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Miscellaneous - 24 HEWITT AVENUE 4/30/2018
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(SG Conservation Services Group IECC 2009 Duct Tightness Verification Pa / Fail Date: TUCV- 16, ab�a Permit No.: Street Address: a4 �ewA4e Pq c - I t',ts.wef- N N Total conditioned floor area: 40 Washington Street Westborough, MA 01581 Tel 508.836.9500 Fax 508.836.3138 www.csgrp.com HERS Rater: Signature: Builder: Builder Contact: HVAC Contractor Roil 5' n U Postconstruction test ,Total Leakage — 12 cfm/100 ft2 maximum allowed ❑ Leakage to outdoors — 8 cfm/100 ft2 maximum allowed Testing result: Ib. 5 cfm/100 ft2 Rough -in test Total leakage Air Handler Installed? l Yes — 6 cfm/100 ft2 maximum allowed ❑ No -4 cfm/100 ft2 maximum allowed Testing result: S.1 cfm/100 ft2 Conservation Services Group © 2011 C PA Box 1164 Upton, MA 01568 New England Home Energy LLC DUCT LEAKAGE TEST - MA STRETCH CODE 401.3 Customer Information Name: Doms Radiant Heating Address: 23 Elm St City/State/Zip: North Billerica MA 01862 Phone: Email: domsradiant@vahoo.com 978-265-5577 Test Location [City/State/Zip: treet: 200 Berkele Rd North Andover, MA Test Conditions Date: 7/24/2012 Time: 11:OOAM Supply Location: Attic and Basement Return Location: Attic and Basement Duct Leakage Criteria: Post Construction Test Total Leakage < or = to 12cfm per 100 sq/ft of Conditioned Floor Area With Air Handler Conditioned Floor Area: 1911 1092 sf 1 st floor 819sf 2nd floor Total Allowable Leakage: 229.3 CFM @ 25pa Total Leakage Results: 1 st floor 61 CFM @ 25pa 2nd floor 21 CFM @ 25pa 82 CFM @ 25pa Passes Test Performed by: David J Winslow, New England Home Energy LLC Address: P.O.Box 1164, Upton MA 01568 HERS Rater # 0478118 Phone: 617-839-7274 Signature: `Wura u www.newenglandhomeenergy.com Date.. ......... TOWN OF NORTH ANDOVER D PERMIT FOR GAS INSTALLATION certifies that ... alp— This ....... .... has permission for gas installation ... IV.e. in the buildings/of .. !� ..���P! ... ......... at .... . ,�%'1 . / 1le ...... grth ov ass. Fee. Z!caG? Lic. No.. �SG/Z !/!��!?f1 �t ... GAS INSPECTOR Check # Oto G 8244 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: .-o_r .__._G�... _...5 LICENSE # .%9ja.. SIG ATURE � COMPANY NAME:....... 5.........._..._._............._.._...._..._............................... - ...... ADDRESS: CITY: _ t .-1---..._----......__....-------._._._......__......._......._ STATE: ZIP: _Q'.__g..__3FAX TEL: y3G rS_:.la! 7`CELL:_..----_.__...._....._._....__._ EMAIL: MASTER ❑ JOURNEYMANLP INSTALLER ❑ CORPORATION ❑ #PARTNERSHIP ❑ #LLC [I# Qj) M MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F TYPE OR PRINT CLEARLY CITY 1.1 GZ,I,y o a,, MA. DATE(r, ~ < -- / PERMIT # JOBSITE ADDRESS _. rS.SS/� ��-r.. OWNER'S NAME �oC ✓d _ rt x OWNERADDRESS: /6,� 5/c� Nin J �'t�..(f_c,�ar;L: F�4.'jFAX: _b..0_:. 3V'. _ OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL J� ` NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXUTRES 7 FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR' FURNACE / GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER FT INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES ❑ NOW -j If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massach etts General ws, and that my signature on this permit application waives this requirement. ✓ CHECK ONE ONLY: OWNER X AGENT ❑ IGNA�TUREOFOWN OR AGEIIT aC�L(la[(�t 1�c Qhs LcL 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: .-o_r .__._G�... _...5 LICENSE # .%9ja.. SIG ATURE � COMPANY NAME:....... 5.........._..._._............._.._...._..._............................... - ...... ADDRESS: CITY: _ t .-1---..._----......__....-------._._._......__......._......._ STATE: ZIP: _Q'.__g..__3FAX TEL: y3G rS_:.la! 7`CELL:_..----_.__...._....._._....__._ EMAIL: MASTER ❑ JOURNEYMANLP INSTALLER ❑ CORPORATION ❑ #PARTNERSHIP ❑ #LLC [I# Qj) M H O O H U W a z z d ❑ r H w Za co O w LU 3 w O z a a � W a � U J d. a � a � w x w F u. H O z 0 H U W a L7 O a m W E� O z z 0 F U w a d w o ❑ z O E- W W W a � z° u ui x �- W OLUC�4 W, d a p z a � W a � U J a a �a a � w x w F- a , H z° z 0 F U W C7 a a O F4 C ry The Commonwealth of Massachusetts • - Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/d'ia Workers' Compensation Insurance Affidavit: Builders/Contractolr6IElectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizaiiontfndividual):_ L dt W p -,Q d/ C 45d— Address: Sd— Address:a;r g city/state/zip: s4--* 11 ill 4110 01134, Phone M $ 3 / s� //Y Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction l employees (fall and/oxpart-time) * 2rp I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. x 7• 2emodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. [No workers' comp. insurance workers' comp. insurance..9, 5. El We are a corporation and its ❑Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing. repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp, insurance required.] !Any applicant that checks box#I must also fill out the section bel6w showingtheir 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. lContractors 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 thepolicy and job site information. Insurance Company Name% Policy # or Self -itis. Mc. #: Expiration Date lob 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 o.