Loading...
HomeMy WebLinkAboutBuilding Permit #144-14 - 80 BOSTON STREET 8/15/2013 TOWN OF NORTH ANDOVER f APPLICATION FOR PLAN EXAMINATION �]� Permit NO: r Date Received v- ' Date Issued: l IMPORTANT:Applicant must com AL A 1\ P LOCATIONd �5 Print PROPERTY OWNER C�l�U�yr-� 4: Print MAP NO: PARCEL: ZONING DISTRICT:- TYPE OF IMPROVEMENT PROPOSED USE Residen ' 1 ❑ Ne Building 415ne family ddition ❑Two or more family �� P m'AA teration No. of units: ❑ Repair, replacement ❑Assessory Bldg ❑ Demolition ❑ Other peptic. ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PE ORMED: 612I Q� t� r-2!9 1 l�41_-. ( tIdentificatio Pease Type or Print Clearly) OWNER: Name: ��f. "'A 4 ���v-� � ��� Phone: q7,iE?^6E�G-308 Address: , Noy- gv ®� CONTRACTOR Name a � ,c Phone: ` '7 -4iy -_379 Address: d:<-)- l7/ 11f4in, Fn� , 9, C7 j�,�C� Supervisor's Construction License: �CS--C ���} ;3TExp. Date: Ool y Home Improvement License: Exp. Date: MW47- ARCHITECT/ENGINEER E&a inx*rtn 4T Rf Phone: 6.03^ Y75`�- ! Address: 1��c lL`� '`��� , �� Reg. No. � 3z-3 q FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. fit,/2 Total Project Cost: $_ �, _ _ _ S FEE: Check No.: ` Receipt No.: � NOTE: Persons contracting with u ggister� ntractors do not have access to the my fund Signature of Agent/OwnerSignature of contractor c. , Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TOWN OF NORTH ANDOVER I �-f APPLICATION FOR PLAN EXAMINATION Permit NO: / / Date Received !, Date Issued: / I N1 PORTANT: Applicant must complete all items on this page LOCATION AA c--A8-Y,5- Print sem Y,Printn PROPERTY OWNER ������ Print 100 Year Old Structure yes no MAP NO: PARCELLY(O ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residen ' I Non- Residential ❑ N9*Building 4ne family PlAddition ❑Two or more family ❑ Industrial iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other fld Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PE ORMED: �.�,��/y� �h c1 �'cr> 9os�'r.+.�� �3til SI2u� fbu:�r�'Cro 9Y► �����9.�✓°'�.,.— ron47 (Iaentificat" Pease Type or Print Clearly) OWNER: Name: 0�-A Jc2 c4 Phone: 27f3-602- 3018 Address: qo ,/Vow l;�v , ©% CONTRACTOR Name! Av,nQ ch Gh:5"04 ,c Phone: 1j TA,-4qq -.379 7 Address: �i� t�C7X 17l �/Ui �P�tt�v� , 01e90 Supervisor's Construction License: ,S -C �� TExp. Date: /0-2-6 Home Improvement License: Exp. Date: MA147- ARCHIT CT/ENGINEER s jYl nC "PUZ Phone: 6.03 Y75- 13 13 Address: 1-116ML`S��s��� , f7 Reg. No. � 32.3 q J 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 Ffl 2 S FEE: ��7. o. Check No.: Receipt No.: NOTE: Persons contracting with ugisterretractors do not have access to thenty fund ..0 Signature of Agent/Owner _ Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Skmped Plans ❑ Date..` .. ? 1�1 F r&ORTIi, Q �.ao .• 1' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION " g8'�CHUB� This-certifies tha �?h nl.. kP n (J� 1 P!P ............. . 'j8p f ...� P g ......................... . .. ...... has permission for as nstal:lationy���f...K-!�� ` '�r�..I. . .��..!t-.... in the buildings of... r.. .�.a! !. ..... . .......................................................... at........... ......t. ?- ....... .......... North Andover, Mass. , Fee..(OW.-.... Lic. No. .�..7 ......... ............. ..................................................... . GASINSPECTOR Check# :'3u7 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Co Si nature COMMENTS HEALTH Reviewed on Si natur COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 4.Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow2 Engineer: Signature: Located 384 Osgood 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 NOTES and DATA— For department use rr oA S' (`/ p (c- U 4 0 W CEJ Corn ® Notified for pickup - Date Doe.Building Permit Revised 2010 Building impartment The foh.,wing is a list of the required forms to be filled out for the ap riate peLto obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 ❑--Bu4d�n�,.rmit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Phato Copy o H.I.C. And C.S.L. Licenses 03CopyOf Contract ❑� Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (if Applicable) ❑ Engineering Affidavits for Engineered products 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all eases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doe.Bui!ding Permit Revised 2012 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 3999125.00 m $ - $ 4,789.50 Plumbing Fee $ 598.69 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 598.69 Total fees collected $ 6,086.88 80 Boston Street 144-14 on 8/15/2013 Second Floor Addition New Garage on New Foundation Addition over Existing Garage NORTH Town of s E .' . .,, n ove r O No. iq h , ver, Mass, �S i COC HIC"IWICK y1' ASR^TED 0"'* .(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT �I c/4/o.©/y........... ......................... BUILDING INSPECTOR has permission to erect buildings on Foundation Rough to be occupied as .. .: !�C� v!^ `�G �'`�- 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 rela ' g to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. 1�-- .j%'/� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TS Rough ................ ........ .:�s$� ... ....................... Service BUILDING SECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE FTHIS 013 12:44 Coonan Insurance Agency,Inc. (FAX) P.0011001 ;� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/7D/DYYW)13 TIFICATEIS 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 CONTACT NAME: Coonan Insurance Agency, Inc. PHONE FAX (508) 987-7122 IAIQ No: (508) 987-7152 267 Main Street E-MAIL ADDRESS: Tom@coonaninsurance.com Oxford, MA 01540 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Safetv Insurance Company INSURED INSURER B: Concordia Construction, LLC INSURER C: 9 Newton Avenue INSURER D Oxford, MA 01540 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. ILTR TYPEOFINSURANCE ADDLSUBR POLICY EFF POLICY EXP INSR WVD POUCY NUMBER MM/DD/YYYY MM/DDYYYY LIMITS A GENERAL LIABILITY EMA0019665 5/21/13 5/21/14 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES .occurrence $ 100,000 CLAIMS-MADE Fx—]OCCUR MED EXP(Arty one pe(sui) $ 10,000 PERSONAL&ADVINJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMITAPP LIES PER PRODUCTS-OOMP/OPAGG $ X POLICY PRCT LOC AUTOMOBILE LIABILITY COMBINED SINGL E LIMIT Eaacc.derc $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIREDAUTOS NON--OWNED (P OaPEER YtDAMAGE $ AUTOUMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ I $ NK�RKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N T R LMR -R ANY PROPRIETOR/PARTNERIE XECUTNE 7E.L.EACH ACCIDENT $ OFFICERMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101.Additional Remarks Schedule,if mores pace is regui red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Bldg 20 Ste 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Cindy Davis ©1988-2010 ACO RD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E-Mail: 0810712013 09:12 Coonan Insurance Agency,Inc. TAX) P.0011001 CERTIFICATE OF LIABILITY INSURANCE 1 9425092 DATE(MMir DDIYVYY) rCERTIFICAT5 TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE DOES NOT AFFtRMATNELY OR NEGATIVELY AME=ND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, CERTIFICATE OF INSURANCE=DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED RESS v OR OD c o IMPORTANT:It the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policles may require and endorsement, A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: COONAN INSURANCE AGENCY PHONE =A . 