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Miscellaneous - 17 CIDERPRESS WAY 4/30/2018
_� / . i' • TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . / .. . /{P A0 leas permission to perform . . ./.1.1Q . . . l"1(Ikk ..r. . . . . . . . . . . . . . plumbing in the uildings of. P.P. ,1 �?S,P . . .(., .v�, 'vk'r—r. . . at • 1. C-!r/ � �•P�.�2.�'.��: . . . . . . . . . . ,North Andover, Mass. Fee .p�P•�. . . Lic. No. . 1.�./.5� . �' . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# , i i MASSAZHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK d CITY E Ll � MA DATE PERMIT# , JOBSITE ADDRESS _ �o OWNER'S NAME[. P OWNER ADDRESS ct/ ( TEL FAX __— I TYPE OR OCCU;�`=VATION: COMMERCIAL { EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: ® REPLACEMENT:© PLANS SUBMITTED: YES© NO© FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM --111_....._... f ------ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN �__} ..._.....( .--__-_! -.--__ ._--_..._! ► __ ..._I _I ._____1 __-_.1 ._-__.-I . _ ..J __... .! .._. { _ ._. 1 FOOD DISPOSER I . _1 ....___l _._.-( .---_.._{ ' ( __. __-( F71 .! FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY f _---- ... ► __ ._.._1 .___.__I _.___-__4 _.__.__.} _-..__-..! __.___I _.----_._1 ___.._1 _-_-( - .__ 1 ._ I _ I .__._.._I ROOF DRAIN SH ALL SERVICE/ [_ I ------__I ___._._I -___-I } ICE//MMOP SINK .....( J ( __---_� � t __-} T 04 ET i _71 -__ -.1 ----I URINAL WASHING MACHINE CONNECTION f ( ! f I f WATER HEATER ALL TYPES — WATER PIPING r INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES - NO E] IF YOU CHECKED YES,PLEASE INDICATE THE T E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ! BOND MI OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _! AGENT �0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with alt pro ' ' e Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# --lS 7; SIGNATURE MP E2r' JP Q CORPORATION n# i PARTNERSHIP# LLC D O _I COMPANY NAME�jr/ % ADDRESS CITY -- STATE ; ZIP —'�D'Z GTEL FAX ; CELLyP7 EMAIL _ _- / __._.----- ` ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 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): Rqz Address:_oVe Aa City/State/Zip: A/lf'�c,(, - l/ Phone#: ArFlam an employer?Check the appropriate box: Type of project(required): 1. a employer with_� 4. ❑ I am a general contractor and I 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. ❑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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL ME]Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.E]Roof repairs insurance required.]r 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. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing 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 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$250.00 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. Ido hereby certiu.fy der the pair and pen es o the information provided above is true and correct. Signature: Date: J 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-contractor(s)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 future 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 bum 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 ofMassachUsetts Department of Industrial Accidents Office of Investigations 600 Washington Stmet Boston}MA.02111 TeX.#617-727-4900 oxt 406 or 1-877,7MASSAFE Revised 5-26-05 Fax#617-727-7749 v ww-mass,gov/dia a MASSACHUSE T T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK If CITY % i��l ��/�I,C / � MA DATE PERMIT# JOBSITE ADDRESS GOWNER ADDRESS L Q TEI. FAx TYPE OR OCCUPANCY TY COMMERCIAL�_I EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:[l REPLACEMENT: PLANS SUBMITTED: YESF-1 NOQ APPLIANCES I FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14 BOILER - 1. J .. _. f_ i f. I ! _I 1 1 BOOSTER -F---JL---j. _—JI - _ CONVERSION BURNER —11 -- COOK _— -- - I .. _ r__ 1 11 --COOK STOVE _ _a __ _ . i —AL—J .-._ 1 _ I -. DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE ------_I�- INFRARED HEATER LABORATORY COCKS (�. I. �I _ -� -_-�I - - I ----. I-- . I --,-.