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Miscellaneous - 183 FOREST STREET 4/30/2018 (2)
N New England Home Energy Audits 4 Ridge Rd. Hudson, Ma. 01749 Duct Tightness Test Certificate Test Date: 08 /08/ 2013 Address: 183 Forest St. North Andover, Ma. 01845 Tested with Minneapolis Duct Blaster Conditioned Floor Area 2443 Sq. Ft. Leakage 96 CFM @ 25 Pascal Leakage % 3.92 [ CFM Per 100 Sq. Ft. ] Notes: Post Construction Total Leakage Test [ 25 Pa across entire system to include air handler 14 Supplies 3 Returns Filter installed at unit New unit and ductwork / retrofit Patrick Ryan Certified HERS Rater # 3692996 978-790-0848 Provider: Building Efficiency Resources P.O.Box 530 North Creek, NY. 12853 800-399-9620 225 Date.R:..'. '..�. . . F HOR,M TOWN OF NORTH ANDOVER O 4% PERMIT FOR MECHANICAL INSTALLATION A This certifies that ........... . . has permission for mechanical installatio>2 .. i...Z-- :............. . in the buildings of ....ti. `� . ........................ . T- at .... �. "'�? - ""� ! � . . , No�rtLh Andover, Mass. ` Y.e�. Fee. .2>... Lic. No.. Q.�S� . {�- , ►i Y`.. .. GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of Massachusetts Date: - 113 Estimated Job Cost: .95 0 = Plans Submitted: YES NO Sheet Metal Permit Permit # Permit Fee: $ Plans Reviewed: YES NO Business License # �-AO 5 4 Applicant License # 3 C> D 4 - Business Business Information: Property Owner / Job Location Information: Name: O ncA I ecr. Inn A ,,-I L Name: jam( 62- -be or -'.t5 (t o Street: 1lect ry Street: J 3 by e 5� City/Town: Lo We JA G 018C 2, City/Town: 1,I ©g-4) Telephone: Telephone: 411 g (o l Photo I.D. required / Copy of Photo I.D. attached: YES ✓ NO . R. Building Type: Residential: 1-2 family Multi -family Condo / Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC V1 Metal Roofing Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: S new C�u C w arL�- - INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ❑ No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑, 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments a Final Inspection Date Comments Type of License: By ❑ Master Title ❑ Master -Restricted City/Town ❑Journeyperson Signature of Licensee Permit # ❑Journeyperson-Restricted License Number: Fee $ ❑ Check at www.mass.gov/dpi Inspector Signature of Permit Approval Sheet Metal Commercial Guidelines / Life Safety / Critical Systems Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampers with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) Grease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper cleat+antes, fire rated enclosures and pressure testing required. _ _ SFiu;aiv rer,,:aint3 installrz 'ori equipment and du,t:.. o, Duct penetrations in fire'rdtc ivall:i and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct nuns installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -off) Sheet Metal Residential Guidelines / Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" w Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -off) PROPOSAL JMC J on'0d 018 5Z PROPOSAL SUBMITTED TO: Ci --9 g 9 L S 9 3 4- NAME 6 �5u o tan ADDRESS --ro S til. Q•r,dcr 15 PHONE NO. 6 d �� ecatinn D '%" WORK TO BE PERFORMED AT: DATE OF PLANS ARCHITECT PROPOSAL NO. SHEET NO. ,;tg I I We hereby propose to furnish the materials and perform the labor necessary for t^^he g�ompletiQQn of 5-�`A 11 � Z _T0t1_) rn.�.r'. '5-1a dct S kF�G- t2. r S 5 A L t- J GT Xt,> o V ' t�. b '► w %E' n S 1r`C6Sv(t2 c S % nC' V E ,f �,,� a�r1 e a ✓ crane 1 ,4-o e t All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi cations submitted for above work and completed in a substantial workmanlike manner for the sum of S�vcr1 �-v S 4 � %A v ctr- A as op Dollars ($ •dao = ) with p ments to be made as follows a-p� ; �w on 1��ance, vPDn �otrn ��'D'�• Respectfully submitted Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge Per over and above the estimate. All agreements contingent upon strikes, ac- cidents, or delays beyond our control. Note—This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and .conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. �---, n�Signature ' �-•'�f � �"`� Date Signature NC 3818-50 PROPOSAL ACbRlo® CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDIYYYY) 8/5/13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLIER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may mquire an endorsement. A statement on this certificate does not confer ruts to the certificate holder in lieu of such endorsement(s). PRODUCER Michael G Conway Insurance Agy PO Box 1744 77 East Merrimack Street Lowell, MA 01853 NAIVE: SONA SAY PHONE FAX (978) 453-2480 Fdi 97$ 454-5054 No: ADDRESS: SONA@ CONWAYINSURANCE . COM INSURERS) AFFORDING COVERAGE NAIL# INSURER A: NAUTILUS INS CO INSURED INSURER B: NGM Jose Alzate INSURERC: DBA Jonell Heating & Air Condi 71 Jean Ave Lowell, MA 01852 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS `CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS L TY PE OF INSURANCE ADDL SUER POLICY NUMBER POLY EFF MIDD1YYY POLICY MNlDDIYYYYI LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR NN264409 8/13/12 8/13/13 EACH OCCURRENCE $ 1,000 000 DAMAGE TO RENTED rre $ 100,000 NIED EXP (Anyoneperson) $ 5,000 PERSONAL& ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENLAGGREGATELIMITAPPUESPER POLICY PRO LOC JECT PRODUCTS - OOMPIOPAGG $ 2,000,000 $ B auroMOBILELIABIury ANYAUTO ALLOWNED X SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS _ AUTOS MIU5571K 6/25/13 6/25/14 eaccidsrd COhMINED SINGLE $ BODILY INJURY (Per person) $ 100,000 BODILY INJURY (Per accident) $ 300,000 PROPERTY D GE eraccident $ 100 000 UMBRELLA LIAR EXCESS LIAB E OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ OED RETENTION WORKERS COMPENSATION EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERMIEMBFR EXCLUDED? (Mandatory in NH) Ifyes, describe under DESCRIPTION OF OPERATIONS below N i A WC STATU- OTH- T.YAND E.L. EACH ACCI DE NT E.L. DISEASE -EA EMPLOYEE E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is regui red) HVAC CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPT INSPECTOR 1600 OSGOOD ST AUTHORIZED REPRESENTATIVE N AWnOVr..R . MA 01 RAA ss -o- " Y-9" Y-9" 5'-0• 76' Master Bedroom Proposed Addition Dining Room New Bathroom ho t Q% not Existing House ,r.z tiT o Dennis & Susan Holland 183 Forest S',. No. handover. tela. ►-' a ori Dennis & Susan Holland M Forest Si. No. Andover. Ma. Page 1 Residential Heat Loss and Heat Gain Calculation 8/6/2013 In accordance with ACCA Manual J Report Prepared By: Jonell Heating & Air Conditioning 71 jean ave Lowell, Ma 01852 978) 996 5934 MA Master S.M. LIC #4036 For: Dennis and Susan Holland 183 Forrest st North Andover, Massachusetts Design Conditions: North Andover Indoor: Outdoor: Summer temperature: 70 Summer temperature: 88 Winter temperature: 75 Winter temperature: 0 Relative humidity: 55 Summer grains of moisture: 100 Daily temperature range:Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Windows 7,193 0 7,193 8,527 Infiltration 2,387 3,279 5,666 17,402 People 2,700 2,070 4,770 0 Ceilings 3,141 0 3,141 6,735 Skylights 3,062 0 3,062 1,428 Walls 1,577 0 1,577 5,482 Doors 543 0 543 1,886 Glassdoors 0 0 0 0 Misc 0 0 0 0 Fireplaces 0 0 0 0 Floors 0 0 0 0 Duct 0 0 0 0 Whole House 20,603 5,349 25,952 41,460 ( 2 tons ) HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates onty. actual loads may vary due to weather and construction differences. Page 1 Residential Heat Loss and Heat Gain Calculation Report Prepared By: In accordance with ACCA Manual J Jonell Heating & Air Conditioning 71 jean ave Lowell, Ma 01852 978) 996 5934 MA Master S.M. LIC #4036 For: Dennis and Susan Holland 183 Forrest st North Andover, Massachusetts 8/6/2013 Design Conditions: North Andover Indoor: Outdoor: Summer temperature: 70 Summer temperature: 88 Winter temperature: 75 Winter temperature: 0 Relative humidity: 55 Summer grains of moisture: 100 Daily temperature range:Medium 'Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Whole House 2,262 sq.ft. 20,603 5,349 25,952 41,460 ( 2 tons ) First Floor 20,602 5,349 25,951 41,461 Dining Room 422 sq.ft. 4,186 1,852 6,038 -_ _ ... .. 11,073 Infiltration 846 1,162 .... .._._._. 2,008 _.. 6,168 - Tightness: Avg.; Winter ACH:.7 ; SummerACH:.4 ---_-_.-__ ................ ._. __-__ People 3 900 690 -_._._.. -.. 1,590 _. _ ... 0 Floor 422.5 sq.ft. 0 0 0 0 - Over conditioned space N Wall 138.6 sq.ft. 180 0 180 624 -Wood frame, with sheathing, siding or brick; R-19 5 1/2 in.; - _----_ -- ---.._.. -- none ...._...... -_-.. - -----. Door 86.7 sq.ft. 543 0 __.._._.. 543 __._._... 1,886 - Wood; Solid; Wood storm W Wall 95.2 sq.ft. 123 0 123 428 -Wood frame, with sheathing, siding or brick; R-19 5 1/2 in.; ... - -- - --- - . - none - --- -- Window 24.8 sq.ft. 1,121 .. 0 _ ... _ . -.... 1,121 .........-- --.. 923 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. Ceiling 422 sq.ft. 473 0 473 1,044 - Under ventilated attic; R-30 (8 - 9 inch); Light _. --- ---q _ -. ------._ -... .. - -- - master bedroom 422 sq.ft. 3,634 .---_. ---- -----.....-...._._ --- -.- 979 -- --- _ _ - 4,613 ._..__ _.. - -- 6,974 Infiltration 378 519 --- 897 ........... 2,753 -Tightness: Avg.; Winter ACH:.7 ; Summer ACH:.4 _.._ .. __... --._--...-- - - People 2 600 - — 460 -............ 1,060 _._....._. 0 Page 2 Dennis and Susan Holland Building Component Sensible Latent Gain Gain (BTUH) (BTUH) Total Heat Gain (BTUH) 8/6/2013 Total Heat Loss (BTUH) Floor 422.5 sq.ft. 0 0 0 0 - Over conditioned space . .. . ............ . .. .............. W Wall 95.2 sq.ft. 123 0 123 428 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none . ......... . ...... . ....... Window 24.8 sq.ft. 1,121 0 1,121 923 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. .. . .. ......... . .... S Wall 95.2 sq.ft. 123 0 123 428 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none ..... ....... I . ....... .- ........ ... ........ - ---------- -- ---- ---- ---- - --- -- ------------- - ---- ----- Window 24.8 sq.ft. 600 0 600 923 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. .......... . ............. ... ....... ..... .............. - Ceiling 422 sq.ft. 689 0 689 1,519 - Under ventilated attic; R-22 (7 inch); Light ........... . .. _._ ................ __ ----------- ------- .... . ..... . .. ..... .... ..... ...... ---- -- - ---- ------- Bedroom 1 148 sq.ft. 1,657 458 2,115 3,359 Infiltration 166 228 394 1,212 -Tightness: Avg.; Winter ACH: .7; Summer ACH: .4 ------ ---- -------------- --- -------- • People 1 300 230 530 0 ----------- ........ ........ -------- Floor 148 sq.ft. 0 0 0 0 Over conditioned space . .. .... ....... .............. .. _ .. ..... ..... ..... .............. . .. . ..... SW wall 86 sq.ft. ill 0 ill 387 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none ...... .............. .. . Window 11.3 sq.ft. 454 0 454 420 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. I .... ....... .......... . ..... ..... .. - ---- ----- . ....... . ... .. . .......... ........ . ...... . ... ...... ...... ....----- - - - ----- --- S Wall 86 sq.ft. ill 0 ill 387 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none ---- ------- -- --- ------- ...... . ..... . . . ............. .. . . Window 11.3 sq.ft. 273 0 273 420 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. Ceiling 148 sq.ft. 242 0 242 533 - Under ventilated attic; R-22 (7 inch); Light Bedroom 2 148 sq.ft. 1,618 699 . . .... .... - ------------------- - ---------- 2,317 2,879 Infiltration 174 239 413 1,267 -Tightness: Avg.; Winter ACH: .7 Summer ACH: .4 .. ..... . ............ .... . __ _.._ ---- ------- ---------- ------- . ... ......... . .... ......... .. People 2 600 460 1,060 0 Floor 148 sq.ft. 0 0 0 0 - Over conditioned space ........ - -------- .... . ............ .. .--_- _ _.... ........... . .. ..... . . ........ S Wall 74.3 sq.ft. 96 0 96 334 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none ....... ... .. .... Window 23 sq.ft. 557 0 557 856 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. - ------ ---- - ---------- -- ----- - - -----------_- Page 3 Building Component Dennis and Susan Holland Sensible Gain (BTUH) Latent Total Gain Heat Gain (BTUH) (BTUH) 8/6/2013 Total Heat Loss (BTUH) Ceiling 148 sq.ft. 191 0 191 422 - Under ventilated attic; R-26 (7.5 inch); Light . . ........ . ..... .... . ..... . .......... ... Bedroom 3 148 sq.ft. 2,102 ..... ......... . ... ....... .... .. 500 -------- -------- 2,602 ..... . .... ....... . ...... .. ........ 3,821 Infiltration 196 270 466 1,432 Tightness: Avg.; WinterACH:.7; SummerACKA ---- - ------ ----- ......... ... .. __ ----- ---- People 1 300 ... . ............. .... . ..... 230 ------ 530 0 Floor 148 sq.ft. 0 .. ....... . .............. ...... 0 ..... ..... .. . 0 .. ......... .. .... . 0 - Over conditioned space - ...... .... - ------ ----- ----------- - S wall 145 sq.ft. 188 0 188 652 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none ----- -- . ........ Window 3 sq.ft. 73 0 73 112 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. E Wall 74 sq.ft. 96 0 96 333 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none ...... ...... . ............. ...... ... - .......... ...... ..... .. .... . Window 23.4 sq.ft. 1,058 0 1,058 870 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside I ....... .... ............. ..... ............ .. ... shading. .............. . Ceiling 148 sq.ft. 191 0 191 422 Under ventilated attic; R-26 (7.5 inch); Light .-...-_..-__ . ................... - - ---- - ------_--- -- ------- - ....... .... . . .............. .. ... Bathroom 1 35 sq.ft. 485 83 568 1,270 Infiltration 60 83 143 441 - Tightness: Avg.; Winter ACH: .7 ; Summer ACH: .4 . . .... ... ......... -------- Floor 34.7 sq.ft. 0 0 - -- - - ---------- ---------- 0 .... . . ... ........... . - ............ 0 Over conditioned space .......... . .......... . ....... ... .. . .... ....... .... . ...... . .... ...... ..... . ..... E Wall 54.7 sq.ft. 71 0 71 246 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none __ - -......1-1 ...__ ...... . ..... ...... ... ..... . .... .......... ....... .... NE Wall 39.5 sq.ft. 51 0 51 178 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none ........ . .. . .... . ....... - ----------- -- ----- .. . . ........ ..... ....... ...... - Window 7.8 sq.ft. 251 0 251 290 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. Ceiling 40.4 sq.ft. 52 0 52 115 Under ventilated attic; R-26 (7.5 inch); Light ...... ... ... .. I ..... . ........... Hall 150 sq.ft. 194 0 194 427 Infiltration 0 .... ..... . . ............. 0 --- ------------ - ----------- 0 0 - Tightness: Avg.; Winter ACH: .7 Summer ACH: .4 ..... . .................... Floor 150.3 sq.ft. 0 --------- 0 0 0 - Over conditioned space .... ... . .. ....... . .......... ............ - ------ . ........... .. Ceiling 150 sq.ft. 194 0 194 427 Under ventilated attic; R-26 (7.5 inch); Light ------- -------- .... ....... Family Room 289 sq.ft. 4,801 436 5,237 6,592 Page 4 Dennis and Susan Holland 8/6/2013 Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 317 436 753 2,313 Tightness: Avg.; WinterACH:.7; SummerACH: .4 Floor 289.3 sq.ft. 0 0 0 0 - Over conditioned space ............ . ........ .... ------- E Wall 102.9 sq.ft. 133 0 133 463 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none . ....... .. . ......... . Window 41.8 sq.ft. 823 0 823 1,555 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); 85% shaded. Ceiling 270.9 sq.ft. 466 0 466 833 - Roof on exposed beams/rafters; 1 1/2" wood decking, R-1 9; Dark ---------- .. ... ... .. ----- -------------- ----- ...... H Skylight 18.4 sq.ft. 3,062 0 3,062 1,428 - Single, plastic dome; Treatment: None, clear glass or plastic; Horizontal; Wood frame ---- - ----- ---- --------- - - ..... ..... ... Kitchen 395 sq.ft. 510 0 ........ ... ..... . . .............. - --- . ........ 510 1,126 ...... .... ... Infiltration 0 0 0 0 -Tightness: Avg.; Winter ACH: .7 ; Summer ACH: .4 ........ ..... . Floor 395.4 sq.ft. 0 0 ...... ..... . 0 0 Over conditioned space . ..... . ... ...... Ceiling 395 sq.ft. 510 0 510 1,126 Under ventilated attic; R-26 (7.5 inch); Light ... .... ... ..... . .............. .... ------ mud room 103 sq.ft. 1,415 342 ........... . ... ............. ---- ----- . ..... . .... 1,757 3,940 .... ... ......... ._._._- Infiltration 249 342 591 1,817 -Tightness: Avg.; Winter ACH: .7 Summer ACH: .4 - - - - - __ - ---- ------- _- --------- ...... ... .. ...... . .. .... .... .............. ___ ... .... --- ------- ---------- Floor 103.4 sq.ft. 0 0 0 0 Over conditioned space 1. _ .... ....... . ...... ........ ....... ... ... ------ ....... ........... ... . - ---- ------ - W Wall 56 sq.ft. 73 0 73 252 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none -- ----- ----- ____ ...... ........ . ...... . --------- -- -- -- - Window Window 11.9 sq.ft. 538 0 538 443 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. N Wall 76 sq.ft. 98 0 98 342 -Wood frame, with sheathing, siding or brick; R-19 51/2in.;none . . .......... .. ...... . .. ... . . .. ...... .............. ..... --- --------- ---- - . ..... ... ... ...... ..... Window 21.3 sq.ft, 324 0 324 792 - Double pane; Vinyl frame; Clear glass - Draperies or blinds; Coating: None (clear glass); No outside shading. Ceiling 103 sq.ft. 133 0 133 294 - Under ventilated attic; R-26 (7.5 inch); Light Whole House 2,262 sq.ft. 20,603 5,349 25,952 41,460 (2 tons HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may vary due to weather and construction differences. Page 1 Residential Heat Loss and Heat Gain Calculation 8/6/2013 In accordance with ACCA Manual J Report Prepared By: Jonell Heating & Air Conditioning 71 jean ave Lowell, Ma 01852 978) 996 5934 MA Master S.M. LIC #4036 For: Dennis and Susan Holland 183 Forrest st North Andover, Massachusetts Design Conditions: North Andover Indoor: Summer temperature: 70 Winter temperature: 75 Relative humidity: 55 'Building Component Outdoor: Summer temperature: 88 Winter temperature: 0 Summer grains of moisture: 100 Daily temperature range:Medium Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Whole House 2,262 sq.ft. 20,603 5,349 25,952 41,460 ( 2 tons ) First Floor ---------------- 20,602 5,349 25,951 41,461 Dining Room 422 sq.ft. - 4,186 ----- _ ._._._ 1,852 _.. - _._. 