HomeMy WebLinkAboutBuilding Permit #085-2011 - 81 EMPIRE DRIVE 7/28/2010 ORT1�
BUILDING PERMIT Of NO ,b gti
TOWN OF NORTH ANDOVER 3+ 4` -"' *` °
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APPLICATION FOR PLAN EXAMINATION
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C% a.^
Permit NO: Date Received
�gSSACHUs
Date Issued: /"
IMPORTANT: Applicant must complete all items on this page
LOCATION &&L— E Doe(tJ DoT
Print
PROPERTY OWNER Y P U
Print
MAP 210 /07C PARCEL: f ZONING DISTRICTT Historic District yes
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resi Non- Residential
New Buildin One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
.ater/Sewer (�
DESCRIPTION
OF WORK TO BE PREFORMED:A)ttIt
Pu 1 tc. SeWCA
UkIdU UAA.J . cpq4SF
IdentificatioR Please Type or Print Clearly)
OWNER: Name:oJeLg `lu.AlraG GGC. Phone?7J-Rej-31P ,
Address: �� d p 6 0 79• �(9Z
k& 9, T15
CONTRACTOR Name.y 4 Phone: —�� ,�"" �6
Address y 646 L3/UG DeJOC 7ccsP 2U JRA • 0(17?1(
Supervisor's Construction License l6s /Oc;D Exp; Date:
Home Improvement License: 1V/7 F 9 Exp. Date:
ARCHITECT/ENGINEEPhone:ye'S?S2 —63/8
Address:Ag6 /�l�,l / C-� a Reg. No. 7 7�oS
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost:
$ FEE: $_.I,
UCl
x/ >'
Check No. Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
ignature AAgent/Owner Signature of contractor
Location
No. O f�r^ // Date
^T� TOWN OF NORTH ANDOVER
Ip. �
Certificate of Occupancy $
CwUs Building/Frame Permit Fee $ y 74o-
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ G
Check # /.2 2 3
232 / 1
Building Inspector
9512
Date...Z.:�/
NORTH
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... .< :..z........ '. ...............................................
has permission to perform ......d..4.jo--r. ......... .......*...........
AA
/ /2 ....4.7...............
wiring in the building of..... ............. .....
........./,to7 ......... North Andover,Mass.
A-
Fee.. ........ North
P.
ELEcmcAL INspEcmR
Check #
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
v
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
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THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
6
COMMENTS l li(lfl
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CONSERVATION Reviewed on b 0 Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS � - - . : - . - -• ._
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(la.
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: ComM'ents t
Water& Sewer Connection/Si nature& to�' 4;";V;//1--DrivewaPermit
DPW Town Engineer: Signature: D
ocated 384 Osgdoa S eet
FIRE DEPARTMENT -Temp Du p er on sit yes no
Located at 124 Main Street --
Fire Department signature/dat 42 � r
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.a"Lsr—
Total
land areas . ft.: 5F
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
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NOTES and DATA— (For department use
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❑ Notified for pickup - Date
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j Doc.Building Permit Revised 2010
1 '
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Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
tRoofing, 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/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
❑ Certified Proposed Plot Plan �w
❑ 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 2008
i
� pRT1y ,
ONM of
O ndover
No.
d��- ORO# Ae P X,0
-
.LAKE .O dover, Mass.,
COCHICMEWICK
�q AD'QATED
SS BOARD OF HEALTH
Food/Kitchen
Septic System
PERMIT T D
BUI ING INS CTOR
THIS CERTIFIES THAT......... �� ' �..1�...L..C� 1........., ^.L- .l�-....................................................... F un
G
� .../ ............ Ro hhas pBfmISS10n to erect..............:......................... buildings on ........
to be occupied.as......................................, �...:5.......rte .. ./ ? .��. �........................................ ................ y /r c
provided that the person accepting this permit shall in evd�respect conform tX, terms of the application 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 INPEC_
VIOLATION of the Zoning or Building Regulations'Voids this Permit.
...Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECT
UNLESS CONSTRUCTION STARTS T_ - Io
E..... .,u!......
Se '
BUILDING INSPECTOR
rinjal ��
Occupancy Permit Required t0 Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the- Premises - Do, Not Remove Finale
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street-lo.
SEE REVERSE SIDE Smoke Det. �,mo*4 /'dei '
- 3z
.i
ORTH
® of �. O
And
over .
dover, Mass.,
COCHICHEWICK
7,p ADRATED
`SS BOARD OF HEALTH
Food/KitchenPERM IT T D I
Septic System,
BUIJvQING SPECTOR
THIS CERTIFIES THAT.........
all; .. �(...1.., t ........A./-,.� Q�
`.................................. F un
ls��..... Cr�F.................... Ro h
a
has permission to erect..............:......................... buildings on ........ �.....1.! �
to be occupied.as
provided that the person accepting this permit shall in evdry respect conform tj terms of the application on file in final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING IN PECTOR
VIOLATION of the Zoning or Building Regulations-Voids this Permit. � �
.. � Final
PERMIT EXPIRES- Fi
IN 6 MONTHS n
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECT31
40 00:
Se .
BUILDING INSPECTOR
final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the- Premises — Do Not Remove Final,
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street o.
SEE REVERSE SIDE Smoke Det.
MORIN
•r;r' y
f
s , '
tfAC
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 857 L 1 Date: January 20,2012
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 81 Empire Drive.North Andover, MA 01845
MAYBE OCCUPIED AS new single famHy IN ACCORDANCE VUH TIIE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certifiicate-I."fed to.- Orchard Vitlage LLC
277 Washington.Street
Gra eland KA 4143
Building Inspector
Fee: 1-00::00 previously paid
R�aeipt 2371
LAWRENCE H. OGDEN, P.E.
198 EAST MAIN STREET
GEORGETOWN,MA 01833
978-352-8318 fax 978—352-2858
cell: 978-502-5921
November 6,2010
Mr. Robert Messina
Orchard Village LLC.
Empire Drive
North Andover, Ma 01845
RE: THE WILLOW GB# 6213
Lot 17 Empire Drive,North Andover,Ma. 01845
Dear Mr. Messina
As you requested I visited the site 11/4/10 to review the installation of the
Engineered Materials consisting of LVLs and Engineered Joist utilized in the framing
of the above project. These are shown on plans prepared by G.J. Bruno and Associates A-
I to A-5 Dated 7/30/09 with the framing sheets certified by me 6/15/10.
The following items require additional work.
4. Insure that the 3-16d nails from the plate to between the studs as shown on the
Braced Wall Additional Connection Detail are in place. As I discussed with
Jeff Horne this nailing should be from the plate to the rim board.
5. Add additional studs under the LVLs at the Breakfast Area to insure the
number of studs required match the plan. Review post at all other locations.
6. Note the Rough Plumbing,Electric and HVAC was not complete at the time
of this visit.
Based on the above site visit and based on what I could visibly see provided the
above additional work is completed I can certify that to the best of my knowledge the
LVLs members and Engineered Joist utilized in the framing as shown on the drawings
are installed properly and meet the loading conditions of the Massachusetts State
Building Code for 1&2 Family Residences. This certification assumes that all other
framing requirements of the drawings and code, including but not limited to materials,
nailing schedules, blocking, connections and other details were properly complied with
by the licensed construction supervisor responsible for the project.
Should you have any questions please do not hesitate to call. OF
Yours truly,
g WRENCE �yG
HAROLD
GDcN �'+
ti
65 O
Lawrence H. Ogden P.E. Structural 27765 or�ssQ;
Cc:Mr. Gerry Bruno lr jb to
Copy mailed to Mr. Robert Messina, 44 Great Pond Road,Boxford, Ma. 01921
ORTH
® of _ Andover
lit
No. '' `
C% v0i1 LAKE o dover, Mass.,
COC".C..'W..K V
7�A0RATED
`ss BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT......... ...