-i --a l MAKEUP AIR UNIT OVA N _I J _ T_ . . �J POOL HEATER ROAM 1 SPACE HEATER ROOF TOP UNIT -1, TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ _J - ___ ! l i__ h__ 1 ..... OTHER J( I -. . - _-_-- INSURANCE COVERAGE ,-�,/ have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES li0 D I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE NECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND Ell OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENTEj SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with allpertinW he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME - ,..-. :--_._ � LICENSE# ._S/_. SIGNATURE MP[9MGF E] JP LI JGF LPGI ] COR-PO—RATION�# PARTNERSHIP # .._ LLC P,-I# ,� COMPANY NAME: GiJ .__ �f _._.._IIADDRESS CITY - -- - - --.. . j STATE ZIP �� �9TEL FAX CELL EMAIL ltJ _ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES y M � L Date 61-2(1113 . . . �` • sy'�LN�76r•� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . has permission for gas installation . . /(J 0 . . .1� r!1,, .c, , , , , , , , , in the buildings of. p �. -e (7�, • • • . . at . . . �. /Y •�• • t• •�•���=�•� '�• SJ'• • • • • • • . . . , North Andover, Mass. Fee , ,/(C ` . Lic. No. ./ f�/ . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR check# P The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA. 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: ;::;Qo 6�tl el_" City/State/Zip:/a �,�D 7 hone#: 9ZfJ T� S^� C Amore u an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer with f 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] o 3.F1 am a homeowner doing all work right of exemption per MGL ME]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. i Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing 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 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$250.00 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. Ido hereby certify unde the ains andpen Ities perjury that the information provided above is true and correct. - Signature: Date: Z_/ Phone#: $,6�r�£�� —�3 p 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#: y 6� 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 future 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 ofMassachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-877�,MASS.AFB Revised 5-26-05 Fax#617-727-7749 wv w-Mass,gov/dia Date....b.�-./..lr-..�, 3....... �E,NOpTM� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88ACHU5� Thiscertifies that ...................I..................................(................................................................... has permission to perform ............Ne g) L l�jt ....................................... . .................................. wiring in the building of..............1.� ''�'' U:..................0 l.C................ at ......J 7. S , y ,North Andover,Mass. ................. .......... ........ . Fee....I.y�?_4 Lic.NdM.45/� ALEMFUC�AL ....� .. .1�'...... INSPECTOR V Check# I�7. Commonwealth of Massachusetts Official/Ulse Only Department of Fire Services Permit No. z Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC),527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) DaI l I ( 3 City or Town of: NORTH ANDOVER To theIn pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant / -t A,, Telephone No. —Z63 Owner's Address (� �,,q��-� Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate]Box) Purpose of Building BSc I e,,Qk prt, Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: -"""""'" I """""""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Key Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: OD Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value o Electrical Work: , Op(fir (When required by municipal policy.) Work to Start: b Inspect ons to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covera is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: _ �1,� i1-C_-- LIC.NO.: A-t t(�ti Licensee: ,Mtfg&L,2_ VN Signature LIC.NO.: (If applicable ent,W exempt"in the license number line) Bus.Tel.No.: Log 3 1-7—--Dag 7 Address: A -VC, i�'(.