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 ofup 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. I do Hereby cerO under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town:. PermitUAcense # 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 #: V"Frf --.a Information and Iustructi®u� 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 ofpublic 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 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 and printedlegibly. 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. 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 orpermit 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 anal fax number: Tho CoMyAonwoalth o l�iassachvsetts De-p.aftent of fadustdal Accidents . pf�ice n�Iu�esti�atJions . 6.00 Washington Street Boston? MA02111 Tool. # 617-7.27-4900 ort 406 or 1-877, A.SSM? Revised 5-26-05 Fax # 617-727-7749 tvww Wass,gov1cNa AC<:)Rb CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDNYYY) 0611312012 PRODUCER Cowan Insurance Agency, Inc. 359 Main Street Haverhill MA 01830 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Edward Case dba Case Plumbing & Heating 113 Crystal Street Haverhill MA 01832 INSURER A: Nautilus POLICY EFFECTIVE INSURER B: LIMITS INSURER C: Fax: (978)688-9573 INSURER D: INSURER E: CAVFRAnFA 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDT POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS Fax: (978)688-9573 GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $50,000 A X COMMERCIAL GENERAL LIABILITY NN171092 1112912011 0611312012* MED EXP (Any oneperson) $5,000 CLAIMS MADE a OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 x POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVq-7 E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 1 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Attention : Building Inspector Plumbin & heating contractor. *Policy terminated 0611312012. CFRTIFICATF Hnl nFR CANCELLATION ACORD 25 (2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are re Is red marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 1600 Osgood Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR North Andover, MA 01845 REPRESENT IVES. JAUTH07RI,D REPRE IVE -- Fax: (978)688-9573 ACORD 25 (2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are re Is red marks of ACORD The Commonwealth of Massachusetts Department of £ndustriall4ccidents Office ofInvestigations ..600 Washington Street Boston, AM 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nniirant Tnf�...--i-t,... vaaov 1 1t 111E LG lUl. ' Name (Business/Orgmization/Individual):_ C( k10 X,4 n14C .. - Address: City/State/Zip,_. ,, j /d/ ll Vhone M / - � Y Are you an employer? Check the appropriate box: 1 • ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).' 2. ( I am a sole proprietor or - have hired the sub -contractors listed the partner on attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. El. I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] f employees. [No tborkers' • comp. insurance required.] *41y EPPlicant that checss box rl m+?«i also fill out the «ecrion below El.,.y'-- . Type of project (required):' 6. E]New construction 7. Remodeling 8. ❑ Demolition 9. ElBuilding addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12-ElRoof repairs 13.[]Other T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a mew 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 information. my employees Below is the policy and job site Insurance Compiny Name:. Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: Attach a cCity/State/Zip: opy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby cen*ynder the pains and penaltiess of perju'J, that the information provided above is true and correct•: - Date.: Phone #: U,lficial use only. Do not write in this area, to be completed by city or town offzciaL City or Town: PermitUcense # Issuing Authority (circle one): . I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing inspector 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 6r 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 bean employer." MGL chapter 152;§25C(6) also states that "every state or local licensing'ageney shall xvithhold 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) m#.m 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. Boedvised 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 bs ret's's_rnarl to the city or town th-t the ENPEaG- moa for the pe• r tr r. e ebeingi te' t the A e t ,. -- �� o� k�e�s i. req,�eS.,.a�, na tn.. D..partm,.n . 