... r �.. ...1... ........ ! .l .C�....................................................... Foundation
r p
has permission to erect........................................ buildings on ........��...../1 .�.9.j�1'?e.... .................... Rough
to be occupied.as t 1�'. %� �a �t'�'�respe'... �t ..1.`. Chimney
.. . . . . ...............................................
provided that the person accepting this permit shall in ev ry ct conform t he terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
LESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
UNLESS
' Rough
.............1. ... . !'r..d:. .... .......................:.......................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the- Premises Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner.
Street No.
SEE REVERSE SIDE Smoke Det.
LAWRENCE H. OGDEN,P.E.
198 EAST MAIN STREET
GEORGETOWN,MA 01833
978-352-8318 fax 978—352-2858
cell: 978-502-5921
September 7, 2010
Mr. Robert Messina
Orchard Village LLC.
Empire Drive
North Andover, Ma 01845
RE: THE KINGSTON GBA 5341
Lot 18 #81 Empire Drive,North Andover,Ma. 01845
Dear Mr. Messina
As you requested I visited the site 9/3/10 to review the installation of the
Engineered Materials consisting of LVLs and pre-engineered floor joist utilized in the
framing of the above project. These are shown on plans prepared by G.J. Bruno and
Associates A-1 to A-5 Dated 6/9/10 with the framing sheets certified by me 6/15/10.
The following items require additional work.
1.0 The LSTA24 strap at each end of the Garage Header on the inside has to be
installed as shown on 2-F Framing sheet A5. The method used at the Garage
Doors is a prescriptive method developed by the APA and allowed in the IRC
code and the details must be followed to insure proper performance.
2.0 Add additional Fasten Master Truss Lok screws to connect the LVLs together
as shown on the plans and the detail on sheet A-5. Note 16d Gun nails are not
acceptable. These requirements are engineered to connect the LVLs based on
the load applied to the LVL and must be followed.
3.0 Hurricane clips must be added to all roof rafters, some rafters do not have
Hurricane clips. These are required to resist the wind uplift requirements of
the Building Code.
4.0 Add blocking between the rafters as shown on the Braced Wall Panel
Additional Connections shown on A-5. Also 3-16d nails are required every
16"between studs from the wall plate to the rim board,blocking or joist.
These additional connections as shown on sheet A-5 are required in the code
to insure proper performance of the prescriptive wall bracing requirements of
the code.
1
Page 2
RE: THE KINGSTON GB# 5341 Lot 18 981 Empire Drive,North Andover,Ma. 01845
Based on the above site visit and based on what I could visibly see provided the
above additional work is completed I can certify that to the best of my knowledge the
LVLs members utilized in the framing as shown on the drawings are installed properly
and meet the loading conditions of the Massachusetts State Building Code for 1&2
Family Residences. This certification assumes that all other framing requirements of the
drawings and code, including but not limited to materials, nailing schedules, blocking,
connections and other details were properly complied with by the licensed construction
supervisor responsible for the project.
Should you have any questions please do not hesitate to call.
Yours truly,
�o SN OF Mgs�o
AWRENCE G
DtN X17 2 0 I O
Lawrence H. Ogden P.E. Structural 27765
Cc: Mr. Gerry Bruno FSS NAL ENG\��
Copy mailed to Mr. Robert Messina
44 Great Pond Road
Boxford, Ma. 01921
I
I
Office of Consumer Affairs&Business Regulation
HOME IMPRRYEMENT CONTRACTOR
Registrationj,•"
,,,,x.64829
Expira, _=1 011 Tr# 290708
Type'-
tion
MESSINA DEV ��r,� ANY INC.
ROBERT MESSai - y,�r°�
44 GREAT PONDS
BOXFORD, MA 0192ef Undersecretary
— [Massachusetts - Depai-tment of Public Sirfetl
Board of Building Re-ulations and Standardb
Construction Supervisor License
License: CS 102931
Restricted to: 1 G
ROBERT MESSINA
44 GREAT POND DRIVE
BOXFORD, MA 01921
a--
���� Expiration: 8/31/2012
('ommisioner Tr#: 102.931
•
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LOT 18
35.5'
�1
'y
25.2'
• EXISTYND.
