HomeMy WebLinkAboutMiscellaneous - 266 BARKER STREET 4/30/2018N)
March 5, 2015
THENORIFOLOCCO-MEDHAMGROUN
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
Building Commissioner, or Inspector of Buildings
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Board of Health or Board of Selectmen
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Fire Department or Arson Squad
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
RE: Our File No.: P1589048
Insured: ANDREW MCDEVITT
ELIZABETH L MCDEVITT
Address: 266 BARKER STREET, NORTH ANDOVER, MA
Policy No.: F0546417
Loss Date: 02/23/2015
Loss Type: Building or Other Structure Damage
A claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be
applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct
it to my attention and include a reference to the captioned insured, location, policy number, loss
date and claim or file number.
If no reply is received from your office within ten days, we will assume you have no liens of any
type against this property, and the claim will be paid in our customary manner.
Sincerely,
t I ,
Linda E. Babineau
Property Claim Examiner
1-800-688-1825 x1 253
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109
DORCHESTER MUTUAL INSURANCE C 0. Telephone: (800) 688-1825
FITCHBURG MUTUAL INSURANCE CO . Fax: (781) 329-1818
Daie ... q
"ORT11
TOWN 0 /ORTIH ANDOVER
PERMIT FOR PLUMBING
S US
This certifies that
has permission to perform . ..............
plumbing in the buildings of ..............
t .................. North Andover, Mass.
F e e L i c. N o.
...... .......
PLUMB14 INSPECTOR
Check #
7086
It I
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location 46 O/v ke LS� -
New
Renovation 1:1
Owners Name
ape of Occupancy
Replacement El
FIXTURES
Date ? 7 16�
Permit # 26ffF—
Amount 4-1—or—
Plans Submitted Yes No
(Print or type) 4
h I Check W: Certificate
Installing Company Name_ k'" '9
Corp.
L4j
Address E] Partner.
Business Telephone Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicat2_the tyV0'of insurance coverage by checking the appropriate box:
Liability insurance policy D -l" Other type of indemnity El Bond
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature Owner F1 Agent F1
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 Massachus apter 142 of the General Laws.
By: Signature of Licensea PjursDer
Type of Plumbing License
Title
City/Town License Numuer Master Journeyman
APPROVED (OFFICE USE ONLY.
Date. -C. e, -
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that !q A-?
.. . . .........................
has permission to perform ... 0 ................................
plumbing in the buildings of �j C 5?. 1 ...................
at. North Andover, Mass.
Fee. Lic. No..1 )LI 13CI ....
Check # PLUMBING INSPECTOF(
6 � 9 5
N
11
It
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBiN
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Z// TJ (I I/
Building Location Owners.Name L16 co Permit #
Amount
Type of Occui)ancv
New Renovation
Replacement ri
FIXTURES
Plans Submitted Yes
11 No 11
(Print or type)
Installing Company Name
Check one: Certificate
11 Corp.
FlPartner.
E]—Firrr)/CO.
Name of Licensed Plumber: lAnrd -3-cam TL
Insurance Coverage: Indicate the ty f *
w -o insurance coverage by checking the appropriate box:
Liability insurance policy 0--- Other type of indemnity 0 Bond
100
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature Owner 11 Agent F1
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 perfori-ned under Permit issued for this application will be in
compliance with all pertinent provisions of the M2�s-4
,95�t,ate Plymbing Code and Chapter 142 of the General Laws,
y:
1APPROVED (OFFICE USE ONLY
Type of Plumbing License
ilyav 9 --
License Tqumoer Master 0--�Journeyman M
,to
Date.... �//�/w 4�.
VIL, TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission f Ration
or gas inst I
in the bi, of
di
gs qj ..... 9 .......
at ..... ... Nortrhndover, Mass.
Fee. ic. No. J/ w- 1�22
GASIN$ ECTOR
Check 4
V
MASSACHUSEMUNNORMAPPUCATON PERNUr TO DO GAS FrrnNG
(Type or print) Date q
NORTH ANDOVER, MASSACHUSETTS
Building Locations 166 –4 Permit #
Amount $
Owner's Name Fho I' PI&
New Renovation Replacement Plans Submitted
(Print
Name
Addre
Name of Licensed Plumber or Gas Fitter
cl�
C1.
