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HomeMy WebLinkAboutBuilding Permit #500-2017 - 97 SUTTON HILL ROAD 11/14/2016' /it � �1� AA -4 1� L� Permit No#: 5.00 - 90 1-7 "Mio scRr�wa� BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received / I - 10 - X01(0 Date Issued: (t % '90/b IMPORTANT: Applicant must complete all items on this OCIARP .n F t S rint PROPEF TJY.Y 011VNER r1 Gin - .__.._.v..._ _.. � _ Pint? 9flD�Y_reara5t�ui PARCEL.-. _. _ ,ZONING DIST RICT``Histor�e D�sf M OF IMPROVEMENT PROPOSED USE TYPE Residtial Non- Residential ew Building ne family ❑ Industrial ❑ Addition ❑ Two or more family ❑ Alteration No. of units: ❑ Commercial ❑ Others: ❑ Repair, replacement ❑ Assessory Bldg ❑ Demolition ❑ Other aFloodplain 'rWetlands ershDistnct 1]; V1lated� i--nEINell_. _ ater/Sewer• x _ nrnrnonncn. f.0 UtbumiY 1 IVIV Vr vvvrxrn a v v- i� 314 Identification - OWNER: Name: 4�Y-ir�1r1 Address: COntraC Of Name: Email: Address Supervs_ort's Consructiomucer silrinmailmnff�iVPM,__Ah .L1CenSe ... ARCHITECT/ENGINEER Type or rrini hone-Go?o `i ID - Ex Dates .Exp Phone: Address: Reg. No. L� LD/NG PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925 00 PER S.F. �r FEE SCHEDULE. BU 1pCO FEE: $ . a© Total Project Cost: $ -1r--- Check No.: Receipt NOTE: Persons contracting with unregistered contractors do not have access to guar anty fund gnature of Agent/Owne _ >M Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tauning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECrIONS FOR -OFFICE- USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS VCf h ZI I Reviewed On)vlt�_ Signature_ ►cam CONSERVATION Reviewed on < < 1 cp Si nature COMMENTS .: _ ..- - , f .. , s E _ : .. • ,... . • . HEALTH r , Reviewed.on- Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes n Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: �FIREDEP,,ARTMENT Dum stet o Located 384 Osgood Street n site Tem , I?. ay +,Located.at9�124�NIaintStreet P es �-- no d 'Eire+Departmentsignature/date ,(.✓/ 9 \C'OMM ENTS>',� 11 �� r __-- 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine ►f R•'. NO I E5 and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name - Doc.Building Pemit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location�'�� No. gn Date J / /f ZD/j TOWN OF NORTH ANDOVER Certificate of Occupancy $ r> Building/Frame Permit Fee $ /! Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �fo 9 ' t 7 7 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 124,600.00 m $ - $ 1,495.20 Plumbing Fee $ 186.90 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 186.90 Total fees collected $ 1,969.00 97 Sutton Hill Road new SFH 500-2017 on 11/14/2016 E M. ON rA y JO 2 LL O oc a mJ N o O LL N T V) u CL (n U LWa/1 Z Z D _ co O O a v 7 LL r =1 w T c C E U - C LL O w N Z m Q. t Zto OC -to C LL Lu Z Q " W J W t O K u > N _ ca C LL 0: p U Wa Z tA a ., r O K ro LL Z W w Q W a LJJ uj LL L 7 m O Z v �`.' y N p Y O E (A O� . �• �: •0 0 V� c a ..: N E n ' ID o dor tiN � v LL y.+ y V 0 m MA con a �'• O �. 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O a z Z m co 0 U Z 0 Cl) J V O E Z 0 AV/ W •N CL d O V CL .Q r_ V CL U) rW— Donald Belanger Inspector of Buildings Please print DATE: 10(-31 I TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Telephone (978) 688-9545 Fax (978)688-9542 JOB LOCATION: q 9 6y,40 h 4111 q d Number Street Address Map/Lot HOMEOWNER (106 n ne (Z6 -b loo 3 -7 7a' 3(e I C, Name Home Phone Work Phone PRESENT MAILING ADDRESS I Ao Rl 1 K 5-t ndoo City Town State Zip The current exemption for "homeowners" was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one -or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned "homeowner" assumes responsibility for compliance with State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 44 O 3 4 y N S^' to J S d O � ' Q O _ Q J N W 7 �I E=3p, r` aC t� I� Dr D �p DDD 0 ,SZ; - m VIVO' Vwog 0,AKI Atoll 4ij Ao i i ot% Vixli'A A 44 a � J r e'! 