C4 EL.=293.3'
;y
10.4'
34.5'
MICHAEL q�S
S -1
v 33191 y
A V
OFfSS10�o�
EMPIRE D � SURv
FOUNDA TION L O A TION /CERTIFYTHAT THE PR/MARYSTRUCTURE SHOWN CONFORMS
TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL
APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED.
CLIENT• ORCHARD VILLAGE, LLC (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER
RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS,
THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT ORDERS OF CONDITIONS,ETC.)THIS DRAWING SHALL NOT BE
LOCATION:NORTH ANDOVER,MA. OUTLINE ABOVE Mxc�WTHTHEEi�PERMISSIONER of
CHRISTIANSEN&SERGI INC.FURTHERMORE THIS DRAWING IS
DATE.- 7/20/10 SCALE.1=20' THE COPYRIGHTED PROPERTY OFCHRIST/ANSEN&SERGI INC.
AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRIST/ANSEN&
SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE
OF THIS DRAWING OR ANY INFOR-MATION CONTAINED HEREON.
PROFESSIONAL ENGINEERS& LAND SURVEYORS
CHRISTIANSEN & SERGI, INC.
160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830
WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX 978-372-3960
D W G.NO.:06029.001.04 7
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MAScheck COMPLIANCE REPORT I
Massachusetts Energy Code I Permit # I
MAScheck Software Version 2.01 Release 2 I I
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I Checked by/Date I
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CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non-Electric Resistance)
DATE: 6-28-2010
DATE OF PLANS: 6/9/10
TITLE: The Kingston
PROJECT INFORMATION:
Orchard Village, Empire Drive
COMPANY INFORMATION:
Orchard Village, LLC
COMPLIANCE: PASSES
Required UA = 556
Your Home = 332
Area or Cavity Cont. Glazing/Door
Perimeter R-Value R-Value U-Value UA
-------------------------------------------------------------------------------
CEILINGS 1425 38.0 0.0 43
WALLS: Wood Frame, 16" O.C. 2505 20.0 0.0 148
BSMT: Conc. 8.0 ht/7.0 bg/0.01 insul 0 0.0 0.0 0
GLAZING: Windows or Doors 307 0.350 107
DOORS 70 0.000 0
FLOORS: Over Unconditioned Space 1025 30.0 0.0 34
HVAC EQUIPMENT: Furnace, 96.0 AFUE
HVAC EQUIPMENT: Air Conditioner, 13.0 SEER
--------------------------------------------------------------------------------
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 requirements of the Massachusetts Energy Code.
The heating load for this building, and the cooling load if appropriate,
has been determined using the applicable Standard Design Conditions found
in the Code. The HVAC equipment selected to heat or cool the building
shall be no greater than 125% of the design load as specified in
Sections 780CMR 1310 and J4.4.
Builder/Designer Date
Massachusetts Energy Code
MAScheck Software Version 2.01 Release 2
The Kingston
DATE: 6-28-2010
Bldg. l
Dept. l
Use I
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I CEILINGS:
[ l I 1. R-38
I Comments/Location
I
I WALLS:
[ ] I 1. Wood Frame, 16" O.C. , R-20
I Comments/Location
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I BASEMENT WALLS:
[ ] I 1. Conc. 8.0' ht/7.0' bg/0.0' insul, R-0 (uninsulated)
I Comments/Location
I
I WINDOWS AND GLASS DOORS:
[ ] I 1. U-value: 0.35
I For windows without labeled U-values, describe features:
I # Panes Frame Type Thermal Break? [ ] Yes [ ] No
I Comments/Location
I
I DOORS:
[ ] I 1. U-value: 0
I Comments/Location
I
I FLOORS:
] I 1. Over Unconditioned Space, R-30
Comments/Location
I
I HVAC EQUIPMENT:
[ ] I 1. Furnace, 96.0 AFUE or higher
I Make and Model Number
[ ] I 2. Air Conditioner, 13.0 SEER or higher
I Make and Model Number
I
I AIR LEAKAGE:
[ ] I Joints, penetrations, and all other such openings in the building
I envelope that are sources of air leakage must be sealed. When
I installed in the building envelope, recessed lighting fixtures
I shall meet one of the following requirements:
I 1. Type IC rated, manufactured with no penetrations between the
I inside of the recessed fixture and ceiling cavity and sealed or
I gasketed to prevent air leakage into the unconditioned space.