Che;k one: Certificate Installing Company
Corp.
Partner.
0--F-j;Qco.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 NoO
If you have checked yes, please indicate the type coverage by checking the appropriate box. 0
Liability insurance policy 0, Other type of indemnity 13 Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent C-3
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 �tat.S-Gas-epde 9nd �*pter 142 of the General Laws.
I BY:
Title
City/Town
APPROVED (OFFICE USE ONLY)
gnature of Li
lZrIp'llumber
rj Gas titter
Master
Joumeyman
secf Plumber Or Gas Fitt-er
jjJ4 ��
License Number
2ND. FLO R
i6TH. FLOOR
(Print
Name
Addre
Name of Licensed Plumber or Gas Fitter
cl�
C1.
Che;k one: Certificate Installing Company
Corp.
Partner.
0--F-j;Qco.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 NoO
If you have checked yes, please indicate the type coverage by checking the appropriate box. 0
Liability insurance policy 0, Other type of indemnity 13 Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent C-3
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 �tat.S-Gas-epde 9nd �*pter 142 of the General Laws.
I BY:
Title
City/Town
APPROVED (OFFICE USE ONLY)
gnature of Li
lZrIp'llumber
rj Gas titter
Master
Joumeyman
secf Plumber Or Gas Fitt-er
jjJ4 ��
License Number
N
Location -Qte&
No. - 7041,
Date
40RTot TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
17 3 i 3 A)A (
Building Inspector
i
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI$ RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERNUT NUMBER: /74 DATE ISSUED:
SIGNATURE:
Building Commissioner/Inspector of Buildings Date
SECTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning Dia; ict Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
R��Wred Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHW/AUTHORIZED AGENT _r____Rstoric
District: Yes No
2.1 Owner of Record
k)e�� F J_ / o 1A, 143 A'//
/Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
I -Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
6 PA1 7'11Q A/ �,- /V/ r z> f
Licensed Constructi6n Supervisor:
A
Address
0'7,? 6—Y -1-3Y 6-8
9'ignaiure Telephone
4
Not Applicable D
5? -7 6—
License Number
6-
Expiration Date
3'2 Registered Home Improvement Contractor
1*
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Signature Tele2hone
00
M
X
ic
_q
z
0
0
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M
90
0
mn
r
M
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G)
I SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 § 25c(6) I
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 permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check
applicable)
New Construction 0
Existing Building R'
Repair(s) 0
Alterations(s) 0
Addition k�'
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work: �' P_ VVL .4.0 0(
/.7,k/j 77,1-4- 0- '�-o
440 72 0 /V IF rZ, -4 C�FAr,;7'-' 7 _P o 4- 7/_1
�'- / r e A/ CIr e— " W, /--., 'V C- e t?'V A, ce R 6F F j1V'q ec
1(f 7 , C 6 /.---,6 .0 f CZ1;PJf0VR40_f
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost �.Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
>'5274,-���
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total C ost of
Construction
12,
Plumbing
Building Permit fee (a) x (b)
-3
Mechanical (HVAC)
-4
5 Fire Protection
-6 Total (1+2+3+4+5) -2-71 6_0V
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, AN IrAIOAip, ^/.- C -- I as 0,Amer/Audiorized Agent of subject property
Hereby authorize to act on
My �b&half, in �allmatt�erive �tork �ao�rized by this building permit application.
Si6iai�:ue of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 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
Print Name
Signature of Owrier/Aaent Date
-NO. OF STORIES CAI e_� SIZE
_BASENIENT OR SLAB _X�7-
SIZE OF FLOOR TUvMERS V/,? I s�r 5',?,.- .7 6- 2ND 3RD
-SPAN
_DRVIENSIONS OF SILLS
_DRVIENSIONS OF POSTS
DEVIENSIONS OF GIRDERS
-HEIGHT OF FOUNDATION THICKNESS
-SIZE OF FOOT]NG X
-MATERIAL OF CHEVINEY
-IS BUILDING ON SOLID OR FMLED LAND
LS BUILDING CONNECTED TO NATURAL GAS LINE
FORM - U - LOTELLEASE FORM
a 0 —qkA�
Czo 01
INSTRUCTIONS: This form 's used -to verify that all -necessary approval / permits -from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and' or landowner from compliance with any applicable requirements.