6,038 11,073 _ _ ..._ _ master bedroom _ 422 sq.ft. 3,634 979 4,613 6,974 ....._..----._._.. Bedroom 1 148 sq.ft. 1,657 458 2,115 3,359 Bedroom 2 148 sq.ft. - 1,618 699 - - -- 2,317 _------. 2,879 _. Bedroom 3 --- 148 . - - sq.ft. --- 2,102 - 500 - - - 2,602 - ------ 3,821 -------- --- Bathroom 1 35 sq .ft. 485 83 568 1,270 Hall 150 sq.ft. 194 0 194 427 Family Room ---- - 289 sq.ft. 4,801 ____._._.__ _ __--.___ 436 .._.__ _...._._._ 5,237 _ _.... -- 6,592 _........ -.-._-__. Kitchen 395 sq.ft. 510 0 510 1,126 mud room 103 sq.ft. 1,415 342 1,757 3,940 Whole House 2,262 sq.ft. 20,603 5,349 25,952 41,460 ( 2 tons ) HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may vary due to weather and construction differences. Page 1 Residential Heat Loss and Heat Gain Calculation Report Prepared By: In accordance with ACCA Manual J Jonell Heating & Air Conditioning 71 jean ave Lowell, Ma 01852 978) 996 5934 MA Master S.M. LIC #4036 For: Dennis and Susan Holland 183 Forrest st North Andover, Massachusetts 8/6/2013 Design Conditions: North Andover Indoor: Outdoor: Summer temperature: 70 Summer temperature: 88 Winter temperature: 75 Winter temperature: 0 Relative humidity: 55 Summer grains of moisture: 100 Daily temperature range:Medium Building Component Sensible Latent Total Total • Gain Gain Heat Gain Heat Loss • (BTUH) (BTUH) (BTUH) (BTUH) • Whole House 2,262 sq.ft. 20,603 5,349 25,952 41,460 ( 2 tons ) First Floor _... 20,602 - 5,349 -- - -- - - 25,951 ------ - -- ----------------- 41,461 Dining Room -- ._....-- 422 sq.ft. 4,186 --..__.. 1,852 .__..._.__......... 6,038 . ......... . _.. _... 11,073 master bedroom _......_.._ _ ..._____ ______ 422 sq.ft. __ 3,634 ___ _._. 979 _..__. _..__. _.._._ 4,613 ._......._ ..._____ ----- -- -- 6,974 Bedroom 1 148 sq.ft. 1,657 458 2,115 3,359 Bedroom 2 148 sq.ft. _ 1,618 _...._-.. . _...._..__ 699 _..__ ---------- --- ___..__ 2,317 2,879 Bedroom 3 148 sq.ft. 2,102 500 ___. 2,602 _..._........... ...__. 3,821 Bathroom 1 35 sq.ft. ..... _......__.._._ 485 ..._. _ ...... . ...... 83 -- -.. 568 ------- --..._._ ._. _._... 1,270 Hall _.__.. 150 sq.ft. ... _..-_._ 194 0 194 _._._... 427 Family Room _ - -- - 289 - -- sq.ft. ._.._._ - ---- 4,801 .... -.._. _ .._ 436 --- - _ - ...... .._.._..5,237 -._ ... 6,592 Kitchen 395 sq.ft. -. ---- 510 -------- ------ - - 0 --- 510 - - -- ---------...._. 1,126 mud room 103 sq.ft. 1,415 342 - 1,757 3,940 Whole House 2,262 sq.ft. 20,603 5,349 25,952 41,460 ( 2 tons ) HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may wary due to weather and construction differences. The Commonwealth of Massachusetts - Department ofIndustrial,Accidents Office of Investigations UV. 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Con>tractorslElectricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorAndividual): VA 2 Gt �y, Q ,f\ t -O' A 0,- Address: A Address: -1 .���in P� \,/ — City/State/Zip: Lo (I, "{`Q p l$ SZ Phone #: 9'2 c6 q"l 6 Are you an employer? Check the approliriate box: Type of project (required): L ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction f mployees (full and/or part-time).* have Hired the sub -contractors %• Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ? ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. F1 Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions required.] officers have exercised their 3-0 1 am a homeowner doing all work right of exemption per MGL 11. F1 Plumbing repairs or additions 4 myself. [No workers' comp. c. 152, § 1(4), and we have no 12.[]Roofrepairs insurance required.] employees. [No workers' 13.❑Other comp. insurancerequiredJ *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 tCre doing all work and then hire outside contractors must submit anew affidavit indicating such. iContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy anJjob site information. Insurance Company Name: - Policy 4 or S elf -ins. Lic. #: Yob Site Address: _ Expiration Date: 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 requireclunder 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. T do Izereby x fy under the paf�dpenalties ofperjusy that the Information provided above is true and correct. only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 13 Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Person: Phone #: 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 employeY is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of au 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 chapterhave 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 maybe submitted to the Department of Industrial Accidents for confirmation of -insurance coverage. Also be sure to sign and date the affidavit. 'The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that -the affidavit is -complete -andprinted legibly: The Departineiithas provided a space at the bofioin 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. 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: Tho Coinxzowealt oTassa.,rhv.:setts Department offadusWaj AAccldejits oface offavestigatio.ps. 600 WasbingtoA Street Boston} M.A, 02111 ` QT, # 617-7-27-4900 o7t406 or- 1:-8,77,MASSAk`F, Revised 5-26-05 BaY# 617-727-7749 Date/ ./.. �• . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .4. C. /....'P/ � ........................ has permission to perform ......P. C.k Q.� .+¢ t �.'. \.......... . plumbing in the buildings of 4 ................. at .. 1. Y3 ............ North Andover, Mass. Fee. !Z. ! .. Li c. No. .. .......1.,r-^�.... . PLUMBING INSPECTOR Check # it L 68`•7 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location Owners Name �[ �--�' 5 Permit # � Amount b"2 Tyde of Occuoancv �P 41 , .f[��. n 0 1 1 f New ri Renovation F7 Plans Submitted Yes 7r No ❑ _ 1 1`►III -..-MMM I M1111 M , .. MM • KV. DIVA 9 ������-M��������-�-�-M-.