I 2. Type IC rated, in accordance with Standard ASTM E 283, with no
I more than 2.0 cfm (0.944 L/s) air movement from the the
conditioned space to the ceiling cavity. The lighting fixture
I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure
I difference and shall be labeled.
I VAPOR RETARDER:
[ ] I Required on the warm-in-winter side of all non-vented framed
I ceilings, walls, and floors.
I
I MATERIALS IDENTIFICATION:
[ ] I Materials and equipment must be identified so that compliance can
I be determined. Manufacturer manuals for all installed heating
I and cooling equipment and service water heating equipment must be
I provided. Insulation R-values, glazing U-values, and heating and
I cooling equipment efficiency must be clearly marked on the building
I plans or specifications.
I
I DUCT INSULATION:
[ ] I Ducts shall be insulated per Table J4.4.7.1.
I
I DUCT CONSTRUCTION:
[ ] I All accessible joints, seams, and connections of supply and return
I ductwork located outside conditioned space, including stud bays or
I joist cavities/spaces used to transport air, shall be sealed
I using mastic and fibrous backing tape installed according to the
I manufacturer's installation instructions. Mesh tape may be
I omitted where gaps are less than 1/8 inch. Duct tape is not
I permitted. The HVAC system must provide a means for balancing
I air and water systems.
I
I TEMPERATURE CONTROLS:
[ ] I Thermostats are required for each separate HVAC system. A manual
I or automatic means to partially restrict or shut off the heating
I and/or cooling input to each zone or floor shall be provided.
I
I HVAC EQUIPMENT SIZING:
[ ] I Rated output capacity of the heating/cooling system is
I not greater than 125% of the design load as specified
I in Sections 780CMR 1310 and J4.4.
I
I SWIMMING POOLS:
[ ] I All heated swimming pools must have an on/off heater switch and
I require a cover unless over 20% of the heating energy is from
I non-depletable sources. Pool pumps require a time clock.
I
I HVAC PIPING INSULATION:
[ ] I HVAC piping conveying fluids above 120 F or chilled fluids
I below 55 F must be insulated to the following levels (in. ) :
I
I PIPE SIZES (in.)
I HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-4"
I Low pressure/temp. 201-250 1.0 1.5 1.5 2.0
I Low temperature 120-200 0.5 1.0 1.0 1.5
I Steam condensate any 1.0 1.0 1.5 2.0
I COOLING SYSTEMS:
I Chilled water or 40-55 0.5 0.5 0.75 1.0
I refrigerant below 40 1.0 1.0 1.5 1.5
I CIRCULATING HOT WATER SYSTEMS:
[ ] I Insulate circulating hot water pipes to the following levels (in. ) :
I PIPE SIZES (in.)
I NON-CIRCULATING I CIRCULATING MAINS & RUNOUTS
I HEATED WATER TEMP (F) : RUNOUTS 0-1" I 0-1.25" 1.5-2.0" 2.0+"
I 170-180 0.5 I 1.0 1.5 2.0
I 140-160 0.5 I 0.5 1.0 1.5
I 100-130 0.5 I 0.5 0.5 1.0
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----NOTES TO FIELD (Building Department Use Only)-------------------------
The Commonwealth ofMassachus
Department o efts
f rftdustrial Accidents
Off ce of rnvestib adons
600 ifravhintrton Street
Boston, A L4 62111
Workers'
A m � id
Compensation Insurance Affidavit:
Www-Mas$ �ers
/Contractors/Electricians/Plumbers .