7 y tEti� lEn IEEI f N � N a' oc I� 0 1t It MAOA f�irtt\**t MVM R i• �'�VR�l IA FFA ! �,.•.*�YYF�./�;y .il �R t{om• V YIiApJ .r " ,►!►viYV Yplm 1 j i � E ' •� f YM ! �! fY !+ `� +eta . C�• F pft oofuW�. li f 1 Wl 114: 'k.mv4v4% i1VifV,q P2 �i1 #At'oi jI Ifpj tz :vY.4tV YtAFtia { p I {, � 1 cll+111$jefr ! • m f4y a .r n� vi ^�._.. tt}tq tA�+rrAwVA - • � F. yt sA r � � ` ;�j -- wr�.aa,.a •fi r ar Jtrt1A cr<K,vy #rMwrd<' �f�! ty 1 ir s .r wr 1t,-�r_ � e-FZ o•i o•vy iJ SAY$15". "«, YVY4 f>tr)7.+W'14 Ft tJ qiy W N N11 •r : jA „h N y�(y .�(ttfil [t�xtt+y irFxe�11A�' .M J�„/7 t 1� g jY• h Is 1 h N iQj iso I, i Y I I l i I �Y AF UZ f5 -Olt awvv yAna 1 -4a. 3WV?il `A*33(l Q,NQ':)3S o ----- KI 17 o-oti OA% a-3 o•i o-! O•oj o.i o•M e. o• o. o•! o•= o.h O•a o•b oa .•i e•t w o } ,p �YPb yoPC MD ou ^_ 4t.y,es 1r 9!*A�11Q v • ?!,t �rf4o� 01 e aO i� (-Zson bzxhl If"V -zz tia+ewltrw � • tiy�r�vb f�t�XS•f •ca�ma aanaa��► r ! £8'rq,sk �i,Y�19ti 1 I OI1Md,11)8G 1 0•51 i•1'rl Z'� sl p`17�1 N141d 10crl3 .l"IA N O v a Y C WliS y•pa U"✓ L _ O .O O REScheck Software Version 4.6.3 Compliance Certificate Project Energy Code: 2012 IECC Location: North Andover, Massachusetts Construction Type: Single-family Project Type: New Construction Conditioned Floor Area: 0 ft2 Glazing Area 11% Climate Zone: 5 (6322 HDD) Permit Date: 0.0 Permit Number: 152 Construction Site: 97 Sutton Hill Road North Andover, MA Owner/Agent: Designer/Contractor: Peter Loughlin 508-228-0048 Compliance: 2.9% Better Than Code Maximum UA: 380 Your UA: 369 The % Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum -code home. Envelope Assemblies Ceiling 1: Flat Ceiling or Scissor Truss 384 38.0 0.0 0.030 12 Ceiling 2: Cathedral Ceiling 1,561 38.0 0.0 0.027 42 Wall 1: Wood Frame, 16" o.c. 3,049 21.0 0.0 0.057 152 Window 1: Vinyl/Fiberglass Frame:Double Pane with Low -E 284 0.280 80 Window 2: Vinyl/Fiberglass Frame:Double Pane 40 0.280 11 Door 1: Solid 20 0.200 4 Door 2: Solid 20 0.200 4 Door 3: Solid 20 0.450 9 Floor 1: All -Wood joist/Truss:Over Unconditioned Space 1,666 30.0 0.0 0.033 55 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 me.9t the 2012 IECC requirements in REScheck Version 4.6.3 and to comply with the mandatory requirements lis!4 in the RESchec pection Checklist. Tom Barnes, HERS Rater #4583495 1 --) 11-4-16 Name -Title S gn ure ' Date Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 1 of 8 REScheck Software Version 4.6.3 Inspection Checklist Energy Code: 2012 IECC 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. Section # Pre-inspection/Plan Review Plans Verified Value Field Verified Value Complies? Comments/Assumptions & Req.ID 103.1, ;Construction drawings and ❑Complies 103.2 (documentation demonstrate I 111Does Not [PR1]1 ;energy code compliance for the $ '❑Not Observable ' building envelope. ;[]Not Applicable ; 103.1, ;Construction drawings and ; s❑Complies ; 103.2, :documentation demonstrate❑Does Not 403.7 ;energy code compliance for '❑Not Observable [13113]1 'lighting and mechanical systems. '!Systems Applicable serving multiple g '❑Not ;dwelling units must demonstrate ;compliance with the IECC ; ;Commercial Provisions. 302.1, !Heating and cooling equipment is: Heating: ; Heating: ;❑Complies 403.6 sized per ACCA Manual S based j Btu/hr : Btu/hr !