��,s�.�, ✓y' FV�Slb!�- Alt.Tel.No.: 2, *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: R0/GH I TI Pa ? Failed Re-Inspection Required($.) ❑ Inspectors Comments: r� Inspectors Signature: V Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments. Zfn r Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflndustrittlAccidents 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 LegibiV Dame(Business/Organi'zationffndividual): �c �-Lrt� ✓,ice tau��• Address: City/State/Zip: A-M 1�0 Phone#: Are yoga an employer?Check the appropriate box: TyVwcon.struction 'ect(required): L[911 am a employer with /,=> 4. F1 am a general contractor and I 6. employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance, g El Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑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 ]re q uired. employees.[No workers' Un 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 anew 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 is providing workers'compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: t_k_A.J V 0 fid 1'y S Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: C c City/State/Zip: fib. (A�-t�u Attach a copy of the workers'compensation policy de aration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do Hereby cunder the pains andpenalties ofperjury that the information provided above is true and correct. - Si ert ature: ' - Date: di Phone#• X1)r 3 7,� 'y V(o 2— Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitUcense# 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#: i Information and Instruction's 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 employd is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ofthe 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(ifnecessary)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. 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 (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: Tho Commoawmlth ofM-assachusetts Dep.artmeat ofladustdal.Aecldonts Office oflnyestigations 600 Washing w St c:et Boston}MA 02111 Tot#61.7-727-4900 oxt 406 or 1-877-MASSAFF, Revised 5-26-05 Fay,4 617-727-7749 •rxctn.r,v,n n.. ......zta.:.. TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION i 7- C'I )CS uory Print PROPERTY OWNER S j'LG Print MAP NO:&PARCEL: _ZONING DISTRICT: \ Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ❑ One family ❑Addition 4$Two or more f ily ❑ Industrial ❑Alteration No. of units:q b , I JV\s pkpAj ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg U ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑Floodplain ❑ Wetlands ❑ Watershed,District Water/Sewer DESCRIPUgN�zl K TOPE PERFQRRM D: ti `U �'I' a X02 (Id ntification Please Ty a or Print Clearly) OWNER: Name: I Phone:�17 7"Z6SS Address: CONTRACTOR Name: 446- Phone:'3_R&_?_-Z(JS Address: Supervisor's Construction License: ��s;`��/ Exp. Date: /s—/)z,- Home Improvement License: `r Exp. Date: YY ,� o Q II ARCHITECT/ENGINEER(,)S�I>`nr� /T�hl�f Phone: 7 Address: <Z ,MA Reg. No. 66 FEE SCHEDULE:BULDING PERMIT: 12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ f 96 a Z - FEE: $ Z10, Check No.: ReceiptNo.: 0d Z(� Recei p NOTE: Persons contracting with unregistered co tractors do not have access to the g�#Ianty n _-- �Signature_of Agent/Owner Signature of contractor Plans Submitd �_ Plans Waived ❑ Certifiid Plot Plan ❑ Stamped Plans ❑ (see. �e � � �t iScid� resS is c -er*& bL)Id's TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swmunmg 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 Si ture COMMENTS HEALTH C2Vviewed on Si nature COMMENT Zoning Board of Appeals: Varia c it' No: Zoning Decision/receipt submitted yes Planning Board Decisi . Comments I 11A%� I Conservation D cisvon\ Comments Water & Sewe Connection/Signature& Date Driveway Permit 1 DPW Town 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 ,f Number of Stories: Total square feet of floor area, based on Exterior dimensions. 664 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-$1000 fine NOTES and DATA— For department use � � C�$-�: tZSi,S� �- z �� d � is .