/Frm 7.875 38.000 0.000 Continuous ins 0.000 0.000 0.000 Outside Air Film Total R -Value U -Value 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.610 0.610 0.610 Relative Area UA Total Component UA: 0.036 Total Component Area: 1.0 Component Uo: 0.036 Mechanical Equipment: General Number of Mechanical Systems: Heating SetPoint(F): Heating Setback Thermostat Cooling SetPoint(F): Cooling Setup Thermostat 9.545 39.670 0.105 0.025 0.141 0.859 0.015 0.022 3 68.00 Present 78.00 Present 1.670 0.599 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 15 Heat: GMSS960804CNAA SystemType: Fuel -fired air distribution Fuel Type: Propane Rated Output Capacity (kBtuh): 77.0 Seasonal Equipment Efficiency: 96.1 AFUE Auxiliary Electric: 943 Eae Note: Goodman/Amana AHRI#7365098 NO ECM Location: Uncond bsmnt/enclosed crawl Performance Adjustment: 100 Percent Load Served: 100 Number Of Units: 1 Water Heating Equipment: PROGSOS-32P RU67 PV Water HeaterType: Conventional Fuel Type: Propane Energy Factor: 0.67 Recovery Efficiency: 0.80 WaterTank Size (gallons): 50 Extra Tank Insulation (R -Value): 0.0 Note: Rheem AHRI 6582952 Location: Uncond bsmnt/enclosed crawl Percent Load Served: 100 Performance Adjustment: 100 Number Of Units: 1 Cooling Equipment: 6688361 System Type: Air conditioner Fuel Type: Electric Rated Output Capacity (kBtuh): 46.0 Seasonal Equipment Efficiency: 13.0 SEER Sensible Heat Fraction (SHF): 0.70 Note: Goodman/Amana SW 3/2/15 Location: Uncond bsmnt/enclosed crawl Performance Adjustment 100 Percent Load Served: 100 Number Of Units: 1 REM/Rate - Residential Energy Analysis and Rating Software v14.6.1 • ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 16 Duct System Information: 1 Name ducts Heating System GMSS960804CNAA Cooling System 6688361 SupplyArea(sq ft) 489.0 Return Area(sq ft) 452.8 Conditioned FloorArea(sq ft) 2415.0 # of Registers 4 Duct Leakage Location Qualitative Assessment- Not Applicable Unconditioned basement Duct Leakage to Outside: 86.00 CFM @ 25 Pascals Supply Duct Leakage - NotApplicable Return Duct Leakage - NotApplicable Total Duct Leakage: 95.00 CFM @ 25 Pascals Duct Tightness Test Postconstruction Test Duct Information: 1 2 6 3 Type Supply Return Supply PercentArea 25.0 30.0 30.0 R -Value 6.0 6.0 8.0 Location Unconditioned basement Unconditioned basement Attic, exposed Duct Information: 4 5 6 Type Return Supply Return PercentArea 25.0 45.0 45.0 R -Value 8.0 8.0 8.0 Location Attic, exposed Attic, exposed Attic, exposed REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 17 Infiltration and Mechanical Ventilation Whole House Infiltration Measurement Type: Blower door test Heating Season Infiltration Value: 1000 CFM @ 50 Pascals Cooling Season Infiltration Value: 1000 CFM @ 50 Pascals Shelter Class 3 2009 IECC Verification: Tested Mechanical Ventilation for IAQ Type: Exhaust Only Rate(cfm): 54 Sensible Recovery Efficiency(%): 0.00 Total Recovery Efficiency(%): 0.00 Hours per Day: 24.00 Fan Power (watts): 9.00 Ventilation Strategy for Cooling Cooling Season Ventilation: Natural Ventilation Lights and Appliances Simplified Audit Refrigerator KWh: 724 Refrigerator Location: Conditioned Dishwasher EF: 0.78 Dishwasher kWh/yr: 0 Dishwasher Capacity: 12 Dishwasher kWh/Year: 0 Range/Oven Fuel Type: Propane Induction Range: No Convection Oven: Yes Clothes Dryer Fuel Type: Electric Clothes Dryer Location: Conditioned Clothes Dryer Moisture Sensing: Yes Clothes Dryer Energy Factor: 3.73 Clothes Dryer Gas Energy Factor: 2.67 Clothes Washer Location: Conditioned Clothes Washer LER: 704.0 Clothes Washer MEF: 3.000 Clothes Washer Capacity: 4.500 Clothes Washer Electricity Rate: 0.08 Clothes Washer Gas Rate: 0.58 REM/Rate - Residential Energy Analysis and Rating Software v14.6.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. BUILDING FILE REPORT 73 Mayflower Drive, lot 16 Page 18 Lights and Appliances Clothes WasherAnnual Gas Cost: 23.00 Percent CFLs: 100.0 Percent Fluorescent: 0.0 Percent Exterior Lights: 100.0 Percent Garage Lights: 100.0 Ceiling Fan CFM /Waft: 0.00 REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Property/Builder: Owner's Name: Key Lime, Inc Ben Osgood Property Address: 73 Mayflower Dr City,St,Zip: North Andover, MA 01845 Phone No.: 508-328-4630 Builder's Name: Key Lime, Inc - Ben Osgood Model: H Model unfinished basement Development: Old Salem Village Phone No.: 978-683-3163 Rating Date: 3/2/2015 Rating No.: ABA5303-12-7 IMPORTANT NOTICE TO BUILDER Builder affirms in this affidavit that all components listed in the Building File Report are accurate and incorporated into this New Home. Builder agrees to permit home energy rating system (HERS) Provider and/or Rater, to randomly verify components solely for the benefit of the HERS Provider's and/or Rater's interest. The HERS Provider and Rater do not create or imply any duty or obligations to Builder or any subsequent owner. Builder is responsible for making any inspections to protect Builder's interest. There is no GUARANTEE or WARRANTY, expressed or implied, from the HERS Provider or Rater as to this New Home. Builder's Signatur Date -.-3 /_ 2- / 45 HERS Index: 57 Rating Reason: Confirmed Raters Signature: Date: 3/ REM/Rate - Residential Energy Analysis and Rating Software v14.5.1 This information does not constitute any warranty of energy cost or savings. ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. 2012 IECC Certificate 73 Mayflower Dr, North Andover, MA 01845 Building Envelope Insulation Ceiling: R-40.1 Above Grade Walls: R-21.0 Foundation Walls: R-0.0 Exposed Floor: R-30.0 Slab: None Infiltration: Htg: 1000 Clg: 1000 CFM50 Duct: R-8.0 Total Duct Leakage: 95.00 CFM @ 25 Pascals Window Data U -Factor SHGC Window: 0.300 0.290 Mechanical Equipment HEAT: Fuel -fired air distribution, Propane, 96.1 AFUE. COOL: Air conditioner, Electric, 13.0 SEER. DHW: Conventional, Propane, 0.67 EF, 50.0 Gal. Builder or Design Professional Signatu .44-*..? 6�- 6Qtet-V�e REWRate idential Energy Analysis and Rating Software 04.5.1 4 I iet'l . Ot Public 53oe93TtTf' int d Standards ,,%,usetts Regvlatic%lsI , Mass -ld'Ing B030 of But . Usupt'n S()T onctructlo C " -02 License'ense'. CS ,159 b/ C OSC' . Po 'D- - 690 TON OISAS, NO BEN ANSLA The Commonwealth of Massachusetts , - Department of Indtfstrid Acc!6l fs Q face of investigations 600 Washington Street Boston, MA 02111 www.mass govIdia Workers' Compensation Insurance Affidavit: Builders/Cont°actors/ElectriciansIPiumbero Applicant Information Please Prim Legibly Name (Business/Organizationftdividual):, Address: /0 1�, eA eg b e - Ci iy/State/Zip: kAD 1� �3�y'� `� Phone #: 977 Are you an employer? Check the appropriate bo 1. ❑ I am a employer with 4. 91 am a general contractor and I employees (fall and/or part-time).* have likedthesub-contractors 2. ❑ I am a sole proprietor Or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c.152, § 1(4), and we, have no employees. [No workers' insurance required.] comp. insurance required.] Type of project (required): 6. ❑ New construction 7. 0 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.[] Plumbing.repairs or additions 12. El Roofrepairs 13.❑ Other 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy infbrmation. i -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. X am an employer that isproviding workers' compensation insurance for my employees. Below is thepolley and joie site information. Insurance Company Name: 4�S a � Coif �� �Jz �Lo—Y�' -ex `Z 'zc Policy ## or Self -ins. Lic. #: tUGc- t'06 7t;91- ;LO /f4 Expiration Date: Job Site A ddress: - - Attach a copy of the workers' compensation -policy iieclaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 WORD ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do Hereby cer%'fy under the pains and aloes ofperjury that the information provided above is true and correct. - _�_ Dat,, City/State/Zip: 1�� 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 - ContactPerson, Phone 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 "...everyperson 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 io'do maintenance,%contraction 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 fox any applicant who has not producedacceptable 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 ofpublic 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), addresses) 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 notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, apolicy is. required. Se advisedthattbis affidavitmay be submittedto theDepartmeirt of Industrial Accidents fox 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 Zine. City or Town Officials Please be sure that the affidavit is complete and pxinted'1'egibly::The Department Ias'provided'a space at the bottom of the affidavit for you to fill out in the event the Oftice,of.- vestigatimsl�as-to, contact you regardir�g the applicant. Please be sure to till in the permit/license number whichvrill 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 (ifnecessary) and under "Job Site Address" the applicant shouldwrite "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 fide for future permits or licenses. A new affidavit must be filled out each year. Where ahome owner or citizen is obtaining a license ox 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 Ince to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: `:Elie GQ.ozk�ealtf� 0�],1�Tassa..olzui�Pit� - - a , � . Department o£fndmWal .Acoldmts 60() Waftgoa Stied Boston, MA. 02111 TQL 4 617-7-2' -4900 et 406 ox 1-8,77-MASSA..FB Revised 5-26-05 Fax 0 617-727-7749 WWW -Mu, ,gQV1(9a WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. WCC -500 50Q7581.2014Ai PRIOR NO. WCC -500_5007581-20.13A1 ITEM 1. The Insured: Key Lime Inc DBA: Mailing address: 10 Hepatica Drive FEIN: North Andover, MA 01845 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 09/15/2014 to 09/15/2015 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates - - -- .-.....------ — Code Estimated Per $100 Estimated No, Total Annual Of Annual LRemuneration i Remuneration Premium INTRA 285896 INTER SEE CLASS CODE SCH Minimum Premium $575 Total Estimated Annual Premium GOV 1 GOV Deposit Premium STATEiCLASS MA 5645 MA Assessment Chg. —------- $3,778.00 x 3.4000% This policy, including all endorsements, is hereby countersigned by Autho __.. rized ze'_..g Si....nature ---- _---.. d Service Office. M P Roberts Insurance Agency 54 Third Avenue 1060 Osgood Street Burlington MA 01803 North Andover, MA 01845 WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with Its permission. $4,217 $1,086 $128 07/31/2014 Date I all S J. •a Ilk 1' 1 O 'LLQ. 9 LL X-.9 •a