Pleas Print L.e ibly
Name(Business/Organizadon/Individual): N
d�ri Ve
City/State/Zip:
7
Are you an employer?Check the appropriate boa;
1•❑ I am a employer with 4. ❑ I am a a Type of project(required).-' .
employees(full and/or part-time).* have hirederal contractor and I
the sub-contractors 6• KNew construction
-•�I am a sole proprietor or partner- listed on the attached sheet $ 7• ❑RemodeIin
ship and have no e g
employees ees
P Y These su
b-contractors have
working forme in any capacity, workers coin . ' g Remodeling
working
p insurance.
[No workers'comp: insurance 5. ❑ We are a corpgration and its 9 (�Building addition
3.❑ retluired.] � officers have exercised their I0. �
.I am a homeowner doing all work right o f ❑ kcal repairs or additions
myself, No workers'comp. c. exemption per.MGL 11.0 Plumbing repairs oradditions
insurance required.]t '§1(4),and we have no ❑
q employees. 1- Roof repairs
[No workers _
a lien;the comp.insurance required,] 13.[] Other
-�'-?"? t ch.:�s bos:•u! mast=lsU a o•�t Enc se�ipn b_!o�!�::nog:�.�=i. ,
t Ijomeown=who submit This affidavit indicatin ti a oficwa com•�
# g they a._doing all i;'otk and ruea'hireo r --r , ,;,{kion.
Conthacton;that chi this bax must attache3 an add contrEctc;mt•t,., t
additional sheet showing jb:nt a ne-w affidavit indicating such.
. �the name of�e s,_thconLL�;.tss and their worker;'
lam an em p g ' P comp.Pommy information.
P�J'� that is rovidin workers compensation insurance for my employees. Below is the policy and job site
information.
Insurance Compiny Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Sob Site Address: � _. •
Attach a copy of the workers'compensation policy declaration. ane(show..,City/State/Zip: - -
P tv
Failurethe Policy to secure coverage as required under Section 25A ofM P Y number and expir'afion date).
fine up to$1,50Q.00 and/or one-year imprisonment,as well as c rvil penatties�inead to thee form of a STOP WORK ORD
P criminal penalties of a
Of up to$20.00 a day against the violator. Be advised that a copy ER and a fine
Investigations of the DTA for insurance coverage verification. of this statement may be forwarded to the Office of
I do hereby cerci der the pains and p
Si- e: enalties .fP J o er'u
rJ that the information provided above is true and correct
_natur •
Phone#:
Official use only. Do not write in this area, to be completed bj,cam,or torn official
City or Town:
Permit/License#
Issuing Authority(circle one):
L Board of Health 2.Ddine Department.3. CityTown6. OtherElectricalClerk 4.
lnPect
or
5.PIumbinb inspector
Contact Person:
Phone
i
Information an- d I structlons
Massachusetts General Laws chapter 152 requires all-employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnersbip,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 o,w other legal entity,employing employees. However the
owner of a dwelling house having not more ththree apartnz eats and who resides therein,or the occupant of the
dwelling house an°of another who employs persons to do mainte=nance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be:pause of suchemployment be deemed to be an employer"
MGL chapter 152,§25C(6)also states that"every state or local licensingaDency shall withhold the issuance or
renewal,of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of colanpliance 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 um-t:11 acceptable evidence of compliance with the ineurance
requirements of this chapter have been presented to the contra ctng 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 thm the
members or partners,.are not required to carry workers'comp ensation insurance. If an LLC or LLP does have.
employees,apolicy is required. Be advised that this affidavit: may be submitted to the Department of Industrial
Accidents for confirmation of insurance,coverage. .Also be sure to sign and date the affidavit. The affidavit should
be rct mmicd to the city or ern that the a,;�,uGauou far e perriart'or License is,being request.:d,not the.Dena—errt of
Industrial Accidents. Should you have any questions regardb g the raw or if you are ,; vd 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 Offirials
Please be sure-that the affidavit is complete and printed legibly. The Department has provided a space•at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the pmrait(license number which will be-used
as a-reference number. In an additio �n, a 'can
pph t
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 cityor town may be provided to the
applicant as roof
Y
pp p that a valid affidavit is on file for future perZmits or licenses. Anew affidavit must be filled out each .
year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture
(Le.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit:.