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 perp itllicense applications m 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 flied 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 f6r your cooperation and should you have any questions, please do nbt-hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth e f Massachusetts Department of End-Listrial Accidents 0Mike of InrestigatiEons 60:0 Washing -ton meet Boston, MA, 02111 Tel. # 617-72.7-4900 ext 406 or 1-8.77 M&S.SARE Revised 5-26-05 Fax # 6.17-727-7749 Date. qA! / ? . �;<;�•:1�o TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING .'SS�cMuSE� This certifies that/) r ..... -?�-... .... Vt . ! y. has permission to perform.'�'rT` S .... . n in h buildings of . !1f.F.. plumbing the bu d gs .. .... `�.. ./��. � . at ... .............. North Andover, Mass. Fee .. 9 , 06-' Lic. No...1 % e�Z ...... PLUMBING INSPfCTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORE( _... F CITY .. �R.�} /� ... ....... 0 rJ C' MA DATE .��� �. PERMIT # JOBSITE ADDRESS I OWNER'S NAME �g04 Lw. Vu &I l �I � OWNER ADDRESS ��.,�x. Yd li���...�..10(fTEL 6o3 TYPE OR OCCUPANCY TYPE COMMERCIAL [Q EDUCATIONAL [j RESIDENTIAL 3z C PRINT CLEARLY NEW: [] RENOVATION: P REPLACEMENT: 0 PLANS SUBMITTED: YES Q NOQ FIXTURES 1 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 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ===l�,.�=F._ ?r7C� . ..... . ....I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN�:._ j( ........ FOOD DISPOSER FLOOR/ AREA DRAININTERCEPTOR (INTERIOR) (INTERIOR) KITCHEN SINK LAVATORY I-:..:. i ROOF DRAIN SHOWER STALL;L�_ SERVICE IMOP SINK TOILET URINAL-'r.-1.+ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES_. ........ !L�_ WATER PIPING (_ [__E-7_! OTHER�t�r�^ INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES j NO,n ll IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY BOND [� OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachetts General W s, and that my signature on this permit application waives this requirement. _ CHECK ONE ONLY: OWNER jo` AGENT E] SIGNATURE OF dWNER OR AGENT ;e,--i-Oe 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to t_he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com liance with all Perti pr ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ed w-fae)a �4S LICENSE # /%6 / 5- SI NATURE MP El JPYW CORPORATION#IPARTNERSHIPFI# LLC COMPANY NAME .C,GL S ..-. e ADDRESS CITYC .._� �.�. ../�✓�_� ... -. STATE ZIP 1... b J 3 TEL FAX ]CELL[ EMAIL W O z z 0 H U W a w Z N ° O F � W p w O IL z LLI 3 w F- w w a a 0 o W w W 3 U) a O z a � w a w � J CL M Q c x w F- u. H O z z 0 H U W w a a o x ma . C,2/&�( �& c2ZQ i e- Cd O�Ses� -C Lo- - -&rl-n f- o< Pct -al ff 4 ou) n . ) 0 4-- n An 61`/1-1 1- f 77r IA. CC.,, /'O !l 1<1,-4 l % 4N "Aw JeL L 4 9320 Date .. , !4 TOWN OF NORTH ANDOVER .o -ULM—*- p PERMIT FOR PLUMBING y {, • 1 This certifies that .. .4 �. .`` rr ...... ............. . has permission to perform . -e �....!�!`!.=....... , y plumbing in �t he buildings of ..... v0 at ... y .,t` f'W4 . A,' North Andover, Mass. Fee. � .. Lic. No. 1.0V - ........ . / PLUMBING SPE% Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - -: 'CITY MA (� i j y(f MA DATEJ1/2 I%1 PERMIT if JOBSITEADDRESS �..2 .1 �.( . ,. /qI�L 1 OWNER'S NAME) A► y4f,., jr OWNER AD DRESS._ _ a. _ - TELT. .. ...Ft, TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL j; � RESIDENTIAL, PRINT CLEARLY NEW: (w] RENOVATION: JYf� REPLACEME01..J PLANS SUBMITTED: YES L'I N01-1 FIXTURES 1 FLOOR- BSM 1 2 3 1 4 5 8 7 8 9 10 11 12 13 14 BATHTUB : ...{ LL { _ . .I ..., 9 CROSS CONNECTION DEVICE { _ I ... - I ... _. { _4. _ OEDICATEO SPECIAL WASTE SYSTEM { DEDICATED GASIOIUSAND SYSTEM I { . DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _� DEDICATED WATER RECYCLE SYSTEM { ( I I { I J DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK "I .- . ,I I . : ,I l 1 I LAVATORY ROOF DRAIN SHOWER STALL SERVICE/ MOP SINK I 1 TOILET URINAL WASHING MACHINE CONNECTION I __ - WATER HEATER ALL TYPES - I WATER PIPING._.. ._ ,, .... • ,. I j' i OTHER { ... INSURANCE COVERAGE: I have a current lia_ hility iiisurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ;.� OTHER TYPE OF INDEMNITY { 60NO I I OWNER'S INSURANCE :WAIVER: I ant aware that the licensee does not have the'insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that lny signature on this permit application waives this require) tent. CHECK ONE ONLY: OWNER �, AGENT' SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application ar true and accurate to the best of my knowledge and that all plumbing work add installations performed under the permit issued for this application will bei c mplia ice n i al rt r won of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME lj '; 1av'S -�l _ LICENSE V j SIGNATUR MpId ipl, I CORPORATION{ 1PARTNERSHIP1 1#' 1LLC( COMPANY NAME! �rC r l lC.