IsMossussus a na W.W a a it ...... W..Mo won gaseous 0 ME was WIMMOMM.
APPLICANT FL /0 1,A1 C -
—4q, HONE - 97S 16-15- 3 9 6-Y
ASSESSORS MAP NUNMER (0
LOT NUAMER c?� 1)
SUBDIVISION r
OT NUMBER
-------------
TREET -,96-6- 8Nm krl:Fe J-1—
:F� assussoo STREETNumBER
n am
a &W
a *uses
OFFICIAL SE ONLY
MOEN an *am Sam
RECOMMENDATIONS OF TOWN AGENTS
Mosauff000ns
a a am as a a a a 0 ONE
60-NSERVA-h ON ADMINISTRATOR DATE APPROVED -------------
DATE REEcTED
COMMIRM
TOWN PLANNER DATE APPROVED
COMMENTS
FOOD INSPECTOR - BEALTH
SEPTIC INSPECTOR - HEALTH
COMMENTS
PUBLIC WORKS - SEWER WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
COMMENTS
RECEIVED BY BUILDING INSPECTOR--
DATE REJECTED
DATE APPROVED
DATE REjEcTED
DATE APPROVED
DATE REJECTED
DATE
DATE REJECTED
250
26'
BA RKER S TREE T
DWELLING LOCATION PLAN
CLIENT: NINO NICOLOSI
THIS CERTIFICATION IS MADE AND LIMITED
TO THE ABOVE CLIENT.
LOCATION: NORTHANDOVER, MA.
SCALE: 1'�--40' DA TE. -5110104
I CER77FY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS To
INE HORIZONTAL SE79ACK REQUIREMENTS OF THE LOCAL
APPLICABLE ZONING BY-LAWS IN DrFECT WHEN CONSTRUCTED
OR IS EXCLUDED UNDER M.G.L. CHAPTER 4aA src.z (THIS
CER77FX4770N DOES NOT CONSIDER ANY OTHER RES7WC77oNs
SUCH AS COVENAN7SK7TLAM0SEASEMEN7S, ORDERS OF
CONDMONS.E7C.)
WIS DRAWING ShALL NOT W USED RY THE CL&Wr FW ANY
PURPOSE OTHER THAN THAT WnJWV A80Vr.E)(CfPr WHH THE
WRITTEN PERNWON OF
'o'
V *R
C'
FURTHERMORE THIS D24WING 6 Ty
OF CHRIST14NSEN & SERGI IM 4M USE
71 W* �Rtt I
IS PROHISM.CHNS71ANSSfEN al
FOR THE UMAMORfZED USE IN
IMF�OR-
MA770M CONTAINED HEREON.
PROFESSIONo(L Et4rumaRK
CHRISTIANSEN &SERGI LAND SURVEYORS '08 E0'
160 SUMMER ST HAVERHILL.M4. 01830 TEL 978-373-0310
02004 BY cHRisnumN & SERGI INC. DWG. 4030001
0
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 IVIGL
c 11, S 150 A.
The debris will be disposed of in:
>-/-' DR P�1-7 -P C 14 / �t- t? 67,1 e >Ar 7- IV /,A le -e rC- N'A'/ Cl"
8- k .9 /,, 3 hF7-/,'/-I#eocation of Facility)
Signature of Permit Applicant
4,- - 2 , o !!�
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
Permit Number
REScheck Compliance Certificate Checked By/Date
Massachusetts Energy Code
REScheckSoftware Version 3.5 Release ld
Data filename: C:\Program Files\Check\REScheck\Elio-ranch.rck
CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
BEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE: 05/07/04
PROJECT DESCRIPTION:
Addition & Remodel Ranch
266 Barker St.
North Andover, MA
DESIGNER/CONTRACTOR:
ELIO Inc.