-N 1 11 - 1 11' rNMI ommmmmmmmmm ommmm����NMI NMI W I 11' MM � 1111 MM WON M119410091 11' ����������IMMMI MMM M NMI NMI 1 11 ' -------------------------N (Print or type) Installing Company Name Address Name of Licensed Plumber: Insurance Coverage: Indicate Liability insurance policy 1' �k Alao V-� / c C'`e`c�' K6L4"-< nsurance coverage by check Other type of indemnity Check one: 6 Certificate © Corp. — Partner. ElFirm/Co. box: Bond ❑ Insurance Waiver: he undersigned, have ben made a • re that the licensee of this application does not have any one of the above three ins "M107777 Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts to Plumbin ode and pter 142 o he General Laws. By: a6' R ure o icense um er Title R Type of Plumbing License City/Town icense um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Tbb IUB forQ� ibC BUILDING PERMIT NUMBER: 1 DATE ISSUED: Gni SIGNATURE: Building Commissioned[ of of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: SV, /OG X 4 Nr&C/-14&41- Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Regaired Provided Required Provided —+ 1.7 Water supply M G.L.C.40. 34) I.S. zone : Flood Zane Info tion: / 1.8 sewersp Disposal system: Outside Flood Zen, i3 Municipal ❑ On Site Disoosst=e- Public ❑ Private SECTION 2 - PROPERTY OWNERSEE[P/AUTHORIZED AGENT 2.1 Owner of Record Nam Print) �A ` Location Date Signature No. 2.2 Owner of Record: ,Towt4 OF: NOFRTH ANpQVER ` f •o r�, MO N me Print 12 3 sanCy $ Certificate of Occup Fee $ sr afore'r y SERVI • �' (Frame Permit , • 0 ~" i Building $ - SECTION 3 - CONSTRUCTION �ss"c'"t'� Permit Fee 3.1 Licensed Construction Supervisor: Foundation - $ Other Permit Fee $ Licensed Construction Supervisor: . TOTAL Address # Check Signature Telep ec�t/or Building Insp y�L G1 (J 3.2 Registered Home Improvement Contractor Company Name Registration Number Address F.xniration nate SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building rmit. Si ed affidavit Attached Yes .......0 No ....... 0 SECTION S Descri tion of Proposed Work check an a bit New Construction 0 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition Accessory Bldg. ❑ Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: 30 DwG r vuAA ; k �Cir�a /�� `r/Lt �Qe�ry�dc�� / ��cLi� e/ I SECTION 6 - ESTIMATED CONSTRUCTION CACTR I Item Estimated Cost (Dollar) to be Completed by perntit applicant OFFICIAL USE ONLY 1. Building p� / (a) Building Permit Fee Multi lier 2 Electrical 3 D46 (b) Estimated Total Cost of7/ Construction / J Q 3 Plumbing 7R DDD Building Permit fee (,) z (b) /�O �— 4 Mechanical HVAC ^b — 5 Fire Protection ^ 0 — 6 Total 1+2+3+4+5 0,0a Check Number J1.l.liV1� is v�1�L'AOR �C►v lnvl(iGF►11vP1 1V 0rs %-UMYLL� lEL WHAf4 OWNERS AGENT ONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner/authorized Agent of subject property Herebv authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTIIORIZED AGENT DECLARATION I, D e. t4A ; S E _ 5 ostiK '-I'_ ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief NO. OF STORIES SIZE go 1< A 9' BASEMENT OR SLATS SIZE OF FLOOR TIMBERS 3 RD SPAN 15.1 DIMENSIONS OF SILLS DMNSIONS OF POSTS amns DMNSIONS OF GIRDERS HEIGHT OF FOUNDATION 0 THICKNESS SIZE OF FOOTING /a )(12 a X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILL15D LAND Se P IS BUTLDTNG CONNECTED TO NATURAL GAS LINE Ale m m m x m m v, y C � — O 'C Cl) CD O Z y CL o F, _� c 0.� CO) a� �o Q O r► C7 ? %C d O CD o c �CD y' �•. =0 CO) !OD cn O cn Z Gra z Z S - ro ro z n r T � ►$n n o a� H y 0 9 0 "Ah Z1 lO I t. Y O Town of NORTH ANDOVER 1 BUILDING PERMIT INSPECTION REPORT Rle W 0 d", / /'-c h PERMIT NO.: 2V PROJECT: 1XSf�/16v1Yh44 �i.JI' 1 155&F £ DATE: 9 `8 . 0 S - UNIT NO.: Z FLOOR: WING: r BUILDING NO.: �� 0 REMARKS: ;�- '-/1V5' 000. -- �� `l- 5(30 C Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date: Date: Date: Inspector Inspector Inspector -vire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: -Cof 0# Inspector Inspector Inspector Form #995 Action Press, 585-7000 Dennis & Susan Holland 183 Forest Street N. Andover, MA. 01845 Design Objectives for House at 183 Forest St., N. Andover, MA. Scope: The plan is to build an addition 30'x28' off the rear of the existing one story house. The purpose for the addition is to add a dining room and a new master bedroom with a bathroom. The house presently has 3 bedrooms and would remain so as a result of a reconfiguration of the existing master bedroom to a family room. The kitchen will be redesigned and have new cabinets and countertops, as well as new task lighting. Entry to the new dining room will be an archway where a 4' casement window is to be removed. A 6' sliding door next to the casement window will be removed and the opening resized for a single hinged door. Both the dining room and bedroom will have sliding patio doors leading to the rear yard. All the doors to have wood landings with stairs with rails leading to the back yard. The existing septic system will be used as is. The well currently supplies water to the residence and will remain so. The design stays well within the setback requirements of the town of N. Andover. FORM U -LOT RELEASE -FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT DCn n -� 5 �5ozctq 2k6( LOCATION: Assessor's Map Number /4)(p 14 SUBDIVISION STREET e_ PHONE '?7,e 6 8'( /!P P/ PARCEL` O LOT (S) ST. NUMBER / `'� ***********************.****OFFICIAL USE ONLY ***** TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEAL DATE APPROVED !G, DATE REJECTED DATE APPROVE[ DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT, RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm N Dennis & Susan Holland 183 Forest St. No. Andover, Ma. �I 2'-9•' T-0' 51-0' T-6' 4'-17" I 15' 0 15'-0' I I Proposed Addition I Master Bedroom Dining Room to'-s'• I i 7-7 I New Bathroom I Existing House \ UP I m � / DECK m i rk,.ue���j \ ttr-t•xs'-s• � / i I\ I I eAD" �VGAREA 2t'tt^ Dennis & Susan Holland 183 Forest St. No. Andover, Ma. �I i i As�Iaff'S�t 14 - - IQ al, df,� ovw } �a E ev E3 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 - Workers' Compensation Insurance Affidavit Name Please Print Name: !evy ✓� s Sc r3 4 vi [� Location: 1 g 3 �6 resp qtr 2 27t City IVO r lq1'1 dj Vee Phone # 27e- 6 k( -- 16 e/ p�q I am a homeowner performing all work myself. aI am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone # Insurance Co. Policv # Company name: Address City: Phone * Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment -as -well_as_cim. l.,penalties in theform nfa.ST_OP WORK ORDER..and_aflne of (.