� x u� •. = 1�,� �. -6 Fee-Due �Z 2-'Ob. t 1 U U Cc` + 166. a► ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008mi 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/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 MOTE: 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 IOT€: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit i all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Location No. Date NOR��y TOWN OF NORTH ANDOVER F � a /gip r • i : : Certificate of Occupancy $ ;+ s t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspector OE HOR7M,H 10 9 a X17 O4nY n+*'S9 SStiCNOSE CERTIFICATE OF USE & OCCUPANCY TOWN OF NOR'T'H ANDOVER Building Permit Number 661-11 on 4/4/2011 Date: August 21, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 17 Ciderpress Way 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: Meetinghouse Commons LLC 115 Carter Field Road North Andover, MA 01845 Bui ding Inspector Fee: Prepaid Receipt: 24029 Check : 2088 ORTH Town of 0 Andover 0 L A K E O dower, Mass., • • COCHICHEWICK �t ADRATED PPC5 SS ` BOARD OF HEALTH PERMIT T D ood/Kitchen Se is System N r A BUILDING INSPECTOR THIS CERTIFIES THAT.........A.4.44wn. 46*0.0. ....C40%.ftl0ows......U-400................................. Foundation has permission to erect........................................ buildings on .....� ...... u ... 1 ►......1111� d;rl SC141�� to be occupied as.... ..�.... q......V.N4TS........ A . ....C�. �....�...................... ney iim provided that the person ac ptmg this permit shall in every respect conform tot terms of the application on file in final `p .? 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. PLUMBINq),NSPECT VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough ��> / Final �✓� f PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR a UNLESS CONSTRU STARTS ....................................................................................................... Service BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GABS 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. Smoke Det. SEE REVERSE SIDE p�_�3 T%OR'rh D�SttEO '6 qti t p APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ^o / 44°qrao�PP`y�(5* BUILDING PERMIT # co (-7A1 �SSACHUS�� ADDRESS/LOCATION OF PROPERTY: C[�G�prnteSSKV a' —r Map D C Parcel 3 Lot Number N fA SUBDIVISION: /"'ee.14 Ih DATE REQUESTED FILED/READY FOR INSPECTION: /20 �3 "/Z'/1 CLOSING DATE ON PROPERTY: 8/Z3tj_3 FIVE 5 DAYS NOTICE PRIOR TO CLOSING DATEAS RE UIRED ALL WORK AND SIGN-OFFS MUST BE COMPLET ITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20 0 ILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICAB CODES. APPLICANT SIGNATURE Permit Issued to: Address: /I AAA ROUTING TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW CONSERVATION 1>&*7-42- 1/14 a-� � ��� /7 PLANNING f.A DPW-WATER METER SEWER CONNECTION DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW ,..' �-- 8. 2-d(1;3 SIGNATURE File:Application for OC form revised Jan 2007/2011 NORTI1 16�'1O APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION pA�Rwrco Pp•�c5* BUILDING PERMIT # �SSACHut' ADDRESS/LOCATION OF PROPERTY: CfJPrnteSS Map-dj C- Parcel Lot Number w1A SUBDIVISION: I"'�P/�G fn DATE REQUESTED FILED/READY FOR INSPECTION: /2o t 3 2 1 CLOSING DATE ON PROPERTY: 8/Z 3/1_3 FIVE 5 DAYS NOTICE PRIOR TO CLOSING DATEAS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETW WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20 0 ILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICAB CODES. APPLICANT SIGNATURE Permit Issued to: )m iriero Address: /t Sa- 1'1�(DC �0�� N • �l ,� Jl/� ROUTING / TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW CONSERVATION ���•� V. Z4Z- 111 y 06 �Ajk e; � 1' U " PLANNING N�,Ai tv j - c ko 13 DPW-WATER METER CY I Z,,,/� - SEWER CONNECTION DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW l �". G �--- &4-6/13 SIGNATURE File:Application for OC form revised Jan 2007/2011 ORTH 0Twn o 0Andover LAKE -O over, Mass., • COC MICME W ICK _t 0/;? RATED p'P "`� `SS BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... �iirti.... . ... .. ....