267 MARN STREET (A/C.No,Extl: E-MAIL OXFORD,MA 01540 ADDRESS: 78JFM INSURER($)AFFORDING COVERAGE NAIC 4 INSURED INSURER A: F(ARTFORD UNDBRWIalaRS INSURANCE COMPANY CONCORDIA CONSTRUCTION LLC INSURER B: INSURER C; INSURER D: 9 NEWTON AVaNUE INSURER E; OXFORD,MA O 154 0 INSURER F: COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: 4AVF SEEN ISSUED TD T R AMEO ABOVE FOR THE POLICY PH 100 0 NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN-THE INSURANCE AFFORDED EY THEPDUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS, INSR ADO SUB POLICY EFF OATE POLICY EXP OATE LTR TYPE OF INSURANCE L R POLICYNUMBER (Mk%001VYYY) (MM1001YYYY) UMTS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY $ CLAIMS MapDAMAGE TO RENTED E OCCUR, PREMISES(Ea occurnmus) EO EXP(Ary one Perron) $ E-L AGGREGATE LIMIT APPLIES PER; ERSONAL&AOV INJURY $ POLICY 0 PROJECT 0LOC ENERAL AGGREGATE $ RODUCTS-COMPlOPAO(3 $ AUTOMOBILE LIABILITY COMBINED SINGLE 5 ANY AUTO LIMIT(Ea accidert) ALL OWNED AUTOS BODILY INJURY $ sCHEOULE AUTOS (Por pe(son) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE S (Per accident) UMBRELLA UAB OCCUR EACHOCCURRENCE 3 EXCESSLIAS CLAIMS-MADE AGGRECATE $ DEDUCTIBLE RETENTION S $ A WORKER'S COMPENSATION AND WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN U8513999930-13 052212013 05=014 LIMITE3 ANY PRCPERrrOR/PARTNERlEXECVrIVENIA E,L.EACH ACCIDENT S OFF10ERnaeMGGR EXCLUDED? Q 100,000 (MandaloryIn MR) E.L.DISE=ASE•EA EMPLOYEE $ 100,000 If yea,dewba undar DESCRIFTION OF OPGRATIONa eclaa EL,DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIRESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER APFECTWO WORKERS COA1P COVERAOB. CERTIFICATE HOLDER CANCELLATION NORTH ANDOVER RILRLDING DEPT SHOULD ANY OF THE ABOVE OUCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 1600 OSGOOD STREET IN ACCORDANCE WITH THE POLICY PROVISIO : BLDG 20 STS 2035 AUTHORIZED REPRESENTATIVE Owe— NORTH ANDOVER,MA 01845 y ACORD 25 2010 o e ACORD name ana logo are reR s e ON;of A090 1§88-20-10 ACORD CORPO —SM rued. c- P�Lie�ca�ranrorcure�eh,C o�n/�<rJsac�iccvefh ffiee of Consumer Affairs;&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return Office of Consumer Affairs an ess Regulation Registration: 175425 Type: 10 Park Plaza-Suit Expiration: 5/10/2015 Supplement �and Boston,M 6 CONCORDIA CONSTRUCTION LLC. JOSHUA LEMPICKI 37 MARBLEHEAD ST NORH ANDOVER, MA 01845 Undersecretary Not valid without signature i Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction SuperNisnr License. CS-083439 JOHN A MCALOQN 37 MARBLEHEAD STk' N ANDOVER MA 01845.7,,� J Expiration Commissioner 12/27/2014 Rightfax N1-1 7/25/2013 6 : 13 : 23 AM PAGE 2/002 Fax Server " 0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) T TIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: COONAN INSURANCE AGENCY PHONE FAX 267 MAIN STREET (A/C,No,Ext): (A/C,No): E-MAIL OXFORD,MA 01540 ADDRESS: 78JFM INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY CONCORDIA CONSTRUCTION LLC INSURER B: INSURER C: INSURER D: 9 NEWTON AVENUE INSURER E: OXFORD,MA 01540 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM%DD\YYYY) (MM I)MYYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE 0 OCCUR. REMISES(Ea occurrence) ED EXP(Arry one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY [—]PROJECT [=]LOC DRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X�WCSSTATUTOREMPLOYER'S LIABILITY Y/N UB-513999930-13 05/22/2013 05/22/2014 ANY PROPERITOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? 