❑Does Not [PR2]2 ion loads calculated per ACCA {Cooling: ;Cooling: ❑Not Observable Manual J or other methods Btu/hr japproved by the code official. S : Btu/hr❑Not i Applicable t Additional Comments/Assumptions: 11 High Impact (Tier 1) 2 1 Medium Impact (Tier 2) 3 1 Low Impact (Tier 3) Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 2 of 8 # & Re .ID I Foundation Inspection Complies? Comments/Assumptions 303.2.1 11A protective covering is installed to ;OComplies [F011)2 R protect exposed exterior insulation ;Oboes Not :and extends a minimum of 6 in. below ;grade. UNot Observable []Not Applicable 403.8 ;Snow- and ice -melting system controls DComplies [FO1212 installed. PDoes Not ,Not Observable ONot Applicable Additional Comments/Assumptions: 111 High Impact (Tier 1) 2 1 Medium Impact (Tier 2) 13 1 Low Impact (Tier 3) Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 3 of 8 Section # Framing / Rough -in Inspection Plans Verified Value Field Verified Value Complies? Comments/Assumptions & Req.1D 402.1.1, Door U -factor. ; U- U- ;❑Complies ; See the Envelope Assemblies 402.3.4 i =❑Does Not ;table for values. [FRl]1 ❑Not Observable ; ❑Not Applicable 402.1.1, IGlazingU-factor(area-weighted U- U -I ❑Complies ;See the Envelope Assemblies 402.3.1, !average). !❑Does Not ;table for values. 402.3.3, t ` i ! !,[:]Not Observable ; 402.3.6, 402.5 ; :❑Not Applicable ; [FR2]1 303.1'3 I U -factors of fenestration products 10Complies [FR4] care determined in accordance I ;❑Does Not ; (with the NFRC test procedure or Etaken from the default table. ; ❑Not Observable, i❑Not Applicable , 402.4.1.1 lAir barrier and thermal barrier ! DComplies [FR23]1 `installed per manufacturer's ;❑Does Not E ! instructions. []Not Observable `❑Not Applicable 402.4.3 Fenestration that is not site built '❑Complies [FR20]1 its listed and labeled as meeting 1Ol/per /A44 ❑Does Not 10 nAAMA /WDMA/CSA or has ! ; ❑Not Observable E []Not Applicable 400 that do not exceed code I ; limits. 1 402.4.4 IC -rated recessed lighting fixtures; ❑Complies ; [FR16]2 (sealed at housing/interior finish ❑Does Not Iq land labeled to indicate s2.0 cfm !leakage at 75 Pa. + []Not Observable : E a []Not Applicable ; 403.2.1 Supply ducts in attics are R- R- ;❑Complies [FR12]1 insulated to zR-8. All other ducts in unconditioned spaces or E R R_ ;❑Does Not E ` ; ;❑Not Observable E outside the building envelope are Applicable Insulated to zR-6. ; : ;❑Not ; 403.2.2 All joints and seams of air ducts, '❑Complies [FR13]1 ;air handlers, and filter boxes are []Does Not E !sealed. 1 [:]Not Observable ! ! ❑Not Applicable ; 403.2.3 ' Building cavities are not used as ❑Complies [FR15]3 Educts or plenums. ; []Does Not []Not Observable ❑Not Applicable 403.3 { HVAC piping conveying fluids ; R- R- ;❑Complies [FR17]2 ! above 105 QF or chilled fluids ! '❑Does Not below 55 QF are insulated to zR- E : i ;❑Not Observable : 3 ' . ❑Not Applicable 403.3.1 Protection of insulation on HVAC ; ❑Complies [FR24]1 'piping. Z '❑Does Not E UNot Observable :E1 Not Applicable ; 403.4.2 i Hot water pipes are insulated to R- R- ;❑Complies [FR18]2 1zR-3. E UDoes Not E ;❑Not Observable 4:1 Not Applicable 111 High Impact (Tier 1) 12 1 Medium Impact (Tier 2) 13 1 Low Impact (Tier 3) Project Title: Report date: 11/03/16 Data filename: C:\UserslcarynlDocuments\REScheck\Sutton Hill - 97.rck Page 4 of 8 Section # Framing / Rough -In Inspection Plans Verified Value Field Verified Value Complies? Comments/Assumptions & Req.ID 403.5 ;Automatic or gravity dampers are, ElComplies [FR19]2 installed on all outdoor air ❑Does Not 14I intakes and exhausts. []Not Observable ❑Not Applicable Additional