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HomeMy WebLinkAboutBuilding Permit #231-13 - 87 ADAMS AVENUE 9/20/2012 t pORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: v Date Received I� 5 �1 p°a�reo�PP�'l Date Issued: `�� IMPORTANT:Applicant must complete all items on this page - - ,.ter,, _ -- - • -• - --- - - - - ,_r' L©CATION Pint PROPERTY°QWNERa 1 P 1 ��d� C�fl.: t kT Pnnt . { 'MAP-NO'. t PARCEL: ZONINGUSTRICT: �Histonc:Distnct yes MachineShop;Village; „yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne famil Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Well Floodplain' Wetlands Watersfied.Qistrict` atef/S TSCRIPTIONL OF WORK TO BE PREFORMED: C�C- Identificati n Please Type or Pri t Clearly) OWNER: Name: a Phone: Address: ��-- CONTRACTOR, Name ,>MIrX10 Phone: ,�r,n D Su ,ervisor'.s,Construction'License ( ^a0 1 ):/_ Exp 'DateLI . . Home Improvement License s.�. _< --54. ARCHITECT/ENG IN EER I,�} p,._�2�� Ile Y-) — Phone: Address:, K E Aj%Q 6 C cz pe- L4 meg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$ 5.00 PER S.F. Total Project Cost: $ FEE: $ > a �l��� ��av� Cdr✓� �S� Check No.: ecerpt"No.: NOTE: Persons contracting with re ' teYed'contractors%dW not have access to the guar ty fund Signature of- gen At/Ovvner Signature.of contractor Location '� 1 A&A M2 yQ` No. Z / _ Date T-Q 12,-- TOWN vTOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $/0 0 Other Permit Fee $ tl TOTAL $ �1 410 0 Check A 25736 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans i TYPE OF SEWERAGE DISPOSAL 1 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 I DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT I COMMENTS I 1 ' CONSERVATION Reviewed on ( 'L Si nature \ 4A COMMENTS HEALTH viewed on Signature C del EM NTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes I 'Planning Board Decision: Comments ' Conservation Decision: Comme s g- Water & Sewer Connection/si natu DW,&— Drivewav Permit DPW Town Engineer: Signature: Located 384.0s reet FIRE"DEPARTMENT -Temp D mp er on a yes .. no. 4 Located at-'124 Mam;Street x , Fire'Department`signaturd1da 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) ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Building Department artment 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 a 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 ❑ 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 V OTE: 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 r 'o • r" r 04 • sr:» °r Yg'TlcllUS CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 231-13 on 9/20/2012 Date: March 4,2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 87 Adams Avenue 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: Belford Construction 130 Marbleridge Road North Andover,MA 01845 Building Inspector Fee: Pre Paid Receipt: 25736 Check : 4395 R t1oRTF� q SS O �T LED f6 ti to • ~ ' APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION O w Le<wic °R' CHUS 5 BUILDING PERT# / BUILDING ADDRESS/LOCATION OF PROPERTY: 6 7-aAMS 4V P Map 045 Parcel � 4 Lot Number SUBDIVISION: DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE(5)DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WIL _ CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT S GNATURE Permit Issued to: z 4 Address: /30 /?'arh ROUTING TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW ❑ CONSERVATION 31'MI�3 PLANNING l DPW-WATER METER SEWER CONNECTION DPW MUST INDICAT T THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF T C ANCYANSPECTION REQUEST DPW SIGNATURE File:Application for OC form revised Jan 2007/2011 NORTk QR"TLED 06'91r 32 ht.fit_ M. tb, Q 0 ` Tfi APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION 4 �ic.i rcw 1 * i �qsR"TE° CHUs BUILDING PERMIT# r L3 SA ADDRESS/LOCATION OF PROPERTY: YY1 Map 0 5 Parcel ,�a 4 Lot Number SUBDIVISION: DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: Z -7 FIVE(5)DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL_R CHARGED IF THE-STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. .• APPLICANT SIGNATURE Permit Issued to: Address: ROUTING TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW ❑ CONSERVATION '14Ic3 PLANNING l DPW-WATER METER 3-4- 172 SEWER CONNECTION LSI `TMJ 3'�✓�� DPW MUST INDICAT T THE WATER METER HAS BEEN INSTALLED PRIOR TO ° SUBMITTAL OF T E ANCY/INSPECTION REQUEST DPW__P7 - SIGNATURE File:Application for OC form revised Jan 2007/2011 " 7 �. NORT1y I ve,. r O 1� No. 3 n h ver, Mass '�� ' �� O Lt 7. A- COCMIc Hl WICK � !,4 q�%ATEG ►Pp,`'�5 S u BOARD OF HEALTH Food/Kitchen Septic Systen9 THIS CERTIFIES THAT.....PERVJ ..�...A.......C"444w.. ............ ...................... BUILD N INS OR / ... Founda�iori has permission to erect .................. buildingson .... ...... ...... � ....... ............ ,� - �" � ��� to be occupied as ..........SvtgU� P .... A.... .... .. ................................. C j provided that the person accepting this permit shall in eve respect conform to th t ms of the application nal on file in this office, and to the provisions of the Codes and By-Laws relating to the I pection,Alteration and ' Construction,of Buildings in the Town of North Andover. PLUMBING INSPECTOR Al— VIOLATION Rough v 1 VIOLATION of the Zoning or Building Regulations Voids this Permit. Final " PERMIT EXPIRES IN 6 MONT. U �iELECTRICALINSPECTOR UNLESS CONSTRUCTI T h t� � /-z r 2- � J ' ............... . ................................... ............. BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough 9 1` Display in a Conspicuous Place on the Premises — Do Not Remove Final 's 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 ��� r r 71 NORTH ver o . No. y ZZ01 — ver .Mass 6 o13 �h 1. CO[NICHl WICK V p�"OATED S V BOARD OF HEALTH Food/Kitchen PER T D Septic System A THIS CERTIFIES THAT ....... .. ...... .r. ....... ...... BUILDING INSPECTOR ................................... has permission to erect ................ buildings on !� Foundation . ....� ..... ............. .......A.N.V00........ Rough ... to be occupied as o.��Ml�..:.. �..... .....T.W. . ...................:............... Chimney provided that the person accepting this permit shall in eve respect conform to th t ms of the application Final on file in this office,and to the provisions of the Codes and By-Laws relating to th_e I pection,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 OMONT ELECTRICAL INSPECTOR UNLESS CONSTRUCTIT Rough Service ............... ................................... ............. Final BUILDING INSPECTOR 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. IL SEE REVERSE SIDE The Commonwealth of Massachusetts Department of Fire Services 'Ve Office of the State Fire Marshal P.0.Box 1023 Srite Road,Stow,M4 01775 ; PERMIT Date: North Andover permit No Ci of Town Dig Safe Num er (City. ) (IF Applicable) In accordance with the provisions of M G.L.l 4 8 Chap.ter_]TO as provided in sectio' S 7 7 MR 3 4 / (; Start Date This Pcimit is grantcd to: _Z_r G Ah � FUU name of persca,Firm'or Corporation Permissicnto locate dumpster for construction/renovation/demolition of building. Comments: dumpster must be . 25t from structure if unable to place with reouired Restzictians:clearance dumps-ter must be covered with plywood or tarD end of work dap at !/ (Give location by stree and no.,or d e in such manner as to provied adequate identification of location) Fee P aid S 50.00 �.'.?- .l r �,` j'o Fire Chief This Permit will exirc +t p _Z (S igna o oFfical panting permit) Ofcal granhngpermit (Title) - 4 REScheck Software Version 4.4.3 1�f Compliance Certificate Energy Code: 2009 IECC Location: North Andover,Massachusetts Construction Type: Single Family Glazing Area Percentage: 15% Heating Degree Days: 6322 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: 87 Adams Ave. North Andover,MA Compliance:7.6%Better Than Code Maximum UA:291 Your UA:269 The%Better or Worse Than code index reflects how close to compliance the house is based on code tradeoff rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. 1•• . i 1064 38.0 0.0 32 Ceiling 1:Flat Ceiling or Scissor Truss 2112 21.0 0.0 100 Wall 1:Wood Frame,16"o.c. 0.300 77 56 Window 1:Vinyl Frame:Double Pane with Low-E 238 0.190 7 � Door 1:Solid 60 0.300 18 Door 2:Glass1064 30.0 0.0 135 ` Floor 1:All-Wood Joist/Truss:Over Unconditioned Space i Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other The proposed building has been designed to meet the 2009 IECC requirements in calculations submitted with the permit application. REScheck Version 4.4.3 and to comply with the mandatory require ants li din the REScheck Insp tion Checklist. Name-Title Signature Date it II I I Report date: 09/07/12 Project Title: Page 1 of 4 i Data filename: Untitled.rck (b)Ceilinglattic:Air barrier in any dropped ceilingisoffit is substantially aligned with insulation and any gaps are sealed. (c)Above-grade walls:Insulation is installed in substantial contact and continuous alignment with the building envelope air barrier. (d)Floors:Air barrier is installed at any exposed edge of insulation. (e)Plumbing and wiring:Insulation is placed between outside and pipes.Batt insulation is cut to fit around wiring and plumbing,or sprayed/blown insulation extends behind piping and wiring. (f) Comers,headers,narrow framing cavities,and rim joists are insulated. (9)Showeritub on exterior wall:Insulation exists between showers/tubs and exterior wall. Sunrooms: F1 Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U-factor of 0.50 and the maximum skylight U-factor of 0.75.New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Materials Identification and Installation: F1 Materials and equipment are installed in accordance with the manufacturer's installation instructions. F1 Materials and equipment are identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. F1 Insulation R-values and glazing U-factors are clearly marked on the building plans or specifications. Duct Insulation: EI Supply ducts in attics are insulated to a minimum of R-8.All other ducts in unconditioned spaces or outside the building envelope are insulated to at least R-6. Duct Construction and Testing: Cj Building framing cavities are not used as supply ducts. All joints and seams of air ducts,air handlers,filter boxes,and building cavities used as return ducts are substantially airtight by means of tapes,mastics,liquid sealants,gasketing or other approved closure systems.Tapes,mastics,and fasteners are rated UL 181 A or UL 181 B and are labeled according to the duct construction.Metal duct connections with equipment and/or fittings are mechanically fastened.Crimp joints for round metal ducts have a contact lap of at least 1 112 inches and are fastened with a minimum of three equally spaced sheet-metal screws. Exceptions: Joint and seams covered with spray polyurethane foam. Where a partially inaccessible duct connection exists,mechanical fasteners can be equally spaced on the exposed portion of the joint so as to prevent a hinge effect. Continuously welded and locking-type longitudinal joints and seams on ducts operating at less than 2 in.w.g.(500 Pa). Duct tightness test has been performed and meets one of the following test criteria: (1)Postconstruction leakage to outdoors test:Less than or equal to 8 cfm per 100 ft2 of conditioned floor area. (2)Postconstruction total leakage test(including air handler enclosure):Less than or equal to 12 cfm per 100 U. (3)Rough-in total leakage test with air handler installed:Less than or equal to 6 cfm per 100 ft2 of conditioned floor area. (4)Rough-in total leakage test without air handler installed:Less than or equal to 4 cfm per 100 ft2 of conditioned floor area. Temperature Controls: F-I Where the primary heating system is a forced air-furnace,at least one programmable thermostat is installed to control the primary heating system and has set-points initialized at 70 degree F for the heating cycle and 78 degree F for the cooling cycle. Heat pumps having supplementary electric-resistance heat have controls that prevent supplemental heat operation when the compressor can meet the heating load. Heating and Cooling Equipment Sizing: ❑ Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code. For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2009 IECC Commercial Building Mechanical and/or Service Water Heating(Sections 503 and 504). Circulating Service Hot Water Systems: F-1 Circulating service hot water pipes are insulated to R-2. Circulating service hot water systems include an automatic or accessible manual switch to tum off the circulating pump when the system is not in use. Heating and Cooling Piping Insulation: F-I HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-3. Project Title: Report date: 09/07/12 Data filename: Untitled.rck Page 3 of 4 Swimming Pools: O Heated swimming pools have an on/off heater switch. A O Pool heaters operating on natural gas or LPG have an electronic pilot light. Lj Timer switches on pool heaters and pumps are present. Exceptions: Where public health standards require continuous pump operation. Where pumps operate within solar-and/or waste-heat-recovery systems. ❑ Heated swimming pools have a cover on or at the water surface.For pools heated over 90 degrees F(32 degrees C)the cover has a minimum insulation value of R-12. Exceptions: Covers are not required when 60%of the heating energy is from site-recovered energy or solar energy source. Lighting Requirements: F1 A minimum of 50 percent of the lamps in permanently installed lighting fixtures can be categorized as one of the following: (a)Compact fluorescent (b)T-8 or smaller diameter linear fluorescent (c)40 lumens per watt for lamp wattage—15 (d)50 lumens per watt for lamp wattage>15 and—40 (e)60 lumens per watt for lamp wattage>40 Other Requirements: F-1 Snow-and ice-melting systems with energy supplied from the service to a building shall include automatic controls capable of shutting off the system when a)the pavement temperature is above 50 degrees F,b)no precipitation is falling,and c)the outdoor temperature is above 40 degrees F(a manual shutoff control is also permitted to satisfy requirement'c'). Certificate: ❑ A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R-values;window U-factors;type and efficiency of space-conditioning and water heating equipment.The certificate does not cover or obstruct the visibility of the circuit directory label,service disconnect label or other required labels. NOTES TO FIELD:(Building Department Use Only) Project Title: Report date: 09/07/12 Data filename: Untitled.rck Page 4 of 4 C2009 IEC ner y . Efficiency Certificate Ceiling/Roof 38.00 Wall 21.00 Floor/Foundation 30.00 Ductwork(unconditioned spaces): �.