143 NO Road
North Andover, MA
COMPLIANCE: Passes
Maximum UA = 54
Your Home UA = 535
1.7% Better Than Code (UA)
Gross Glazing
Area or Cavity Cont. or Door
Perimeter R -Value R -Value U -Factor UA
Ceiling 1: Flat Ceiling or Scissor Truss
1772 30.0 0.0
62
Wall 1: Wood Frame, 16" o.c.
3105 11.0 1.0
231
Window 1: Wood Frame:Double Pane with Low -E
308
0.330
102
Window 2: Wood Frame:Double Pane with Low -E
10
0.330
3
Door 1: Solid
42
0.350
15
Door 2: Glass
122
0.330
40
Floor 1: All -Wood Joist/Truss:Over Unconditioned Space
1772 20.0 0.0
82
Boiler 1: Other (Except Gas -Fired Steam), 85 AFUE
COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications,
and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts
Energy Code requirements in REScheckVersion 3.5 Release ld (formerly MECchec4 and to comply with the mandatory
requirements listed in the REScheckInspection Checklist.
The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design
Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the
design load as specified in Sections 780CMR 13 10 and J4.4.
Builder/Designer Date
REScheck Inspection Checklist
Massachusetts Energy Code
REScheckSoftware Version 3.5 Release Id
DATE: 05/07/04
Bldg.
Dept
Use
Ceilings:
1. Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 cavity insulation
Comments:
Above -Grade Walls:
1. Wall 1: Wood Frame, 16" o.c., R-11.0 cavity+ R-1.0 continuous insulation
Comments:
Windows:
1. Window 1: Wood Frame:Double Pane with Low -E, U -factor: 0.330
For windows without labeled U -factors, describe features:
# Panes Frame Type_ Thermal Break? Yes No
Comments:
2. Window 2: Wood Frame:Double Pane with Low -E, U -factor: 0.330
For windows without labeled U -factors, describe features:
# Panes Frame Type_ Thermal Break? Yes No
Comments:
Doors:
1. Door 1: Solid, U -factor: 0.350
Comments:
2. Door 2: Glass, U -factor: 0.330
Comments:
Floors:
1. Floor 1: All -Wood JoisttTruss:Over Unconditioned Space, R-20.0 cavity insulation
Comments:
Beating and Cooling Equipment:
1. Boiler 1: Other (Except Gas -Fired Steam), 85 AFUE or higher
Make and Model Number
Air Leakage:
Joints, penetrations, and all other such openings in the building envelope that are sources of air
leakage must be sealed.
When installed in the building envelope, recessed lighting fixtures
shall meet one of the following requirements:
1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture
and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space.
2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfin (0.944
L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture
shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled.
Vapor Retarder:
Required on the warm -in -winter side of all non -vented fi-amed ceilings, walls, and floors.
Materials Identirication:
Materials and equipment must be identified so that compliance can be determined.
Manufacturer manuals for all installed heating and cooling equipment and service water heating
equipment must be provided.
Insulation R -values, glazing U -factors, and heating equipment efficiency must be clearly marked on
the building plans or specifications.
Duct Insulation:
Ducts shall be insulated per Table 14.4.7. 1.
Duct Construction:
All accessible joints, searns, and connections of supply and return ductwork located outside
conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed
using mastic and fibrous backing tape installed according to the manufacturer's installation
instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted.
The FIVAC system must provide a means for balancing air and water systems.
Temperature Controls:
Thermostats are required for each separate HVAC system. A manual or automatic means to
partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided.
Heating and Cooling Equipment Sizing:
Rated output capacity of the heating/cooling system is not greater than 125% of the design load as
specified in Sections 780CMR 13 10 and AA
Cimulating Hot Water Systems:
Insulate circulating hot water pipes to the levels in Table 1.
Swimming Pools:
All heated swimming pools must have an on/off heater switch and require a cover unless over 20%
of the heating energy is from non-depletable sources. Pool pumps require a time clock.
Heating and Cooling Piping Insulation:
HVAC piping conveying fluids above 120 OF or chilled fluids below 55 OF must be insulated to the
levels in Table 2.
Table 1: minimum insulation 7,hicknessfor. Circulaging Hot Water pipes.