� ADDRESS (j_ CQ, -j `ll54Aq,Ave, ` CITY Q)j���=G�- STATE I.. j,7;� ZIP I�oZ -� TEL��`7�'•� 76 FAX ' CELL H Se y.,. EMAIL E _. O W a� d 0 d� � w O a z U � F O e w ® O W W F v J 0. 0. Q f�i � U.1 LU F- LL. W � Q U F� w ' a a� o 9 f w coil Ln Ln -4 Q. oC Lij ul U) tZ z in U, C) :3 -0 LA • UJ . 6.4. Lu D '64. UL ix, ad' aft' to Date. 2-' Z2, �2--.... . TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION .t This certifies that .. R� C .. nn has permission for gas installation... .. e . in the buildings of ..�L'Qv�. ............................ at ... Z�/. / ew�.A!!�` ........... North Andover, Mass. C� /� FeeG1.Z: �. Lic. No.i?�%%2... .rl./.�?r� �'�..... GASINSPECTOR Check # 31 8064 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes gr�o ❑ If you have checked Yes, please 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 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent E] By checking this box ❑, 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and Cor w 1— ..OL vl Illy f%l compliance with all Pertinent anu mai all piumoing worK ana installations performed under the permit issued for this application will be in 1�of the Massachusetts State Plumbing Code and Chapter 142 of the Genscal Lfiws. By Type of License: El Plumber Title ElG Fitter Signature of Licensed Plumber/Ga itter Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE UN—Ly) ❑ LP Installer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: WIN? 40OV %Z -,MA. Date: 4reb- alAL Permit# Building Location: Owners Name: Aw Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: [L"'� Replacement: ❑ Plans Submitted: Yes ❑ No ❑ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes gr�o ❑ If you have checked Yes, please 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 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent E] By checking this box ❑, 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and Cor w 1— ..OL vl Illy f%l compliance with all Pertinent anu mai all piumoing worK ana installations performed under the permit issued for this application will be in 1�of the Massachusetts State Plumbing Code and Chapter 142 of the Genscal Lfiws. By Type of License: El Plumber Title ElG Fitter Signature of Licensed Plumber/Ga itter Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE UN—Ly) ❑ LP Installer 2 W a 4 0 U)Z� C) = co CO I O W o co m w w (� 0 z z o W w F z � W w o e: O Q 5 Xw > 0 w U z m 0 0 w 0 a p w 0LU = > 0 w U) W Z O 0 w W ❑ W LL w W co J F- 1— 0 Z J 0 u. F= Fw- 013❑ a t7 C7 = 2 J 0 11 F- >>> 3 O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 1H FLOOR 7THFLOOR 8 FLOOR r r Installing Company Name: � �- � Check One Only Certificate A /� Address: 42 C.;a. � City/Town: t f State:Ad ❑Corporation // Business Tel: `� $`� �� (p �� Fax: s� ❑ Partnership ElFirm/Company Name of Licensed Plumber/Gas Fitter: :� C� INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes gr�o ❑ If you have checked Yes, please 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 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent E] By checking this box ❑, 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and Cor w 1— ..OL vl Illy f%l compliance with all Pertinent anu mai all piumoing worK ana installations performed under the permit issued for this application will be in 1�of the Massachusetts State Plumbing Code and Chapter 142 of the Genscal Lfiws. By Type of License: El Plumber Title ElG Fitter Signature of Licensed Plumber/Ga itter Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE UN—Ly) ❑ LP Installer The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations ..600 Washington Street Boston, MA 02111 4".mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleciricians/Plumbers Name (Business/Organization/Individual): I � � - - -Address: V- -- Com'.(=-� City/State/Zip: Phone #: Are you an employer? Check the appropriate boa: 1 • ❑ I am a employer with 4. ❑ I am a general contractor and I e nPloyees (full and/or part-time).** have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 3. 0. 1 am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. C. 152, § I (4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *Any aYpficant that cheeks box #1 must also fill out the section be?ow ���•_�••� +s e:_ �: _ t Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 111 - ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submim.P=* 2110n POLICY t 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 information. insurance for my employees Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date:. Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert v Ider the nd of per ry that the information provided above is true and correct: Sienature: l ,.� Date: Phone #: Official use only. Do not write in this area, to be completed by city or town officiaC __ City or Town: PermitUmnse =, 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 Information and Instructions 11 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 certificates) 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 pest of linense 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 Ceammonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.74900 ext 406 or 1-8.77 MAS.SAEE Revised 5-26-05 Fax # 617-727-7749 mm,w-rnass._govfdia • S I th �> :W- Ln . J co o .` W u! i z tul a a uj W >. W p N a*.m LU a-'InZ r+' i 1fj X10 ,. 1�a 3? . -'.N o; TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.....�J`7 G.,. ............................... ........ J has permission to perform .'qff1:....... wiring in the building of r! C d �y at ..j3 .� '....� '! ��......................... .North Andover N Jass. Feel .......... Lic. No...�� . ............ .. . ......... IC NSPE Check # 35(3 "►0670 r Commonwealth of Massachusetts Official Use Only kirDepartment of Fire Services Permit No. - ' -7 0 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.l/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTINM OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notic of his or her intention to perform the electrical work described below. cgLocation (Street & Nu ber) (!, fit/ /' Owner or Tenant � Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No Purpose of Building F-1(CheckAppropriate Bog) Utility Authorization No. Existing Service Amps / Volts Overhead Und rd ---- h ❑ g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: k/d QC C d L � A /' f' . No. of Recessed Luminaires o. of Luminaire Outlets of Luminaires of Receptacle Outlets No. of Ceil: Susp. (Padd No. of Hot Tubs Swimming Pool Se ind No. of Oil Burners tO. of Switches /a No. of Ranges No. of Gas Burners No. of Air Cond. No. of Waste Disposers Heat Pump Number 7 Totals: __........._............. No. of Dishwashers Space/Area Heating K` No. of Dryers Heating Appliances - �- Heaters KW 1,40. 01 r Signs 13 No. Hydromassage Bathtubs No. of Motors T OTHER: /.r iAI�l G91t4 of the followinn tahh, mml ho,u..i—,41,...L.. r.____. . le) Fans No. of - Total V " Transformers KVA . Generators KVA ❑ In- ❑ rnd. o, o mergency rg ne Batte Units FIRE ALARMS No. of Zones i No. of Detection and A Initiatins Devices Tonsl No. of Alerting Devices ons ........W No. of Self -Contained Detection/Alertin Devices Loc ❑ Municipal al ❑ Other Connection KW Security Systems: No. of Devices or E uivalent o. of allasts Data Wiring: . No. of Devices or Equivalent otal HP Telecommunications Wiring: No. of Devices or Equivalent �r -0 g Attach additional detail f desired, oras required by the Inspector of Wires. Estimated Value of Elec 'cal Work: Lt/ V (When required by municipal policy.) Work to Start f� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepains qndpenalftes o perjury, that the information on this application is true and complet FIRM NAME: /("C )ri C /j LIC. NO.: v Licensee: Z 1( �p ., ��t to Signa (If applicable, el''!�eexeni ` to the icense number line.)LIC. NO.:Address: f/� 7 Bus. Tel. No.:*Per M.G.L c. 7-61, security rk requires Department of Public Safety%f S" "License: Alt. TelLic. No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally Owner/Agent required law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner E]owner's agent. Signature Telephone No. PERMIT FEE_$�ij� 16 The Commonwealth of ltlassachusetts �:- Department of Industrial Accidents j L•- Office of Investigations •�'� 600 Washington Street Idu Boston, MA 02111 { ' www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plnmbers nniicant rnfnwvmn"-- Name (Business/O Eaniza6on/Individual): Address: City/State/Zip: Phone #: . Are you an employer? Check the appropriate box: I - ❑ I am a employer with 4. ❑ I 2.M 3. ❑ employees (full and/or part-time).