Comments/Assumptions: 111 High Impact (Tier 1) 12 1 Medium Impact (Tier 2) 13 1 Low Impact (Tier 3) Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 5 of 8 Section # Insulation Inspection Plans Verified Value Field Verified Value Complies? Comments/Assumptions & Re: 303.1 [IN13]2 'All installed insulation is labeled or the installed R -values ;❑Complies ❑Does Not provided. ❑Not Observable ; f ❑Not Applicable 402.1.1, Floor insulation R -value. R- ; R- ;❑Complies ; See the Envelope Assemblies 402.2.6Wood ; E] Wood :[:]Does Not table for values. [INlj1 ❑ Steel ❑ Steel ;❑Not Observable i ;❑Not Applicable 303.2, ; Floor insulation installed per ❑Complies ; 402.2.7 (manufacturer's instructions, and ❑Does Not [IN2)1 I in substantial contact with the + i ❑Not Observable ; underside of the subfloor. g ❑Not Applicable 402.1.1, !Wall insulation R -value. If this is a! R- R- ;❑Complies ;See the Envelope Assemblies 402.2.5, ' mass wall with at least'? of theWood ; ❑ Wood ;❑Does Not f table for values. 402.2.6 Ewall insulation on the wall ; Mass ❑ mass❑Not Observable [IN3]1 ;exterior, the exterior insulation !requirement applies (FR10). i ; ; ❑ Steel ; ❑ Steel ; , ;❑Not Applicable ( 303.2 lWall insulation is installed per ;❑Complies [IN4]1 manufacturer's instructions. ! '❑Does Not ; t '❑Not Observable I `❑Not Applicable ; Additional Comments/Assumptions: 11 High Impact (Tier 1) 2 1 Medium Impact (Tier 2) 3 1 Low Impact (Tier 3) Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 6 of 8 Section # Final Inspection Provisions Plans Verified Value Field Verified Value Complies? Comments/Assumptions & Re .ID 402.1.1, ;Ceiling insulation R -value. ; R- ; R- ;❑Complies ;See the Envelope Assemblies 402.2.1, i Wood a ❑ Wood ;❑Does Not ;table for values. 402.2.2, 402.2.6 I Steel !Not ❑ Steel ❑ Observable ; [FI1]1 t ; ;❑Not Applicable , 303.1.1.1,,Ceiling insulation installed per j []Complies 303.2 !manufacturer's instructions. ! !❑Does Not [F12]1 1131own insulation marked every ,Not Observable 300 ftz. []Not Applicable 402.2.3 ;Vented attics with air permeable ❑Complies [F122]2 Rinsulation include baffle adjacent ❑Does Not soffit and eave vents that !extends ! extends over insulation. ;[-]Not Observable t❑Not Applicable 402.2.4 ;Attic access hatch and door ; R- R- ;❑Complies [F13]1 ! insulation zR-value of the ;❑Does Not ,adjacent assembly. ; ,❑Not Observable ; ! ❑Not Applicable 402.4.1.2 ! Blower door test @ 50 Pa. <=5 ACH 50 = ; ACH 50 = ,❑Complies [FI17]1 tach in Climate Zones 1-2, and ;,[]Does Not ! <=3 ach in Climate Zones 3-8. ;[:]Not Observable ; 6 ;❑Not Applicable 403.2.2 Duct tightness test result of <=4 ; cfm/100 cfm/100 �,❑Complies [FI4]1 ,cfm/100 ft2 across the system ori ftz ftz �❑Does Not j <=3 cfm/100 ft2 without air ❑Not Observable handier @ 25 Pa. For rough -in ; I'tests, ! Applicable verification may need to ! ; ;❑Not ; =occur during Framing Inspection. 403.2.2.1 GAir handler leakage designated ❑Complies ; [F124]1 by manufacturer at <=2% of ❑Does Not !design air flow. 3 j❑Not Observable ; ❑Not Applicable 403.1.1 Programmable thermostats ❑Complies [F 19]2 installed on forced air furnaces. ;❑Does Not ow []Not Observable f❑Not Applicable 403.1.2 ° Heat pump thermostat installed '❑Complies [FI10]2 'on heat pumps. ❑Does Not '. ❑Not Observable ❑Not Applicable 403.4.1 ;Circulating service hot water 7OComplies [Fill ]2 .systems have automatic or ❑Does Not accessible manual controls. ❑Not Observable ; ❑Not Applicable 403.5.1 All mechanical ventilation system I ❑Complies ; [F125]2fans not part of tested and listed ❑Does Not HVAC equipment meet efficacy []Not Observable and air