Table 2: Minimum Insulation Thicknessfor RVAC Pipes.
Fluid Temp.
Insulation Thickness in
Inches by Pipe
Sizes
Heated Water
Non -Circulating Runouts
Circulating Mains
and Runouts;
Temperature ( F)
up to In
Up to 1.25"
1.5" to 2.0"
Over 2"
170-180
0.5
1.0
1.5
2.0
140-160
0.5
0.5
1.0
1.5
100-130
0.5
0.5
0.5
1.0
Table 2: Minimum Insulation Thicknessfor RVAC Pipes.
NOTES TO FIELD (Building Department Use Only)
Fluid Temp.
Insulation Thickness in Inches by Pipe
Sizes
Piping System Types
Range (F)
2" Runouts
1" and Less
1.2511 to 211
2.511 to 411
Heating Systems
Low Pressure/Temperature
201-250
1.0
1.5
1.5
2.0
Low Temperature
120-200
0.5
1.0
1.0
1.5
Steam Condensate (for feed water)
Any
1.0
1.0
1.5
2.0
Cooling Systems
Chilled Water, Refrigerant
40-55
0.5
0.5
0.75
1.0
and Brine
Below 40
1.0
1.0
1.5
1.5 -
NOTES TO FIELD (Building Department Use Only)
-- ;Z)
�� 6-11I.AnlanflVall1l al—M.,"o4amm
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 063976
Birthdate: 04/15/1945
Expires: 04115/2006 Tr. no: 20588
Restricted: 00
ANTHONY NICOLOSI
143 MILL RD
N ANDOVER, MA 01845
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Location
No. —32W Pr— Date
TOWN OF NORTH ANDOVERR
Certificate of Occupancy $
Building/Frame Permit Fee $
Foun ati n rmit Fee
C - / P 1$
X Wer Fee $
Sewer Connection Fee $ 11-�
Water Connection Fee $
TOTAL $
/*P, -f-4 B611ding lr�spector
C"44 r- 2
91 A f2l
Div. Public Works
lit"11[tt, NO. 3 --Z) L71 j
MAP 4-40.
ZONE
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE I
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS I 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
I/
DATE FILED. 7/
SIGNATURE OF OWNER ? AUTHO ED AGENT
.1
F E E 369
PERMIT GRANTE� 19 'Z6
—Joo(os- —
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST7.
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
V�&
humbims iNspmcvon
OWNER TEL. #
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK ;PAGE
CONTR.LIC.#
SUB DIV. LOT NO.
-&, I
H.I.C. # /0
LOCATION
PURPOSE OF BUILDING
OWNER*S NAME
NO. OF STORIES IF SIZk-
OWNER*S ADDREIV
BASEMENT OR SLAB
ARCHITECT*S NAME
SIZE OF FLOOR TIMBERS IST 2NO 3RD
BUILDER*S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES — SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS I 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
I/
DATE FILED. 7/
SIGNATURE OF OWNER ? AUTHO ED AGENT
.1
F E E 369
PERMIT GRANTE� 19 'Z6
—Joo(os- —
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST7.
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
V�&
humbims iNspmcvon
OWNER TEL. #
CONTR. TEL#
/
C2- IS r-4
CONTR.LIC.#
J-3�VQ
H.I.C. # /0
3 9 t7
BUILDING RECORD
I OCCUPANCY 12
SINGLE FAMILY
To It
MULTI. FAMILj::::::#jOFF!lLCRS
APARTMENTS
I
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
3 1 2 13
PINE
CONCRETE
CONCRETE BLX
BRICK OR STONE
HARDW D
PIERS
PLASTER
61RY WALL
1-1
JNFIN
3 BASEMENT
AREA FULL
V, 1/1 1/1
t!C, 8 M -T
FIN. B M'T' AREA
FIN. ATTIC AREA
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
DROP SIDING
WOOD SHINGLTS
8
1
2
3
CONCRETE
TARTH
ASPHALT SIDING
ASBESTOS SIDI G
VERT. SIDING
WARDNVID
COMIACN
_;�SPH TILE
STUCCO ON M�SONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR
CONC. OR CINDER BILK.
WIRING
SU!