$100.00.)_arlay against.me, I understand that a copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification. I do hereby cer ff� under the pains and penalties of perjury that the information provided above is true and correct. /.a-Ai,f Print name De -q,,; •N$ tl" Sor-cL, . Aa IlPhon e# 97�-1 Official use only do not write in this area to be completed by city or town official' City or Town Permit/Ucensinci Building Dept ❑Check If immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE_ (� I O 5 JOB LOCATION % 2)-� r Owed X06' Number Street Address Map / lot "HOMEOWNER De",1 ,,S L'. F-6 N."'A' g 7e— 7!F' a SO —00003 Name Horne Phone Work Phone Susi -7- fid A2 4.14(4 �(� - �!��/ . . PRESENT MAILING ADDRESS / �-� )"O reQ f ,46 dl;� 11�evex D/"s- City Town State Zip Code The current exemption for "homedwners" was extended to include owner -occupied dwellings of two units or less and to alkrwr such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor: (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: 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 ac- cessory 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. The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner' certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedL HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFIC The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City. Phone # Insurance Co. Policv # Comnarn/ name: Address City: Phone # Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment.as.well_as_civil..penaltiesinlhefonnjofA_STOP WORK.ORDER..and..aflne.of (5140.00) -clay against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification, I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept []Check if immediate response is required Licensing Board p Selectman's Office Contact person: Phone #.• F-1 Health Department ❑ Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: A.J /x ..d f vocation of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Commonwealth of Massachusetts 011icial I OnI` Pcrmit No. % ,.� Department of Fire Services Occupancy and Fce Checked j Y..y; BOARD OF FIRE PREVENTION REGULATIONS[Rev. 9.05 ] Heave hl:Ink) ` FOR P APPLICATIONERMIT TO PERFORM ELECTRICAL WORK \II ,Mork to he performed ;n accordance ttith the \las.:lchusclts I:IC06C ll Code (\IF.C). 527 (AIR 12.00 ll'LE.ISE PRLAT IN LA7t OR TYP•El.1.LL I.AFORH ITIO,A/ Date: %z/Qp�, City or Town of: /''' ' ��Ib�,,�5t To the h7SIVL101• O if'i1TS. By this application the underSlgned gives notice othis or her intention to perform the electrical work described below. Location (Street & Number) ��,3 J'� �u5'% Owner or Tenant /Iii / dlf% "e-* V Telephone '40. Owner's Address ^�4f1E Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Afo400F Utility Authorization No. Existing Service 'AL Inps / 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: +i No. of Ceil.-Susp. (Paddle) Fans Ami +rbd c)� No. of Hot Tubs N No. of Luminaires ove In- Swimming Pool ' I.nd ❑ red. ❑ o. o mergency Lighting Battery Units _ No. of Receptacle Outlets No. of Oil Burners J No. of Zones T - No. of Switches ('arrrpleliorl of IJre fr,lfou it �, table may be a crincJ !iv the lrrspi° loa rel 11 ;re 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 ove In- Swimming Pool ' I.nd ❑ red. ❑ o. o mergency Lighting Battery Units _ No. of Receptacle Outlets No. of Oil Burners PRE ALARMS No. of Zones T - No. of Switches No. of Gas Burners of Detection and INo. Initiating Devices No. of Ranges No. of Air Cond. Tons) i No. of Alerting Devices No. of Waste Disposers Heat Pump Numher Tons _ ..._.._ KW _...... No. of Self -Contained Totals: i.... Alertin Devices Detectionluniripal No. of Dishwashers Space/Area Heating KW Local ❑ Connection ❑ Other No. of Dryers Heating Appliances KW 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 _ Felecommunications Wiring: No. of Devices or Equivalent OTHER: "7-;? ftrarh r,h.lilrorru! Irt cr! 11 J Sired, (XIIS rrclua_rJ ht IiW hiaperh:r II Estimated Value of Electrical Work: (when required by municipal policy.) 1kork to Start: Inspections to be requested in accordance with AIEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner. no permit for the performance of electrical work may issue unlc.s: the licensee provides proof of liability insurance including ",onlpleted operation" coverage ur its Substantial equivalent. t tic• undcrsiL,i% t certifies that Such Cox cra`;e i:, in Ii,rce. ,Incl ha; e:.hihited proot ot:,ame to the permit i,; .uin office. ('IIECKONE: INSI IZAN 't 13(.)til) ❑ OfIII:R ❑ (Specify:) I tii ✓►i/j, winder the pains iind pert✓a/iies :)f j✓erjurr, jitif the rta%rlrnruliwl ,✓✓t ibis ,✓pplicadon i.v trtie and co✓✓✓p/efe. W1011 NAME:— ,3 �c%,�i� 'i L,'ll d�`yr—� / LIC. \,o.: f - LOVicensee: I_i1c. Ao.: /,' wk !.ILr rrul;r ;rr t11r lir; r r. ;.c rnh i ine., _ / 11us. Tel. ?lo.:-�,�si � U' address: oe I� 4 z �3 s d�� '�T N � d . 