* I am .a.sole proprietor or partner- ship and have no employees working for mein' any capacity. [No workers' comp. insurance required.] I am a homeowner doing all work myself. [No•workers' comp. insurance required.] t •Anv annU-++6 5. am a general contractor and I have hired the sub -contractors listed on the attached sheet I These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL C. 1.52, § 1(4), and we have no .employees. [No workers' comp. insurance required..] Type of project (requiral): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 1 I -❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other . dbu ilu out me section below showing their workers' compensation policy information. Homers eownwho submit this affidavit indicating they aro 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 work---'c---p polis; irwzration. I am an employer that is providing:workers' compensation insurance for information. my employees: Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and coned Si iure. Date: Phone #: Official use only. Do not write in this area, to be completed by city or town. officio( City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: w - 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, nofthe 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 numberlisted below. Self-insured companies should enter their i self-insurance license number on the appropriate line. City or Town Officials t 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 permittlicense 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 of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia JY ' Date. ! /... . HORTti TOWN OF NORTH ANDOVER pf to ,6,40 6 p� PERMIT FOR MECHANICAL INSTALLATION D This certifies that ..C?r1.. ... ?" !!.......... .... . has permission for mechanical installation .. -,Ao.LK. 11w� .. . in the buildings of . IIA:1.A.. �............... . at ..... North Andovej, "s. Fee. ,).:.. Lic. No.. gcfl.. .......................... r GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer A, Commonwealth of Massachusetts Date: 6 k//�- Estimated Job Cost: $ 7 Plans Submitted: YES NO Business License # FO?? Business Information: Sheet Metal Permit Permit # Permit Fee: $ Plans Reviewed: YES NO Applicant License # Property Owner / Job Location Information: Name: fKr�n�.S o ��LD�s J%,Ii Street: ,S� Q` ffl IIA f- 0,'. AV -e Street: City/Town: 41Ai/Pr City/Town: Telephone: q7�1 30e -j c2�_ (7 Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES NO Staff Initial J-1 /(9nrestricted license J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family (/ Multi -family Condo / Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 e completed: sq. ft. Number of Stories: Sheet metal work t p leted: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: -� SN j NPS gm�fv'jsysfP�y - 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. Date Date Duct inspection required prior to insulation installation: YES NO Prollress Inspections Comments Final Inspection Type of License: By ❑ Master Title ❑ Master -Restricted City/Town ❑Journeyperson Permit # ❑Journeyperson-Restricted Fee $ El Inspector Signature of Permit Approval Comments Signature of Licensee License Number: Check at www.mass.gov/dpl s The Commonwealth ofMassachusetis , - Department ofIndustriglAccidents Office oflnvestigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation: Insurance Affidavit: BuUde:rs/Contractors/Electrxcians/.Plumbers Aalicant Information Please Print Legib1Y Name (Business/Organization/iudividual): City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of proj ect (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. [ New cbnstraction employees (full and/orpart time).* have hired the sub -contractors 2. ❑ I am a sole proprietor orpartner- listed on the attached sheet. 7• E] Remodeling ship anThave no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions Myself. [No workers' comp. c. 152, §1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' •13.❑ Other comp, insurance required.] Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensation policy information. Homeowners who submit this affidavit indicating they hie 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. IM an employer that is,providing workers' compensation Insurance formy employees Below is the•policy antyjob site information. Insurance Company Name:. Policy # or S elf -ins. Lic. #; Expiration Date: Job Site Address, 'City/State/Zip: Attach a copy of the workers' compensation policy tleclaration page (showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL o.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 sof Investigations of the DIA for insurance coverage verification. Ida hereby certio under flee pains and penalties ofperjury Mat Me in, formation provNerl above is true and correct. Signature: Date: Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1.33oard of Health 2.33uUdingDepartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information an Iustructi®nms Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employeeis defined as "...everyperson inthe service of anotherunder any contract ofhire, 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 dwellinghouse having notmore than three apartments and who resides therein, or the occupant ofihe 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 shalliuot because of such employment be deemed to bean 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 subdrvnsxons 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 numbers) 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. Nan LLC or LLP does have employees, a policy is required. 