AAVAtORY
AlMiOl( —SINX
Ao —PLvmkl!p—
RN FIXTUff
TILE F
Ift,f 0A00
STONE ON MASONRY
71
_
—
—
I
STONE ON FRAME
5 ROOF
GABLE I HIP
GAMBREL MANSARD
FLAT A SHED
ASPHALT SHINGLES
WOOD SHINGES
SLATE —
TAR & GRAVEL
ROLL ROOFING
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H*T'G
UNIT HEATERS
7 NO. OF ROOMS
AS
-OIL
�WT 2nd
B
lo 3rd I
ELECTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA-
RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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Location o266 rR k
No t7D 6 Date
TOWN OF NORTH ANDOVER
Certificate Occupancy $
of
reo &
CH
Building/Frame Permit Fee $
Foundation Pe it Fee $
,,,g
5
Other Permit Fee
Pv-p(Aw?,v-T$
TOTAL $
Check#
17456
Building Inspector
0
(C'�N
0/
527 CMR 4.00 Form 1
Application. for Permit, Pen -nit, and Certificate of Completion for the
Installation or Alteration of Fuel O'l Burning�E-3.iipmerit and the Storage of Fuel Oil
(City or Town) (Date)
Permit #'s: FD . . Elec. FDID#: --- Fee Paid:
Owner/Occupant Name- Tel.#:
Installation Address: 0& ------- i1ir Serviced Floor'or Unit #:
Heating Unit 0 Domestic Water Heater F1 Power Vent Other
Burner: New EJ Existing El Location:
Trade Name: Mfg:
Type: Model# or Size: Nozzle size:
YFuel Oil Kerosene 11 Waste Oil
Storage Tank.- New Existing
Type: Lsxv/
Location:
_717.0—
Capacity: g I a . 11 . ons
Special requirements (or additional safety devices)
N o. of T anks:
0 OSV valve Oil Line Protected 0 Sheet Rock El Sprinkler
Co. Name: 7�F;"Oe Z
Address: City:
Completion Date: Av
Combustion Test: Gross Stack Temp.:_ J75
CO, Test:
Smoke: Overfire Draft- 1—Z
r47 4 &,
AFU EX yes 0 no EF: El yeqiJKno
(furnace and boilers) (wateir heater)
Tel # t"
Zil):
Net Stack Temp.: ..... VS -0
Breech Draft:
Efficiency Rating %:
1, the undersigned certify that1he installation of fuel burning equipment has been made in accordance with M.G. L. Chapter 148 and 527 CMR 4.00
currently in effect. Furthermore, this installation has been tested in accordance with such requirements, is now in proper operaling condition and
complete instructions as o its use and maintenayce have been furnished to . the person or whom the installation (or alteration) was rr,4de.
Installer:
P' I Name Cell of C# Signature (no Stamp)
Address:
Once signed b�ythe �Ifire d pa�rtm, IN . �sa PO�ERfor the storage of fuel! oil and use of the oil burning equipment.
Approved by:. Date:
Keep original as application. Issue duplicate as permit. This form may be photocopied.
Form 1 (revised 8/11 /00)
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M01313 SW311 01 0311INII ION -ISI-NT3-HO/S3!ON Maine 1"
Date ... 71171 /
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This cegifiesthat..//�/laev.a-f.//Iqz � .. i.;WA . .....
Tj f I
. .. .. ... /
has permission to perform .......... ......................... .. . .....
wiring ftAhe building of .........
7
at CZ4�4 ......... . 6iq. . ....... North ;Andopyr Mli�s.
Fee,f4 ... :� ........ Lic. No. -7.. .......
.... . ... ...................
EcrRICAL INSPECTOR
Check #
5344
TBECOMMONWEALTHOFMAS94CHUSE77S Office Use only
DEPAR7A11AT0FPUX1CS4FMY Permit No. —3
BOAMOFFMPRMUMONMr,UL4HONS,5VOR12.iW
Occupancy & Fees Checked
APPLICA77ONFOR PERMU TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUATS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector of Wires:
The undersigned applies for a perrnit to perform the electrical work described below.