flow limits. j ;❑Not Applicable 404.1 �75% of lamps in permanent ; '❑Complies [FI611 (fixtures or 75% of permanent ❑Does Not !fixtures have high efficacy lamps. ❑Not Observable Does not apply to low -voltage lighting. ! ❑Not Applicable ; 111 High Impact (Tier 1) 12 1 Medium Impact (Tier 2) 13 1 Low Impact (Tier 3) Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 7 of 8 Section # Final Inspection Provisions Plans Verified Value Field Verified Value Complies? Comments/Assumptions & Re .iD 404.1.1 !Fuel gas lighting systems have ❑Complies [FI23]3 no continuous pilot light. i '0Does Not ONot Observable ONot Applicable 401.3 jCompliance certificate posted. VCompiies [FI7]2 '0Does Not 0Not Observable ONot Applicable 303.3 1 Manufacturer manuals for Complies [FI18]3 !mechanical and water heating ElDoes Not :systems have been provided. low[]Not Observable 'ONot Applicable Additional Comments/Assumptions: 111 High Impact (Tier 1) 12 1 Medium Impact (Tier 2) 13 1 Low Impact (Tier 3) Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 8 of 8 2012 IEcc Energy Efficiency Cenificate Above -Grade Wali 21.00 Below -Grade Wail 0.00 Floor 30.00 Ceiling / Roof 38.00 Ductwork (unconditioned spaces): Window 0.28 Door 0.20 Heating System: Cooling System: Water Heater: 77 777 71,7 Name: Name: Date: Comments Date e you l ll adhere this t® electric panel at end of job. AssumIlng we g® thru �Il assSave incentives program, ff give you this at end of job from my reports using full energy modeling. Rt will reflect blower door, elc00.testse CD lot M o 0 CN 0 0 o o a et 3 o m oq ® t') 0 0 0 0 0 °e a 00\0 000 � d O CD C Lh b tAO N O O O ~ N `o ti. 0o J p V1 0o I-+ to N O Vl �o ►+ Vl 00 1 J y�y c r 0 yay x x x x x x CID r r r r r r o 0 r r r r r r 0 0 0 0 0 d d d 0 0 d e d d v o d b b ro b ro x z z z z z CL � N o � y o 5 C G1 C 0 N �> rH xx N :� y xH x O r Opp > r oz GQw oz w a y z H o oz o �r 0 o 7� o 12 o o o tr1 rn a, rn rn _ rn En o x H [ o H cn3 tV m m y m CL ro 000 -3 x O 00 'm-) 0000 .. C 0o Oo O\ 00 00 ' w W 2 a\ d w LA `i9 O tWii O N � N B O �� o O O <9 N n o � m `< 0 d z z C o. ITI CD a �o CD, o z z W fA F+ o fA N O "'h bH d C!3 d 9 EH N n d t9 CD c�ii cn tlAi tTl x CD o O C y A N N yq b9 691.0 CD '_ O A A W 00 C !11 C to C J ON O Q4 A y 00 0 0 0 0 0 0 0 0 0 0 0aq P ro m �; � � y co UQ (P nj to NN N N bi O 1.0 N A pr to A N N N to 4t CD lot M Workers' .The Commonwealth of Massachusetts Department of Industrial Accidents X Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Compensationinsurance Afftdavit: Buildexs/Contxactoxs/Electricians/lumbers. TO BE FILED WITH THE PERMUTI"7 G AUTHORITY. Name (Business/Oiganizationlludividual)' oZ 0 l Address: 6} o � CitylSiate/Zip:_ Ar1�of—r' H Q" Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time).* IF] I am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3. I am a homeowner doing all work myseli [No workers' comp. insurance required] t 4. a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.t 6.Q We are a corporation and its, officers have exercised their right of bxemption per MGL c. 152 §im ,,IWhaveno' [No workers' comp. insurance required] Type of pro at (required); 7, dw construction 8. [] Remodeling 9. ❑ Demolition. 10 ❑ Building addition 11.