` � .. �1.. ................................. . .... ........... ..... Foundation has permission to erect........................................ buildings on � !t ... 11". 16 � Rough to be occupied as....t........ ..... ......V.N S........ !1� C..�.l v....•.. ............... Chimney provided that the person ac pting this permit shall m every respect conform tot 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 UNLESS CONSTRU STARTS ELECTRICAL INSPECTOR aL Rough ......................................................................... 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. _, A NOTES: AIL `\ 1�,�]_��--�_f`- 1) THE BOUNDARY INFORMATION SHOWN HEREON WAS TAKEN FROM A 1 y,rA4,�ttRb; �I PLAN ENTITLED "PLAN OF LAND, MEETINGHOUSE COMMONS AT SMOLAK FARMS, SOUTH BRADFORD STREET, NORTH ANDOVER, i�/ OFFICE. EC RDEDSCALE: PLAN #14828 DATE: THEJULY ESSEX COUNTY THIS MAP 104C AL if I `� �' LOT 28 NORTH DISTRICT REGISTRY OF DEEDS. f 2) THE INTENT OF THIS PLAN IS TO SHOW THE AS-BUILT LOCATION OF THE FOUNDATION ONLY. 3) THE FOUNDATION SHOWN HEREON IS NOT WITHIN THE 100 YEAR FLOOD ZONE AS TAKEN FROM THE FLOOD INSURANCE RATE MAP FOR THE TOWN OF NORTH ANDOVER MASSACHUSETTS COMMUNITY PANEL NUMBER 250098 0007 C. MAP REVISED. 6/2/83. ' rtip` SNR=ry�p• I 4) THE CONCRETE FOUNDATION SHOWN HEREON HAVE BEEN INSTALLED / / c9�4�,r, y _y HR�\ Pe �g�0 SUBSTANTIALLY IN ACCORDANCE WITH THE 40B SITE PLAN AS APPROVED BY THE TOWN OF NORTH ANDOVER PLANNING BOARD. 25' NO �g6a / d \ , DISTZORNBANC I HEREBY CERTIFY THAT THE LOCATION OF THE TOWNHOUSE UNIT \ _ g/ N NUMBERS 5-8 FOUNDATION SHOWN HEREON IS THE RESULT OF A g FIELD SURVEY BY THIS OFFICE MADE ON AUGUST 18, 2010. Q AIL w CH 0101,1111811 AILFRAWHER AIL <�' tin 3111% X14 AL A AL �i �\ LICENSED LAND SURVEYOR DATE AL /l `� Jill AIL CERTIFIED FOUNDATION PLAN f 1 MEETINGHOUSE COMMONS TOWNHOUSE UNITS 5-8 GRAPHIC SCALE CORTLAND DRIVE / 0 25 30 too NORTH ANDOVER, MASSACHUSETTS ` t PREPARED FOR AL I I`�f_ ' ff MEETINGHOUSE COMMONS, LLC ROAD 's _————— _f "�� f ` \ 1 inch 60FEET)AL (IN tt NORTH21 CARTER ANDOVER, MAS ACHUSET`TS _ \ ` 7/ ` \ ® M SRNs Read Sulk on. MEETINGHOUSE _ 'k AL '°'""'m.Nampwfo OW79 1 1 (603)093-MO l�bl/qO �-., ` MNF Design Consultants,Ina. ENGINEERS"PLANNERS"SURVEYORS 1� Ug CONC E7E _\ = SCALE: 1" - 50' DATE: AUGUST 23, 2010 1 DRAWING lj0 ]� a _� NO. DESCRIPTION BY DATE DRAWN BY: CHECKED BY: PROJECT N0. NAME AL I "' REVISIONS CMF 250508 1 2505CFP.DWG f RES-.�ecfr Sofhnvare Version rsion 4.3.1 Compliance Certificate Project Title: Meeting House Commons Energy Code: 2009 IECC Location: North Andover,Massachusetts Construction Type: Multifamily Building Orientation: Bldg.orientation unspecified Glazing Area Percentage: 13% Heating Degree Days: 6322 Climate Zone: § Construction Site: Owner/Agent: Designer/Contractor: Building 3 Tara Leigh Development,LLC O'Sullivan Architects,Inc: North Andover,MA 115 Carter Field Road 580 Main Street North Andover,MA Suite 204 978-6876-2635 Reading,MA 01867 781-439-6166 Compliance:1.9%Better Than Code Maximum UA:784 Your UA:769 The%Better or Worse Than Code index reflects how dose to compliance the Crouse is based on code tradeoff rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. Floor 1:All-Wood JoistlTruss:Over Unconditioned Space 3769 30.0 0.0 124 Ceiling 1:Flat Ceiling or Scissor Truss 3769 30.0 0.0 132 Front Walls:Wood Frame,16"o.c. 1392 19.0 0.0 67 Orientation:Unspecified Window 3:Vinyl Frame:Double Pane with Low-E 155 0.330 51 SHGC:0.30 Orientation:Unspecified Window 4:Vinyl Frame:Double Pane with Low-E 42 0.280 12 SHGC:0.27 Orientation:Unspecified Door 1:Solid 80 0.160 13 Orientation:Unspecified Sides:Wood Frame,16"o.c. 2052 19.0 0.0 116 Orientation:Unspecified Window 5:Vinyl Frame:Double Pane With Low-E 125 0.330 41 SHGC:0.30 Orientation:Unspecified Rear Walls:Wood Frame,16"o.c. 1780 19.0 0.0 80 Orientation:Unspecified Window 1:Vinyl Frame:Double Pane with Low E 345 0.330 114 SHGC:0.30 Orientation:Unspecified Window 2:Vinyl Frame:Double Pane with Low-E 