100'000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION NORTH ANDOVER BUILDING DEPT SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD STREET BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISION6.­ BLDG 20 STE 2035 AUTHORIZED REPRESENTATIVE NORTH ANDOVER,MA 01845 �="..._ ----------------- ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACO RD CO RPORATWN'?r ATFIF10ts reserved. The Commonwealth ofMassachusetts Department of lndustriqlAcclddents Office of Investigations 600 Washington Street -Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers .Applicant Information Please Print Ledbly Name usiness/Or anization/Individual : CJ Address: City/State/Zip: UU/AG��S A, Phone#:L,6 Are you employer?Check the appropriate box; Type of project(required): 1. am a employer with 4• Ulram a general contractor and 1 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• ❑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 required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 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.❑Roofrepairs insurance required.)i employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they tie 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 their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Vi-y')�Ct l� y`tyY4hr�/ �4�CL/ Policy#or S elf-ins.Lic.4: (DCVO Expiration Date: Job Site Address:_ t TC�?2l13 n Ar�?-A City/statelzip: Attach a.copy of the workers'compensation-policy declaration 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 WORK ORDER and a fine of up to$250.0 0 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. Ido hereby certto under Aepains andpenaldes ofperjury that the information provided above is true 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): I.Board of Health 2.Building Department 3.CitylTown Clerk 4.EIectrical Inspector 5.PIumbing Inspector 6.Other - - Contact Person: Phone#: , Information and b5tructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- 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 j oint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that-the affidavit is-complete-and rinted legiblY: The De aitmerifhas rovrded a s ace afi the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The GornmmwoalthofM-assachimitts Department offadustdal,,Accidents . �ffee o�Fln��esti�ati.ons. 6.Q()Washiragtm Stxeot Boston,MA,0211.1 UL#61.7-72.7 4900 at406 ox 1:-8,77-MASSAFB Revised 5-26-05 Fay,#617-727-7749 ��i�ie�n-�rzrreorccue�cll�c�'C>/l�cc.�:tcrc�iuveCl.� ftice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration:, 375425 Type: 10 Park Plaza-Suite 5170 Expiration: 5/10/2015 Supplement :and Boston,MA 02116 CONCORDIA CONSTRUCTION LLC. JOSHUA LEMPICKI 37 MARBLEHEAD ST NORH ANDOVER,MA 01845 UndersecretaryC_ t valid without signature i 1' REScheck Software Version 4.4.4 Compliance Certificate Project Title: McAloon Energy Code: 2009 IECC Location: North Andover,Massachusetts Construction Type: Singe-family Project Type: Addition Heating Degree Days: 6322 Climate Zone: 5 Permit Date: Construction Site: Owner/Agent: Designer/Contractor: 80 Boston St. Edward McAloon Ed Buckingham North Andover,MA 01845 80 Boston St. Colonial Home Design North Andover,MA 01845 1 Dutchman Lane 978-682-3098 Westford,MA 01886 978-692-0006 edbuck55@aol.com Compliance: 0.6%Better Than Code Maximum UA: 333 Your UA:331 The%Better or Worse Than Code Index reflects how Gose 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 Assemblies GlazingGross Assembly Area or Cavity Cont. or Door UA Floor 1:All-Wood Joist/Truss:Over Unconditioned Space 1,802 30.0 0.0 59 WALLA:Wood Frame,16"D.C. 384 19.0 0.0 22 Window 1:Vinyl Frame:Double Pane with Low-E 11 0.310 3 WALL B:Wood Frame, 16"o.c. 176 19.0 0.0 8 Window 2:Vinyl Frame:Double Pane with Low-E 23 0.310 7 Door 1:Glass 