❑ Elec#ical repairs or additions la. Q -Plumbing repairs or additions 11E] Ro6f repairs 14. n Other *Any applicant that check's box#1 must also fill out the section elm work and then hire outside howing their Workers' compensation ontrac ors must submia new affidavit indicating such Homeowners who submit•this affdavit indicating they g tContractors that check this liox must attached'an additional sheet showing the name of the sub contractors and state whether or not chose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer' that is providingworkers' compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Ns P lit A or Self -ins. Lie. Expiration Date: o y S City/StatCOP: �•�• Q nr�oJ V r KCS 6 Qi�S•� Job Site Address: u the clicy number and expiratio�a date). Attach a copy of the workers' compensation policy declaration page (showm p Failure to secure coverage as required under Mnalties2in he form ofOPWORK ORDERviolation punishable and a cine o£up to $250.00 a and/or one-year imprisonment, as wellciv'l p day against the violator. A copy of this statement may be forwarded to the Office of Iuvestigations of the DIA. for insurance coverage verification. X do hereby certify under tliepains andpenalties ofperjury that the information provided above is true and correct ir.A � \1. QkW _ Date �� 6 3 l �° 7.)_ to Of use only. Do not write in this area, to be completed by city or town offaciaL permit/License # City or Town' issuing Authority (circle one): 1. Board of Health 2- Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other phone 9: Contact Person' � 'M Workers' .The Commonwealth of Massachusetts Department of Industrial Accidents X Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Compensationinsurance Afftdavit: Buildexs/Contxactoxs/Electricians/lumbers. TO BE FILED WITH THE PERMUTI"7 G AUTHORITY. Name (Business/Oiganizationlludividual)' oZ 0 l Address: 6} o � CitylSiate/Zip:_ Ar1�of—r' H Q" Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time).* IF] I am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3. I am a homeowner doing all work myseli [No workers' comp. insurance required] t 4. a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.t 6.Q We are a corporation and its, officers have exercised their right of bxemption per MGL c. 152 §im ,,IWhaveno' [No workers' comp. insurance required] Type of pro at (required); 7, dw construction 8. [] Remodeling 9. ❑ Demolition. 10 ❑ Building addition 11.❑ Elec#ical repairs or additions la. Q -Plumbing repairs or additions 11E] Ro6f repairs 14. n Other *Any applicant that check's box#1 must also fill out the section elm work and then hire outside howing their Workers' compensation ontrac ors must submia new affidavit indicating such Homeowners who submit•this affdavit indicating they g tContractors that check this liox must attached'an additional sheet showing the name of the sub contractors and state whether or not chose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer' that is providingworkers' compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Ns P lit A or Self -ins. Lie. Expiration Date: o y S City/StatCOP: �•�• Q nr�oJ V r KCS 6 Qi�S•� Job Site Address: u the clicy number and expiratio�a date). Attach a copy of the workers' compensation policy declaration page (showm p Failure to secure coverage as required under Mnalties2in he form ofOPWORK ORDERviolation punishable and a cine o£up to $250.00 a and/or one-year imprisonment, as wellciv'l p day against the violator. A copy of this statement may be forwarded to the Office of Iuvestigations of the DIA. for insurance coverage verification. X do hereby certify under tliepains andpenalties ofperjury that the information provided above is true and correct ir.A � \1. QkW _ Date �� 6 3 l �° 7.)_ to Of use only. Do not write in this area, to be completed by city or town offaciaL permit/License # City or Town' issuing Authority (circle one): 1. Board of Health 2- Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other phone 9: Contact Person'