The Office ofInvestigations wc)uld h'ke 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 mmnbez_.. .
The Commonwealth- of Massachusatts.
Department afIndustrial A=idents
Office.of hrestigations
600 Wa6ingarton Street
Boston,MLA 02111
Tel. #617-727-4900 ext 4.06 or 1-977-MAS.SAFF-
Revised 5-26-05
Fay.#6.17-72.7-7749
VrvM—Mass._gov/dia.
i,..•,_..,s �.vaarrrrvsr�s�.-QI�•1I f,II r7p„ •Z'S �Illitt:llI CA.Itll”
. Department of Fire Services ►>e t tt„t t,
i
BOARD OF FIRE PREVENTION REGULATIONS (h c upan(� and Fee< tilt c kf d
(1{ev, 9:0j) tlea►c htanl.t
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W
11 , , . . WORK
,i t
k t, It ..-,
< <t i,nn I �
nt aft, r _
{' dance lti it[,thr '+~1rt?`•d4hU\eU\ I.Ieetrital C cui�t 4fl.l }. �_2?t;'ttt{ I'.t?(i
1.11; PRIAT IA 1AK OR T PE ALL INFO itf l7O.1/ Date:
7 �3- i”
( iter or Town of: /J�
l/tc• I►t.vhcc•lut- (►/ 6t'il•cf.�:
lid thi,alllllicatiun site undersiLt led gives tit) ice cit-Itis or her intentitrtt tit hcrtornl the cicctrical ►,ttrk described belut,l.
I.ocalion (Street & Number) 14,
Owncr or ----
/j�_//�l _ Telephone No.
y�Is this this permit in cun•juncltir�with a building permit:' N es � bio � --.-
((`heek Appropriate taut)
1'nrpu�c (of Building -
___- l tilifN Autboriiation No.
Esicting Scr►ice ,1m 101 -
-� p volts erhead t'n(Il;rdA Nci. of Meters
tiew tiers ice Q r/ Anips 't"'u#tsvenc�ad ��nd jrd
�_— Ol }, � No.of Meters
Number of hreders anti Anipacity
I.ocalion and Mature of Proposed Electrical Work: � - ---- '
`—t ulll i<1'11rv1.rl ii€r•1.:�;r;i;plf�!/rfh
~It'll lYti('i iil,' 11il'r1',Iw— ft
,.
No. of Recessed t.urninaires No. of Ceil.-Susp.(Paddle) Fans ° (' ota
Transformers KVA
No. of t.urrlinaire OutletsNo. of Mot ftths
+. (venerators KV A
No. of I.nnrinaires Swimming Pool Aha►e n- i o. o mergenc► 15 Ind
-- g �rnd_ jrn(1- �-� Ba
Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS LNo.of Zones
No. No. of Gas Burners o. of Detection and,
Initialing Ue►ices
fit:. of It lol-,cs No.of Air Cond. Inr2 t No. of Alerting Dc►ices
No_ flf-N ante I)ispt►scrs eat amp um er ons I K ' 'o. fl Nell-(- ontained
Tutals: I)etectionlAlertin Deices
No, cif# iAmashers NpacelArea Cleating KW unrclpa t__,
Local[ Connection --t Other
No. of t}rtrrs licating Appliances KW Securiti Systems:* I
o. o atf r No.of I)e►ices or Ft ui►alent
o•o
K W n. u Data Wiring:
___ 1lcatcrs Si Ballasts
No.of Be%ices or E ui►:hent
No. ihdrunulssa}�e tt:ithfuhs No.of Motor% total IIP elecontttnfnications Is 'frinQ:
- No.of Uc►ices or I: ui►alent
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