47 lit. Tel. No.:_ —_ Z- Security Sy,tran Contractor License rcquircd for this work; if applicable, enter the license number hcru: 00Y%iNER'S INSURANCE IVY,#IVER: I and avmre that the Licensee do,.:: not havc the liability insurance wvvra;_.e n AIMIlly- required by law. By my :;i,maturL below, I hereby waive: this requirenxnt. I ,tnl the (check one) ❑ owner ❑ owner':, I-ent. lb Owner/Agent i;natute ?c ; RightFAX 3/10/2006 8:55 PAGE `L/b ttightrAx 4 V t� 4 Re: 429690 /ems ra?GO/ MiTek Industries, Inc. 14515 North Outer Forty Drive Suite 300 Chesterldd, MO 63017-5746 Telephone 314/434-1200 Fax 314/434-5343 The truss drawing(s) referenced below have been prepared by MiTek Industries, Inc. under my direct supervision based on the parameters provided by Wood Str Inc. Pages or sheets covered by this seal: 19973075 thru I9973076 My license renewal date for the state of Massachusetts is June 30, 2006. WA r t March 8,2006 Liu, Xuegang The seal on these drawings indicate acceptance of professional engineering responsibility solely for the truss components shown. The suitability and use of this component for any particular building is the responsibility of the building designer, per ANSVFPI 2002 Chapter 2. RightFAX 3/10/2006 8:55 PAGE 3/6 RightrAX Job Truss Truss Type Qly Ply 1997307 429690 500 SCISSORS 14 1 Jab Reference(optional) Wood Structures Inc, Biddeford, ME 04005 62W s Oct 18 2DO5 MiTek Industries, inc, Wed Mar 08 11:43AS 2006 Page 1 0-0-0I 8-04 I 154W I 21AI12 I 9q-0-0 I91-UU� 1-0-0 8-04 64142 64112 84).4 14)-0 Scats =1:52.7 5.110 12 5x6 5 3x4 i 3x4 3,4 G 4 6 3X1 3 7 11 10x20 MT2CH = 2 12 10 8 $1 1.5x4 II 1 5x4 II s I$ 0 4x10 = 2.50 12 4X10 01318 8411 15-0-0 211112 I 29-" 94Q-0 n F 038 743-12 6,1142 641-12 733-12 038 Plate Offsets X 2:04A E &044 E el [11:0-141411,0-3-3 LOADING(psf) SPACING 240-0 CSI DEFL in (loc) I1dd Lid PLATES GRIP TCLL 35.0 Plates increase 1.15 TC 0.90 Vorl(LL) -0.63 11 >565 240 MT20 1971144 (Rod Snow=350) Lumberlnc ease 1.15 BC 0.86 Vert(TL) -1.20 11-12 >297 180 M720H 148/108 TCDL 10.0 Rep Stress Ino• YES WB 0.53 Horz(TL) 0.75 8 We We BCLL 00 Code BOCA/TP12002 (Matrix) WeIOI:1101b BCDL 10.0 LUMBER BRACING TOP CHORD 2 X 4 SYP Na2'Exoapl' TOP CHORD Structural wood sheathing directly applied or 1-7-8 oc purlins. 1-4 2 X 4 SYP 2700E 22E, 6-9 2 X 4 SYP 2700E 22E BOT CHORD Rigid ceiling directly applied or 4-7-12 of: bracing. BOT CHORD 2 X 4 SPF 210OF 1.8E WEBS 1 Row al midpt 3-11,7-11 WEBS 2 X 4 SPF 165W 1.5E 'Except' 5-112 X 4 SYP No.2 This truss design Is based upon the building code shorn. This code has been specified by the project engineer/erdniled or building designer. The applicability d this code In any particular jurlsdd an should be cmtlmned with the building official prior to truss fabriratl an. This delermin efion is not the responsibllily of the componentAruss designer. REACTIONS (Ib/size) 2=173710-34 8=173710.3-8 Max Horz2=244(load case 6) Max Uplif12=-851(land case 6), 8=-851(load rave 7) FORCES (Ib) - Maximum Compression/Maximum Tensiona` TOP CHORD 1-2=0137, 2-3=-6198/2685, 3-4=-4334/1607, 4-5=-4212M831, 5-6=-421211872, 6-7=-433411648, 7-8--6197/2447, 8-9=0137 BOTCHORD 2-12=-2591/5709, 1 1-1 2=-2 589157 03, 1 0-1 1=-211 615703, 8-10=-2119/5709 WEBS 5-11=-90712618, 3-12=01172, 7-10-0117Z 3-11=-2109M224, 7-11=-210911242 " f.t NOTES TR 1) Wind: ASCE 7-98; 120mph; h=350; TCDL=5.Opsf; BCDL=S.Opsf; Category It Exp Q enclosed; MWFRS gable end zone; cantilever end right exposed; Lumber DOL=1.60 plate grip DOL=1.60. NU. 2) Unbalancedsnow loads have been considered for this design. 3) All plates are MT20 plates unless otherwise indicated +n 4cl4� 4) This Cuss requires plate inspection per the Tooth Count Method when this truss is chosen for ¢xality assurance inspedion. '� 5) Bearing al joint(a) 2, 8 considers parallel to grain value using ANSI/7PI 1 angle to gran formula Building designer should verify cop ty } dbearingsurface. March 8,2008 6) Provide medlanical cannedion (by others) dTruss to bearing plate capable of withstanding 851 Ib uplift of joint 2 and 851 lb uplift at joint 8. LOAD CASE(S) Standard WHEN A FLAT BOTTOM CHORD GABLE TRUSS SUPPORTED ON TOP OF A BEARING WALL SETS NEXT TO SCISSOR TYPE TRUSS(ES), A HINGE TYPE CONNECTION WILL BE CREATED BETWEEN THE TOP PLATE OF THE BEARING WALL AND THE BOTTOM CHORD OF THE GABLE TRUSS. THIS IS DUE TO THE LACK OF THE LATERAL BRACING PROVIDED BY RIGID CEILING AT THE HINGE TYPE CONNECTION POINT. THE TRUSS DESIGNER ASSUMES NO RESPONSIBILITY FOR THE DESIGN OF THE LATERAL BRACING TO THE HINGE CONNECTION SITUATION. COMPETENT PROFESSIONAL ADVICE MUST BE OBTAINED RELATIVE TO THE DESIGN OF THE ADEQUATE LATERAL BRACING TO THE HINGE TYPE CONNECTION. 19AN1re16 - Rr1Jy darrrpapmvmeleie and READ A0764 O/r1'JDS A19D OCWDiO !r'EI[ XAlJOa1C6 PAeilQF9448 H®OXd OSS ulerFarly, S.Ae #= fP Deux wYdlau»mrywilh Mtf«k cmneclom fikdesign hboedmly xym parmisi shown,mdtrlarm hdivWudbuldhg canpment ChaSlmAdd, MO SMIT Appicob" of deign pormenters and proper hcarpocoSen of compmente respmshft of buYdng kdMer- not tun deigns,.&oorg shown bfor Meld a vpportolindvidudwebor—beamfr. Addliendtcrrpc ybrochgtofnwm sfdsity dudngconstuclim htherespmsbaityol the erector Addliond pemrment bracing of the overal structure is the xalpmsb1hy of the building dekpw. For genera guldmce rogordhg labdoolion. quaSty centoL storage. delivery, erectim mdbmcing. c nft ANSI/RIl Ouaft Cdlexb. DS! -69 and aQnl Guiding Curymerd NM! SdelyInionrialioo ovoloble IronTrussPlain Insfilute, 5&1D'Onofdo Drive, Modaon.VA St719. ghtFAX J/ lU/ZUub 0:00 Y1%Ltm LAID r%JL61Lt.rrl,n Job Truss Truss Type Qly Ply 1997307 429(191) 5D/ GES 1 i Job Reference tonal 8200 s Oc118 2805 MiTek Indu!dit% Inc. Wed Mar 08 11:431)46 2006 Page I Wood SVumurm Inc. Biddeford ME 04005 15-0� 30.0.0 lY1-0 q 11F(1 { 1-0� 1543-0 1-0O 1 S" ScAe =131.9 5.00 12 4x4 10 9 11 9xA 3x4 1 9 2 93 7 14 8 15 5 16 4 17 3 18 19 2) , ,1)1 33 32 31 30 28 28 27 26 25 24 23 22 21 20 4 = 3x4 = SOhQ 30-" LOADING(psf) TCLL 35.0 SPACING 240-0 CSI TC 0.12 DEFL in (loc) Udell Lid Verl(LL) 0.00 18 n/r 180 PLATES GRIP MT20 1971144 (Rad Snow=35.0) Plates Increase 1.15 Lumber Increase 1.15 BC 0.04 Verl(TL) 0.00 19 nir 80 TCDL 10.0 BCLL 0.0 Rap Stress Inv YES WB 008 Harz(TL) 0.01 18 nia nla Weight 1271b BCDL 10.0 Code BOCAITP12002 (Malrix) LUMBER BRACING TOP CHORD 2 X 4 SPF 16MF 1.5E 'Excepr TOP CHORD Structural wood sheathing direly applied or 6-0-0 cc purlins. 