21 0.320 7 WALL C:Wood Frame,16"D.C. 120 19.0 0.0 6 Window 3:Vinyl Frame:Double Pane with Low-E 12 0.310 4 WALL D:Wood Frame,16"D.C. 176 19.0 0.0 9 Window 4:Vinyl Frame:Double Pane with Low-E 27 0.310 8 WALL E:Wood Frame,16"o.c. 176 19.0 0.0 9 Window 5:Vinyl Frame:Double Pane with Low-E 9 0.310 3 i Window 6:Vinyl Frame:Double Pane with Low-E 9 0.310 3 WALL F:Wood Frame,16"o.c. 176 19.0 0.0 9 Project Title: McAloon Report date: 08/14/13 Gross Glazing Cavit Assembly . . Door UA Perimeter U-Factor Window 7:Vinyl Frame:Double Pane with Low-E 9 0.310 3 Window 8:Vinyl Frame:Double Pane with Low-E 9 0.310 3 WALL G:Wood Frame,16"o.c. 32 19.0 0.0 2 WALL H:Wood Frame,16"o.c. 304 19.0 0.0 16 Window 9:Vinyl Frame:Double Pane with Low-E 11 0.310 3 Window 10:Vinyl Frame:Double Pane with Low-E 11 0.310 3 Door 2:Glass 21 0.320 7 WALL A 2:Wood Frame,16"o.c. 208 19.0 0.0 11 Window 11:Vinyl Frame:Double Pane with Low-E 10 0.310 3 Window 12:Vinyl Frame:Double Pane with Low-E 10 0.310 3 WALL A3:Wood Frame,16"o.c. 304 19.0 0.0 17 Window 13:Vinyl Frame:Double Pane with Low-E 18 0.310 6 Window 14:Vinyl Frame:Double Pane with Low-E 6 0.310 2 WALL A4:Wood Frame, 16"o.c. 208 19.0 0.0 12 WALL A5:Wood Frame,16"o.c. 304 19.0 0.0 16 Window 15:Vinyl Frame:Double Pane with Low-E 18 0.310 6 Window 16:Vinyl Frame:Double Pane with Low-E 4 0.310 1 Window 17:Vinyl Frame:Double Pane with Low-E 18 0.310 6 Ceiling 1:Flat Ceiling or Scissor Truss 1,802 38.0 0.0 54 Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other calculations submitted with the permit application.The proposed building has been designed to meet the 2009 IECC requirements in REScheck Version 4.4.4 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. Name-Title Signature Date Project Title: McAloon Report date: 08/14/13 REScheck Software Version 4.4.4 LVJ Inspection Checklist Requirements: 0.0% 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. 2009 IECC Pre-Inspection/Plan Review Plans Verified Field Verified Complies? Comments/Assumptions Value Value 103.2 :Construction drawings and ❑Complies [PR1]' documentation demonstrate energy ❑Does Not Comply code compliance for the building ❑Not Observable envelope. ❑Not Applicable 103.2, Construction drawings and ❑Complies 403.7 documentation demonstrate energy ❑Does Not Comply. [PR3]' code compliance for lighting and ❑Not Observable mechanical systems.Systems serving []Not Applicable multiple dwelling units must demonstrate compliance with the commercial code. 403.6 Heating and cooling equipment is Heating: Heating: ;❑Complies [PR2]2 sized per ACCA Manual S based on Btu/hr Btu/hr '❑Does Not Comply J loads per ACCA Manual J or other Cooling: Cooling: []Not Observable approved methods. Btu/hr Btu/hr ;❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: McAloon Report date: 08/14/13 2009 IECC Foundation Inspection Complies? Comments/Assumptions 303.2.1 A protective covering is installed to protect ❑Complies [FO11]2 exposed exterior insulation and extends a ❑Does Not Comply minimum of 6 in.below grade. ❑Not Observable J ❑Not Applicable 403.8 Snow-and ice-melting system controls ❑Complies [FO12]2 installed. []Does Not Comply []Not Observable ❑Not Applicable Additional Comments/Assumptions: 11 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: McAloon Report date: 08/14/13 2009(ECC Framing(Rough-In Inspection Plans Verified Field VerifiedValueValue Complies? Comments/Assumptions 402.1.1, Glazing U-factor(area-weighted U- U- ❑Complies See the Envelope Assemblies table 402.3.1, average). ❑Does Not Comply for values. 