Location (Street & Number) J9 A Ke
Owner or Tenant E I 1 6 a #,ic. ...........
Owner's Address /V-3 t1lill A �i c)
Is this permit in conjunction with a building permit: Yes [Z] No (Check Appropriate Box)
Purpose of Building — 2) uvc / /r V Utility Authorization No.
Existing Service / 0 0 Amps 120 2J/0Volts Overhead 1:3 Underground No. of Meters
New Service ' Amps — Volts Overhead M UndeFground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work P, r- Lj ir e- SeCT-COIJ
No. of 111 ghting Outlets
1Z
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
[D
Bel ow
Generators
KVA
ground
uo und
No. of Receptacle Outlets
Yo
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
..2— Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
M Connections
Other
No. of Dryers
1.0
Heating Devices KW
No. of Water Heaters KW
No. of No. of
I
-
Signs Bailasis
No. Hydro M4sage Tubs
I
No. of Motors Total HP
OTHER-
IhawawaffiLd)&ykurmxPbkymch*gCompWo
Lw&mcoNaagE.()f1tsajbswntWepvAq YES NO
IhaNesubmiWdvafidptcofofsa=toftOffim YES F1 FIT If)mhawdedodYESplewmdc*thcMrOfCDVWdW-by
ux0angurappfUm*b0x
MLRANCE [__J BCND ouim ED
WO&tosw 7-19- o V ivec6ma*Req�
signcdurxlff.TrP'nV0'd7tA tJ A K -r
FIRMNAMW
U."EM-1
ftaselspa*
EVicatiml)*
-7 VahrofBachicalWbik $
Ra# - Final
LimwNo. -7e,�-6 1,4
— Licawm
BusinmTel.Nb.
Ak Tel. No.
OM7.NWSINSURANCEWAIVEP,Iarnaw&edAtheLxzwdoesmthavetheuur&reoDvw,WerAsatsUMoqrrdiffiasmglkedbyNti%adiLgousGffrdLa"s
and dA mysigmW an lhis pemilapphcation waiws lhis requai awl
(Please check one) Owner M Agent F7
Telephone No. -PERMIT FEE
signature of Owner or Agent
Location -44TIb&� '-�- r-C-� -
No. 2 c) 1(,�, Date
i
Check# I DO-
-7 r
3 �', 2:,-�.Un
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL $
4
Building Inspector
dr
TOWN OF NORTH ANDOVER
C �,J_APPLICATION FOR PLAN EXAMINATION
Pe it NO: Date Received_
Date Issued.
LOCATION
PROPERTY
MAP NO.
TANT:
must complete all items on this
I 4N 6 0.
,'(0 / PARCEL: 6) rnn, ZONING DISTRICT:
TYPE AND USE OF BUILDING
TYPE OF IMPROVEMENT
0 New Building
KAddition
0 Alteration
El Repair, replacement
0 Demolition
El M2ym�g (relocation)
0 Foundation only
ESCRIPTION OF A
I I I it I/ —I
OWNER:
HISTORIC DISTRICT
PROPOSED USE
Residential
V One family
0 Two or more family
No. of units:
11 Assessory Bldg
0 Other
�ry.T,O BE PREFORME I
Identification Fle-ase Type or Print Clearly)
JreLk3 � �e;W yh( �
YES 0
Non- Residential
0 Industrial
0 Commercial
0 Others:
CONTRACTOR Name:_..Ar)6/_+_ Phone: Cl
Address:?,(� 66)e S-C/L/ 0 MCLA Yyk, C) �--6
Supervisor's Construction License: __�Exp. DateJ
Home Improvement License:_,qq Exp. Date: /—
ARCHITECT/ENGINEER Name: Phone:
r-1VJ a)4&A,5) 6 P1
Address: Reg. No.
FEE SCHEDULE. BVLD1NGPERMJT.�J1Z00pER$1000.00 OF THE TOTAL EST,
MA TED CO!S T� B�J
, "SD ON $125. 00 PER F.
Total Project Cost:$ 1 P4 ow xl2.00=FEE:$
Check No.: —Receipt No.:_,50
Page I of 4
7-
-t ,.
� �
t
L � i
,�
�.