7-10 2 X 4 SYP No.2, 10-13 2 X 4 SYP No.2 BOT CHORD Rigid oeiling direly applied or 10-0-0 ac bracing. BOT CHORD 2 X 4 SPF 165OF 1.5E This Uuss design Is based upon the buildng code shown. This code has been sped ied OTHERS 2 X 4 SPF 165OF 1.5E by the project engineer/adliled, or building designer. The applicability d this code In any particular jurlsfdion should be confirmed with the building official prior to truss fabrication. This delerminallon Is not the responsibility of the componentlhuss designer. REACTIONS (Ib/size) 2=250130-0-0, 27=20 913 0-0-0, 28=220/30-0-0, 29=221130-0-0, 30=218130-0-0, 31=228130-0-0, 32=188/30-0-0, 33=311/304-0, 25--220130-04 24--2211304)-0,23=218/30-0-0, 22=228130.0-0, 21-11111130-0-0,20=31111304-0, 18=25013040-0 Max Horz2=246(lood rase 6) Max Uplilt2=409(load case 4), 28=-141(load case 6), 29=-150(load case 6), 30=-145(load case 6), 31=-150(load case 6), 32=-132(loed case 6), 33=-192(load case 6), 25=-136(lood rase 7), 24--152(load case 7), 23=-145(load rase 7), 22=4 50(load case 7), 21=-132(lood case 7), 20=491(lood rase 7), 18=450(load cake 7) Max Grav2=291(load rase 2) 27-209(load cess 1), 28=264(lood case 2), 29=254(lood case 2), 30.253(lood case 2), 31=264(load rase 2), 32=219(load case 2), 33=359(load case 2), 25=264(loed case 3), 24=254(lood case 3), 23=253(load case 3), 22=254(load case 3), 21=219(loedcase 3), 20=359(load rasa 3), 18=291(load case 3) FORCES (lb) - Maximum Compression/Maximum Tension 2-3=-233199, 3-4---1371151,4-5=-711188, 5-6=-521230, 6-7=-511266, 7-8=-131270, 8-9=-51%313, 9-10=-541347, TOP CHORD 1-2=0139, 10-11=-541334, 1 1-1 2=-511266, 12-13=-131193, 1 3-1 4=-5 1 11 89, 14-15=-52112Z 15-16=49%77, 16-17=-59140,17-18---121154 18-19=0139 BOT CHORD 2-33=01202, 32-33=0/202, 31-32=0+202, 30-31=01202, 29-30=01202, 28-29=0202, 27-28=01202, 26-27=0120Z 25-26=0/202, 24-25=0/202, 23-24=0/20Z 22-23=0202, 2 1-22-01202, 20-21.0/202, 18.20=01202 WEBS 10-27---16910,9-28---2241161,8-29=-214117% 6-30=-2141165, 5-31=-221/170, 4-32=-IM151, 3-33=-2901216, 11-25=-224/156, 12-24=-2141172, 14-23=-2141165, 15-22=-2211171, 16.21=-1901151, 17-20=-2901215 u NOTES 1) Wind: ASCE 7-98; 120mph; h=3511; TCD L=5.Opst; BCDL=5.Opsf; Category II; Exp G endoseck MWFRS gable end zone; cenlilever leftqY' .L14 `Il b`.I„-, and right exposed; Lumber DCX -=1.60 plate grip DCX.=1.60 2) Truss designed for wind loads in the plane d the hhas only. For studs exposed to wind (normal to One face), pee Standard Industry ble X.L. Kfi" I`%s End Ddails osapplicable, or consult qualified builcing designer as per ANSIITPI 1-2002 ^na' LI 3) Unbalanced snow loads have been considered for this design. LIC 4) All plates are 1.5x4 MT20 unless olharwiseInd Gated. 5) This pass requiresplade inspection per the Tooth Count Mdhod when this truss is chosen for quality assurance inspection. 01. 6) Gable requires continuous bottom chord bowing. 7) Gable studs spaced at 2-0-0 cc. March 8,200E Continued on pane 2 14616th. 0ulerFaty. �'ywp9plp.Iuftdalppmvwvttn and READIgTI�oATf�MOaCLaD�I�a'10[RDtABMC1C iAaEJQL9493B®ORi aai - e Sidle 0.'l00 Dvalid for use only with M9es conneciors This design bbased only upon paaneters shoen.and 1. la an hdlviduol bulling component Cheslerflaid, MO 63017 AppFCab*V as design poroneniers andp,oper uncap—lion alt p--thresasorabi0lydbuidtn9dmiMm- not Suss designer. 8todng!haen bloioletd arppodolihdbiduZZmdmhersafar. 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TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform ....... 4'0.1")e7' PAC ........................................ wiring in the building of ..........�LLA ...................... ............................................ at .............. 77 .... S.?7� ............ North Andover, Mass. Fee .... Lic. No.. ............... 4wwi�7;-Kz ELECTRICAL INSPECTOR' Check# Q -c-) --- 01,11cial I.se 011IN - Commonwealth of Massachusetts i I3, Department of Fire Services �f Occupancy and Fee Checked j BOARD OF FIRE PREVENTION REGULATIONS Rev. �,0; [ ] (le�,�t blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK SII %cork to he performed in accordance X011 the \,I;lssachUsetts Iaect•ical Code (\IF.C). 527 (AIR 12.00 (PLE,ISE PRL\,T LV LVK OR TYPE, ILL LVFORRIT/O;V) Date: City or Town of: /''` 4�Ob✓"/j' To lhe ln.epeclnr t,j 6)'n cs: By this application the undersigned dives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant /'i, hlE,fj Telephone No. Owner's Address ^4wf-41 Is this permit in conjunction with a building permit? Yes ,® No ❑ (Check Appropriate Box) Purpose of Building Efo4,:f 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 lollrminti [fibre may be iruived by the hrsnech»' ol'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 Above In- • Swimming Pool rnd. ❑ red. ❑ o. o Emergency mer enc Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No, of Gas Burners of Detection and iNo. Initiating Devices No. of Ranges No. of Air Cond. Total Tons _ No. of Alerting Devices g No of Waste Disposers Heat Pum Totals Number Tons KW No. of Self -Contained (Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No, of Motors TntA HP Telecommunications Wiring: No. of Devices or Equivalent (OTHER: (� l�.sl.•t/(,,S - , I Much uddiliorwl "Ielfiil i/ e/rsired, nr us PCquircd bt the lnsy;eclor v;` II7rc:,, Estimated Value of Electrical Work: ( When required by municipal policy.) �kork to Start: Inspections to be requested in accordance with \IEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner. no permit ror the performance of electrical work may issue unless the licensee provides proof of liability insurance including "coinpleted operation- coverage or its substantial equivcdent. -['lie Undersigned certifies that such co�era�e isin force, and has exhibited proofof same to the permit issuing=. office. i CIIECK ONE: INSF.'R.ANC'E BOND❑ OTFIt:,R ❑ (Specify:) I k•erifft, under herr pains and pernalties of pgjurh, dial the infrlrnnaian on this applic•alion A true and ran►plele. QRM NAME: LL/i` !�!,Ct� LIC.. 1'*l 0.:- LIU icensee: e �J/-��.ri ,rte Si;nature LIC. N0.• 4/,/ ;: 1;/i rl.lc, r ter rrupl " III th,r Gcr I rruurhy , Bus. Tet. NO.: �7#ddress: V;040.-,-�,�'3 �1,��7 W"I (IS d%4 Aft. Tel. No.:_ -- St,curity Systetn Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance covQ1"We normally Z) required by law. By my :signature below, I Iteitby waive this requirement. I am the (check one) ❑ owner ❑ owner's ;g cnt. CO Owner/Agent — :Agnature +clEi,hane'ir,. FPFR.;Vf Ii AFF,: �5�� WIMNS EXISTING DRINKING WATER WELL (CONVERT TO IRRIGATION ONLY) PROPOSED PRESSURE WATER SERVICE i ao EST STREET