402.3.3, ❑Not Observable 402.5 ❑Not Applicable [FR2]' 303.1.3 U-factors of fenestration products are ❑Complies [FR4]' determined in accordance with the ❑Does Not Comply. NFRC test procedure or taken from ❑Not Observable the default table. ❑Not Applicable 402.3.5 Sunrooms enclosing conditioned U- U- ❑Complies [FR8]' space have a maximum fenestration ❑Does Not Comply U-factor of 0.50 in Climate Zones 4-8. : ❑Not Observable New glazing separating the sunroom []Not Applicable from conditioned space must meet code requirements. 402.3.5 Sunrooms enclosing conditioned U- U- ❑Complies [FR9]' space have a maximum skylight U- ❑Does Not Comply' factor of 0.75 in Climate Zones 4-8. [-]Not Observable ❑Not Applicable 402.4.4 Fenestration that is not site built is ❑Complies [FR20]' listed and labeled as meeting ❑Does Not Comply AAMA/WDMA/CSA 101/I.S.2/A440 or ❑Not Observable has infiltration rates per NFRC 400 ❑Not Applicable that do not exceed code limits. 402.4.5 IC-rated recessed lighting fixtures ❑Complies [FR16]2 sealed at housingrnterior finish and ❑Does Not Comply s labeled to indicate 2.0 cfm leakage at ❑Not Observable 75 Pa. ❑Not Applicable 403.2.1 Supply ducts in attics are insulated to R- R- ❑Complies [FR1211 R-8.All other ducts in unconditioned ; R- R- ❑Does Not Comply spaces or outside the building ❑Not Observable envelope are insulated to R-6. ❑Not Applicable 403.2.2 All joints and seams of air ducts,air ❑Complies [FR13]1 handlers,filter boxes,and building ❑Does Not Comply cavities used as return ducts are ❑Not Observable sealed. ❑Not Applicable 403.2.3 Building cavities are not used for ❑Complies [FR15]3 supply ducts. ❑Does Not Comply y ❑Not Observable ❑Not Applicable 403.3 HVAC piping conveying fluids above R- R- ❑Complies [FR17]2 .105°F or chilled fluids below 55 IF ❑Does Not Comply' J are insulated to R-3. ❑Not Observable []Not Applicable 403.4 Circulating service hot water pipes are R- R- ❑Complies [FR18]2 insulated to R-2. ❑Does Not Comply' J ❑Not Observable (]Not Applicable 403.5 Automatic or gravity dampers are ❑Complies [FR19]2 installed on all outdoor air intakes and ❑Does Not Comply exhausts. ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 1 Low Impact(Tier 3) Project Title: McAloon Report date: 08/14/13 2009 IECC Insulation Inspection Plans Verified Field Verified Complies? Comments/Assumptions Value Value 303.1 All installed insulation is labeled or the ❑Complies [IN13]2 installed R-values provided. ❑Does Not Comply ❑Not Observable []Not Applicable 402.1.1, Floor insulation R-value. R- R- ❑Complies See the Envelope Assemblies table 402.2.5, ❑ Wood Wood E]Does Not Comply for values. 6 [IN1]1 El Steel f-1Steel '[]Not Observable IN1]' ❑Not Applicable 303.2, Floor insulation installed per ❑Complies 402.2.6 manufacturer's instructions,and in ❑Does Not Comply [IN2]1 substantial contact with the underside ❑Not Observable 2 of the subfloor. ❑Not Applicable 402.1.1, Wall insulation R-value.If this is a R- R- ❑Complies See the Envelope Assemblies table 402.2.4, mass wall with at least 1/2 of the wall ;El Wood El Wood ❑Does Not Comply for values. 402.2.5 insulation on the wall exterior,the ❑ Mass ❑ Mass ❑Not Observable [IN3]' exterior insulation requirement Not Applicable applies. ❑ Steel ❑ Steel ❑ PP 303.2 Wall insulation is installed per ❑Complies [IN4]' manufacturer's instructions. ❑Does Not Comply t9 ❑Not Observable ❑Not Applicable 402.2.11 Sunroom wall insulation has a R- R- ❑Complies [IN8]' minimum R-value of R-13.New walls ❑Does Not Comply separating the sunroom from ❑Not Observable conditioned space must meet code ❑Not Applicable requirements. 