�1• �,h� 'NVt � r':I#�y�T„ Val Window 0.30 0.70 Door 0.30 0.70 PA Heating System: Cooling System: Water Heater: Name: Date: Comments: Massachusetts -Department of PUbiic Safety Board of Building Regulations and Standards C un..trt,ctivn Supers iwr License:CS-014197 MARK F RAE...-` ' 130 MARBLKRIDGE RD,Ir North Andmi,MA 01845 - r _ � ��'L"•� a�+,` Expiration Commissioner 04/24/2014 I r I I i • k p The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ,. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (Y�G f-L �51� )q-e-, Address: (j� 1 r2 City/State/Zip:Ajok folks, M A- Phone#: � R'- ,-D q ^97 y. lj Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I * have hired the sub-contractors 6. Q New construction - employees(full and/or part-time). 2.[�I am a sole proprietor or partner- listed on the attached sheet.$ ? E]Remodeling 1 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.❑Electrical repairs or additions 3.El I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. [do hereby certify hider he pas aid penalties of perjury that the information provided above is true and correct. Sign re: / Date: .' Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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"...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,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 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 produced acceptable 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 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 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 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 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 fixture permits or licenses. A new 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 (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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www,mass.gov/dia REScheck Software Version 4.4.3 Inspection Checklist Energy Code: 2009 IECC Location: North Andover,Massachusetts Construction Type: Single Family Glazing Area Percentage: 15% Heating Degree Days: 6322 Climate Zone: 5 Ceilings: ❑ Ceiling 1:Flat Ceiling or Scissor Truss,R-38.0 cavity insulation Comments: Above-Grade Walls: ❑ Wall 1:Wood Frame,16"o.c.,R-21.0 cavity insulation Comments: Windows: ❑ Window 1:Vinyl Frame:Double Pane with Low-E,U-factor:0.300 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break?_Yes_No Comments: Doors: ❑ Door 1:Solid,U-factor:0.190 Comments: ❑ Door 2:Glass,U-factor:0.300 Comments: Floors: ❑ Floor 1:All-Wood Joist/Truss:Over Unconditioned Space,R-30.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: ❑ Joints(including rim joist junctions),attic access openings,penetrations,and all other such openings in the building envelope that are sources of air leakage are sealed with caulk,gasketed,weatherstripped or otherwise sealed with an air barrier material,suitable film or solid material. ❑ Air barrier and sealing exists on common walls between dwelling units,on exterior walls behind tubs/showers,and in openings between window/door jambs and framing. ❑ Recessed lights in the building thermal envelope are 1)type IC rated and ASTM E283 labeled and 2)sealed with a gasket or caulk between the housing and the interior wall or ceiling covering. ❑ Access doors separating conditioned from unconditioned space are weather-stripped and insulated(without insulation compression or damage)to at least the level of insulation on the surrounding surfaces.Where loose fill insulation exists,a baffle or retainer is installed to maintain insulation application. ❑ Wood-burning fireplaces have gasketed doors and outdoor combustion air. ❑ Automatic or gravity dampers are installed on all outdoor air intakes and exhausts. Air Sealing and Insulation: ❑ Building envelope air tightness and insulation installation complies by either 1)a post rough-in blower door test result of less than 7 ACH at 50 pascals OR 2)the following items have been satisfied: (a)Air barriers and thermal barrier:Installed on outside of air-permeable insulation and breaks or joints in the air barrier are filled or repaired. Project Title: Report date: 09/07/12 Data filename: Untitled.rck Page 2 of 4