13 a advised that this affidavit may be submitted to the Department of industrial Accidents fox 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' compensationpolicy, please call the Department at the number listed below. SeIf-insured companies should enter their self-insurance license number on the appropriate &a. 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 bas a reference number. In addition, an applicant e used that must submit multiple permit/licens0 applications in any given year, need only submit one affidavit Indicating current policy information (ifnocessaty) 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 ciiizen is obtaining a license or pemnit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc) said person is NOTxequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any uestions, please do not hesitate to give us a call. q The Department's address, telephone and fax number: Tho Con onwoalthofmassarhusofts Mpartment offndustdal.A,caaants ofte ofInvestigattom 600 W sh Voij Stye t Boston? MA, 02111 TO, # 617-7-27,4 9 0 0 e 406 or 1-877�W ASS.Ak`B Revised 5-26-05 Fax # 61772777749 06/04/2012 09:29 19785214669 COWAN INSURANCE .�Ro CERTIFICATE OF LIABILITY INSURANCE TIn6 CGRTIVIr-ATF IS ISSUED AS A MATTER C PRODVCQR ONLY AND CONFERS NO RIQH1* UPON TI Cowan Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AME ALTER THE COVERAGE AFFORDED BY THE P 359 Main Street INSURERS AFFORDING COVERAGE Haverhill MA 01880 IN RER . Ern to ars MAY, INSURED Ron Comtois dba Ron's Heating INSURER B;__, 59 Observatory Avenue 1C11eCQ Haverhill MA 01832 PAGE 01/01 DATE (MMIDDNYYY) EXTEND OR NAIC 0 OVERAGESMAY THEFOLICIESOFINSURANCELISTEDBEC N OK ArF- �ANTRAC OR OTHER DOCUMENT WITH RESPECTE OWM CH TS. HIS �ERTIFANOTMTHSTANDING pD �NDIT�ON OF SD 0H ANY Rt;QUIREMENT, TERM OR CONDI MAY PERTAIN, THE INSURANCE AFFORDEDBYTHE POLICIES DESCRIBED HEREIN IS sUB,1ecTT POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAI G CLAIMS. EI FECTIVE. POLICY �x>n�RAIOYr LIMITS GC-;EENE R A L LIABILITY A X COMMERCIAL GENERAfOCCUR ABILITY 4DOY938 CLAIMS MADE L_jN'L AGGREGATE LIMIT APPLIES PER: X I POLI.0 PRO - C AUTOMOBILE LIABILITY ANY AUTO ALL VVYNCL, MVTOJ HIRED AUTOS GARAGE LIABILITY ANY AUTO EXCESS I UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE. RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y11 ANY PROPRIETORIPARTNERJEXECUTNE[— (OMFFIC IMoryEn BER EXCLUDED? II ya daacrlbe undAr ApEl IAI PR(�V1RIr"NS WOW oTHeR 0412112012 10412112013 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE$ / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS 978 666 9542 work. Town of North Andover Building Department 1600 Osgood St North Andover, MA 01945 1 VVIVIeu•�,I J,1•�I�� �,.,i� ,� (Ea ewidenq 90DILY'oNn m ar Pat eon (Per acclOgnc) aROPCRTV n&hAAnP Iter ac,.tuM 11% AUTO ONLY- EA ACCIDENT _ 3 OTHER]MAN �^°rr AUTO ONI.Y; AGG S SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 'v— DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, OUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION PK LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUT14DRIZED ACORD 25 (2009101) __ 198 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered m* ks F ACORD 0 Fold, Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS 11511 11011"INIM.1-m BOARD SM AS A MASTER -UNRESTRICTED. ISSUES THE ABOVE LICENSE TO: t� TYPE RONALD L COMTOIS JR M1 59 OBSERVATORY AVE HAVERHILL MA 01832-4640 �' 9089 01/28/13 996563 { 996563 -i Fold, Then Detach Along All Perforations Page 1 Residential Heat Loss and Heat Gain Calculation 5/31/2012 In accordance with ACCA Manual J Report Prepared By: Ron's Heating and AIC For: Rock Valley Reality 24 Hewitt north andover, ma Design Conditions: Boston Indoor: Outdoor: Summer temperature: 75 Summer temperature: 88 Winter temperature: 70 Winter temperature: 20 Relative humidity: 55 Summer grains of moisture: 88 Daily temperature range:Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Whole House 776 sq.ft. 14,853 1,754 16,607 38,771 ( 1.5 tons ) First Floor 14,853 1,754 16,607 38,772 Bedroom 0 sq.ft. 1,401 51 1,452 2,980 Infiltration 63 51 114 348 Duct 67 0 6_7 142 E_Wall --- --- V 224 sq.ft. -- _ _297- - - 0 - - - -- 297 - - —_ 8_96 S Wall---- - -- - -120 sq.ft. - - -- - �- 159 - 0 159 - - `--480 W Wall 113.7 sq.ft. 151 0 151 455 Window 6.3 sq.ft. 436 0 436 174 N Wall --- - --80 sq.ft. - --- - 106 --- _ _0- -- --- -- 106 -- - 320 -_ Ceiling - - 1.00-sq.ft,.