21 0.280 6 SHGC:0.27 Orientation:Unspecified Door 3:Solid 80 0.160 13 Orientation:Unspecified Compliance Statement: The proposed building design described here is consistentWith the building pl/hs,specifications,and other calculations submitted with the permit application.The proposed building has been designed to meet a 2009 IECC requirements in REScheck Version 4.3.1 and to comply with the mandatory irem listed in th RESche In ction Checklist. ,swig -7 da '0�vl'u off Project Title:Meeting House Commons Report date:07/28/10 Data filename:K:1ZahoruikolMeetinghouse Commons-No Andover\Meeting House TownhouseslCD'slBuilding 31Building_3.rck Page 1 of 2 tans Sub d Plans Waived Certified Plot Plan ' Stamped Plans TYPE OF SEWERAGE DISPOSAL �ublicSeweTanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site y THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE A PROVED PLANNING & DEVELOPMENT d f] COMMENTS N� } A Ck6S CONSERVATION Reviewed on7/w/:2//0 Signature 4,� fl COMMENTS ft&, (IM uad QA L= HE LTH Reviewed on Si natuo COMMENTS O h +0-cw Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Z2— t)Y Comments 7-z'b -ro Water & Sewer Connection/Si natur DaA Drivewa Permit 60 DPW Town Engineer: Signature: Located 384 Osgood Street IRE�ERITTMEN Terme er on site yes t/ no Located -a24 "t, slam Street Fire �De.partmentsignatuTelda*tA:. COMMENTS The Commonwelz&h of Hassachumm Department.o.rrndU9&ia1 Accidws Offwe of Invesk-antras -600 Washin n Sbed Boston, M4 02111 Workers' Compensation lWar" Af6tlawww-Ma g-orldia ADcant Information Builders/Contractors/Electricians/plumbers PIease printLeg bIv Name(Busm r ��zafioullndiviattal): GM M^ Address: Ci /State/Zip: ' � � G'� �A 11�� Phone#: Are you an employer?Check the appropriate bo= I.❑ I am a employer with 4- M I am a genexal contractor and I Type of Proles(required): employees(fill and/or part time)* have hired the sub-contractors 6. XNeu,conMmction 2.® I am a sole proprietor or partner- listed on the a ached sheet.1 7. [❑Remodeling ship and have no employees These sub-Contractors have 8- ❑Demolition Working for me m any capacity. w �T ork�s' �P.insurance. [NO wormers comp.insurance S. ❑ We are a coipotaiion and its 9. ❑B��g addition 3.❑ requirel - officers have exercised#bets I O-❑Electrical repairs or additions I am a homeowner doing an work right of ex �PtiOn per MGL I I.❑ insurance r MYWX[No w� t comp- c. 152,$1(4),and we have no 12.n Roof f�-sus or additions emPloyees. [No workers' r� COMP.malr� .] 13.E]Other Smt r1u bort mnstaiso iY�E aut the elaw Homeown=who aubmit Eris affidavit i ° +Camtrartaia that eherx 9ris box must g� an wa&and thm'hm awmda cWft==meat asaahed as ad&bcuW Sheet snbmtt a new affidavit indi ting_cuch - -- �.same of Sic sari ffieir - w°rkascmP•Piny information. I ant an employrr t&isproviding work= co inforrnadon. n mace for mY emPlgpees Below is&e policy andjob site lnsnrance Company Name: Policy#or Self-ins.Lie.# - Expiration Date: Sob Site Address: Attach a copy of the workers'compeasaiion CtiY/Sf�/Zip:Policy duration page(showing the policy number and Fates to secure coverage as required vnd..r Section 25A of MGL c 152 can lead tr 8te' expiration date). fine up to 51,500.00 and/or one-year imP isol imposition of crinninal penalties of a of up to$250.00 a da as well as civil penalties in the foam of a STOP WORK ORDER and a fie y against the violator: Be #hat a copy of this Investigations of the DIA for it cx s�e�may be forwarded to the Office of oa Ido hereby cera;fy under paw and 006*7 ftztthe iffformadon SiQnattu e: ��� is irm and correct Phone OffLcial use only. Do not write in this area, to be completed by city or town official City or Town: P' ceuse# - Issuing Authority(circle one): - L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical 6.Other Inspector 5.plumb Inspector Contact Person: Phone r :Massachusetts-Department of Public Safety Board of Buildim, ' Regmlations and Standard's Construction Supervisor License License: CS 55417 Restncted.io 00 - THOMAS D. ZAH UIKO 115 CAR TERFIELD N ANDOVER,`MA 01845- c— -d i Expiration: 45=2 (`nannix�ime� Tr#: 21090