303.2 Sunroom wall insulation installed per ❑Complies [IN9]' manufacturer's Instructions. ❑Does Not Comply ❑Not Observable ❑Not Applicable 402.2.11 Sunroom ceiling minimum insulation R- R- ❑Complies [IN10]1 R-value of R-19 in Climate Zones 1-4, ❑Does Not Comply. ,and R-24 in Climate Zones 5-8. ❑Not Observable ❑Not Applicable 303.2 Sunroom ceiling insulation is installed ❑Complies [IN11]' per manufacturer's instructions. ❑Does Not Comply ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: I 11 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 1 Low Impact(Tier 3) Project Title: McAloon Report date: 08/14/13 it 2009 IECC Final Inspection Provisions Plans Verified Field VerifiedValueValue Complies? Comments/Assumptions 402.1.1, Ceiling insulation R-value.Where>R- R- R- ❑Complies See the Envelope Assemblies table 402.2.1, 30 is required,R-30 can be used if El Wood ❑ Wood []Does Not Comply for values. 402.2.2 insulation is not compressed at eaves..El Steel ❑ Steel ❑Not Observable [FI1]' R-30 may be used for 500 ftz or 20% ❑Not Applicable ; (whichever is less)where sufficient space is not available. 303.1.1.1, Ceiling insulation installed per ❑Complies 303.2 manufacturer's instructions.Blown ❑Does Not Comply [F12]' insulation marked every 300 W. ❑Not Observable ❑Not Applicable 402.2.3 Attic access hatch and door insulation . R- R- ❑Complies [FI3]' R-value of the adjacent assembly. ❑Does Not Comply' } ;❑Not Observable ❑Not Applicable 402.4.2, Building envelope tightness verified ACH 50= ACH 50= ❑Complies 402.4.2.1 'by blower door test result of<7 ACH ❑Does Not Comply; [F[17]' at 50 Pa.This requirement may '❑Not Observable instead be met via visual inspection, []Not Applicable in which case verification may need to' occur during Insulation Inspection. 402.4.3 Wood-burning fireplaces have ❑Complies [FI8]2 Basketed doors and outdoor ❑Does Not Comply combustion air. []Not Observable . Not ❑ Applicable 403.2.2 Post construction duct tightness test cfm cfm ❑Complies [FI4]' result of 8 cfm to outdoors,or 12 cfm ❑Does Not Comply across systems.Or,rough-in test ❑Not Observable result of 6 cfm across systems or 4 ❑Not Applicable cfm without air handler.Rough-in test verification may need to occur during Framing Inspection. 403.1.1 Programmable thermostats installed ❑Complies [Fl9]2 on forced air furnaces. ❑Does Not Comply. ❑Not Observable ❑Not Applicable 403.1.2 Heat pump thermostat installed on ❑Complies [F110]2 heat pumps. ❑Does Not Comply J ❑Not Observable ❑Not Applicable 403.4 Circulating service hot water systems ❑Complies [FI11]2 have automatic or accessible manual ❑Does Not Comply; controls. ❑Not Observable []Not Applicable 403.9.1 Readily accessible switch on heaters ❑Complies [FI12]3 for swimming pools. ❑Does Not Comply' J EJ Not Observable [-]Not Applicable 403.9.2 Timer switches on pool heaters and ❑Complies [FI19]3 pumps are present. ❑Does Not Comply J ❑Not Observable ❑Not Applicable 403.9.3 Heated swimming pools have a cover. ❑Complies [F120]3 Covers on pools heated over 90 OF ❑Does Not Comply are insulated to R-12. ❑Not Observable ❑Not Applicable 404.1 50%of lamps in permanent fixtures OComplies [FI6]' are high efficacy lamps. []Does Not Comply []Not Observable []Not Applicable 11 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 1 Low Impact(Tier 3) Project Title: McAloon Report date: 08/14/13 2009 IECC Final Inspection Provisions Plans Verified Field Verified Complies? Comments/Assumptions Value Value 401.3 Compliance certificate posted. ❑Complies [FI712 ❑Does Not Comply J []Not Observable ❑Not Applicable 303.3 Manufacturer manuals for mechanical ❑Complies [FI18]3 and water heating equipment have ❑Does Not Comply been provided. ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: McAloon Report date: 08/14/13 091ECC Energy Efficiency Certificate Wall 19.00 Floor 30.00 Ceiling I Roof 38.00 Ductwork(unconditioned spaces): Window 0.31 Door 0.32 Heating System: Cooling System: Water Heater• Name: Date• Comments: I