- -- -- -122 - - - - 0 -- -- - - -122- - - - 165 _ Family Room - 480 sq.ft. 3,831 686 4,517 11,794 Infiltration 849 686 1,535 4,694 Duct 182 0 182 562 Floor 480 sq.ft. 0 0 0 1,296 S Wall 78.7 sq.ft. 105 0-------105 315 `Window, _ --- - - 28.3 sq.ft. - -- -- 996 - - 0 - --- - 996 --_ -- 80 7 780 -- - - - Door - - 53 sq.ft. - --- - - 519 - 0 - - - - - - 519 - - - 1,563 N Wall 160 sq.ft. 212 0 212 640 E Wall --- -- - _ - 192 sq. ft' - - - ---255--- - 0 - -- --255-- 768 W Wall 96 sq.ft. 127 0 127 Ceiling _ --_ - __-- 480 sq.ft. - -- v - -- 586 - - - 0 _ --- 586 - _384 --- - 792 Kitchen 240 sq.ft. 1,548 59 1,607 5,467 Page 2 Building Component Rock Valley Reality Sensible Latent Gain Gain (BTUH) (BTUH) Infiltration Total 73 - -- - Duct (BTUH) 74 Floor 240 sq.ft. 0 N Wall ------ ----153 sq.ft. 203 _---- _ - Window 7 sq.ft. 141 E Wall - -- - 96 sq.ft. ---- --- -127 --- S Wall -- -_ _ 192 sq.ft. -_ - __ --- 255 -- - _ --T-_ W.Wall--- ----- - 96 sq.ft.- 384 - - -- -- --- S Wall (2) - ______12_7__ 192 sq.ft. 255 Ceiling --- 240 sq.ft. - - -_-_- 293 --- Laundry -- -- __ 0 sq.ft. 11273 Infiltration 702 'Duct --- --- ----- 61 N Wall 35.3 sq.ft. 47 Door _ 36-7 sq.ft. -- - -- --- - -359 -- -- S Wall - - - - 72 sq.ft. -- - - 96 - - - - E Wall - --- - - --- -- - ----106 - 80 sq.ft. - - - W Wall ------ 80 sq.ft--- - 106 -- Ceiling 90 sq.ft 110 Bathroom ---- - -- 56 sq.ft. - _— --_- 519 - — Infiltration 76 --- 42 Duct .---- - - - -- - - - - 25 -- Floor - --- .56 sq.ft.- - O --- - - W Wall � ------ - -48 sq.ft. - - 64 - - N Wall 60 sq.ft. 80 -- Window ----- ------ - - - 4 sq.ft. ----- -56-sq.ft. ------ -- --- 81-- -- - -- E Wall - 74 --- 74 S Wall �- _.- 64 sq.ft.------- ----- - 85- - --- -- Ceiling -- - -- - -- - - 56 sq.ft. - - ----- --_ - - - -0 68- - -_-_-1,307 - - - - - Bedroom _ (2) sq.ft. _ - Infiltration � -- 284 157 Duct_ -_-- -- 62 - 62 W Wall - - _ -- - 80 sq.ft. - -- - � 106 - N Wall - - ---- -- --- 88 sq.ft. ---- - 117---- - - S Wall 73 sq.ft. 97 Window -- - - - - 15 sq.ft.-----_- -- - 528 E Wall - ------ - 80 sq.ft. 106 _ Ceiling 110 sq.ft. 134 5/31/2012 Total Total Heat Gain Heat Loss (BTUH) (BTUH) 59 132 406 0 74 -- __ - 260 0 - 0-- 1,296_ - 0 _ -- 203 �- - 612 0 141 193 0 127 384 -- 0 - - -- 255 768 0 127 384 0 255 --- 768_ - 0 ----293 --- 396 314 1,587 - 4,666 314 702 -2,144 0 - - 61- - -- 222 0- - --- --47 141 0 359 ,083 - - o_______359 --- - 96 __-1,083 28_8 0 106 -_- 320 0 106 320 0 - 110 148 34 2,0_52 34 -------.553- 76 --- - -- 232 0 - --- 25 0- -- - -- -o -- _98 -- 608 0 _ -__- -- 64 y 192 0 _- 80 240 0 81 110 0 f - 74 --- - 224 0 - -- 85 ---256 0 - -- 68 --- - -- - 92 127 1,434 2,8_84 127 — � -- 284 - -869 0 - -_-- -- 62 - 137 0 ,106_ 320 0 - _ _ -- -- --117 _ 352 ------ 0 97 292 0 _ 528 _ 413 0 _ - 10_6 0 _ _ _ 134 _-_320 181 Page 3 Rock Valley Reality 5/31/2012 Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Bathroom (2) 0 sq.ft. 34.3 — 0 343 946 Infiltration 0 0 - 0 - -- 0 -16 ---- - 0 - 16 - --------192 45 E Wall 48 sq.ft. -64 - ---- - - 0 - - - - - 64 -- -- S Wall — ---- S - -56 sq.ft. - ---- 74 -- _ 0 _- - - 74 __ 224.. - - - - -- - W Wall - 4-8-sq.ft.. -- --- --- - - -- 64 0 - - - 192 -- -- N Wall - ---- - - _56 sq.ft. -- - - — -- _ 74 - -- - 0 - - — -- ----64- 74 ^ 224 Ceiling 42 sq.ft. 51 0 51 69 Bedroom (3) _ -- _ _ 0 sq.ft. 4,631 483 _ 5,114 7,983 — Infiltration 598 483 1,081 3,303 Duct 221 0 221 380 N Wall -__-152 sq.ft. ---- - --- - -202 - -- --- - 0 - - -- 202 _----- 608 E Wall 66 sq.ft. � - -_ 88 --- - 0 ----- ---88 ------- --- ---- 264 Window 28sq.ft.----�---1,938 0 1,93_8 1,147 -- Door _- �-_ - --18 sq.ft.--- -- '-- 176 0 -- 176 - -- 531 S Wall -_-- - -152 sq.ft. -- - - 202 0 202 W Wall 101.2 sq.ft. 134 0 _ 134 _ _608 4_05 - Window T 10.8 sq.ft. -- -- - - - - 747 - - 0 --- ---- 747 298 Ceiling - -- -- 266 sq.ft.--- 325 - _- - -- 0 - --- 325 439 Whole House 776 sq.ft. 14,853 1,754 16,607 38,771 ( 1.5 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. , f-- r- Gel ina5 5hdural �ngineerinq L. C Daniel L. Gelinas, P.E. 579A North End Blvd. Salisbury, MA 01952-1738 April 28, 2012 Rock Valley Realty LLC PO Box 40 Newton Jct NH 03859 Phone 978.465.6436 Fax 978.465.5160 email danlgelinas@comcast.net SUBJCT: Single Jack Studs at Headers 24 Hewitt St, North Andover Ma Dear Annie: Per your request Gelinas Structural Engineering LLC (GSE) visited the site on 4/25/12 to observe the header single jack studs per your request and your framers request Summary: Office analysis indicates single 2x4 Jack Studs under headers are adequate and headers are adequate for the structural requirements Headers observed: L. rear 6 foot slider exterior wall 2. front wall: a. 6'-41/2" double window bedroom b. 5'-4" door with two side light windows c. 6'-41/2" double window living room Structural criteria uses was IRC 2009 as amended by the Massachusetts Residential Code 8th Edition Please call with any questions. Very Truly Yours, Daniel L. Gelinas, RE J single Jack Studs at Headers Hewitt St 12054.doc {.�r� GEE INNS