� t
�"
Staple
oideis
-4
OoRih 1�
BUILDING PERMIT
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Date Received 'tArEV
Permit No#: ACHU
Date issued: ImPORTANT: Applicant must comPletc all items on this
LOCATION Print
PROPERTY OWNER Print 1 oo Year Structure yes no
MAP PARCEL: ZONING DISTRICT:.Historic District yes no
Machine Shop Village yes. no .
TYPE OF IMPROVEMENT PROPOSED USE Non- Residential
Residential
0 New Building 0 One family El Industrial
El Addition [I Two or more family Ei Commercial
El Alteration No. of units: Ei Others:
[I Repair, replacement El Assessory Bldg
El Demolition 0 -Other
7 W -at !�hed, Vistrict
nds
Well 0,01604 --on 0 Wet.l[pJ1
Watq:�ISOAer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly Phone:
OWNER: Name:
Address:
Phnne*
Contractor Name:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home improvement License: Exp. Date:
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT.' $12.00 PER $1000-00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Pr . oject Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
I
r- -
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtai . ned.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
copy of Contract s' d Interior Work
Floor Plan Or Propo e
Engineering Affidavits for Engineered products
:)TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4. Building Permit Application
,6 Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract vation Plan Of Proposed Work With Sprinkler Plan And
Floor/Cross Section/Ele
Hydraulic Calculations (if Applicable)
Mass check Energy Compliance Report (if Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
copy of Contract
2012 IECC Energy code red products
Engineering Affidavits for Enginee ior to issuance of Bldg. Permit
10TE: All dumpster permits require sign off from Fire Department pr
Iin all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. one copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2014
Plans Submitted Plans Waived Pertified Plot Plan Stamped Plans
11PE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
well
Tobacco Sales
Food Packaging/saies Ei
Private (septic ta* etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS_
HEALTH
COMMENTS_
Reviewed On Signature,
Reviewed on Signature
Reviewed on- Siqnature
Zoning Board of Appeals: Variance, Petition No: -7 oning Decision/receipt submitted yes
Planning Board Decision:
Comments
-tonservation Decision: omm
Water & Sewer Connection/s
DPW Town Engineer: Signature:_
Dimension
Number Of Stories:_.. Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical inspector Yes -------------- No
DANGER ZONE LITERATURE:
fxpi I U
MGL �—an �Ktz�in.si Yes--- No
chap'erTj6�ec�t'OnIA F d G 0()-$I()Oo fine------
Kfn,rrf C. - - . - . - -
X %11-UaLZeVjSeC[ ZU14
r
.I
TYPE OF SEWERAGE DISPOSAL
Public Sewer TanningNassage/Body Art Swimming Pools
M1
Tobacco Sales
Well c
F1 TOFood PackazginglSales El
Private (septic tank, etc. 11 Permanent Dumpster on Site 11 Electric Meter location to
I ect
NOTE:
Persons contracting Wth unregistered contractors do not have access to the guarantyfund
Signature of Agent/Ownaf Signature of contractor
Plans Submitted 1q/ Plans Waived Certified Plot Plan El SJped Plans El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
XNTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT F1 El
E]Water Shed Special Permit
El Site Plan Special Permit
ElOther
COMMENTS__�jf� I 512d b Qj 0)
DATE REJECTED DATE APPROVED 0 n
XCONSERVATION El
COMMENTS V\\ -r-) , , j, �—k , j . -
DATE REJECTED DATE APPROVED
REALTH El El
cbmwws J�i A -
Zoning Board of Appeals: Variance, Petition No.
Decision/receipt submitted yes
Planning Board Decision:
;W �
Cons&vation Decision:
Comments
Comments
Water & Sewer connection/Sjg��.
Ternp Dumpster on site yes—no— Fire Department signature/date
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 182,000.00
m
$ -
$
2,184.00
Plumbing Fee
$
273.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
273.00
Total fees collected
$
2,830.00
266 Barker Street
1062-2016 on 4/12./16
Addition and Kitchen Expansion
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..............
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-iwf 7Z.-
CREScheck Software Version 4.5.0
�J( Compliance Certificate
Project
Energy Code:
2012 IECC
49.0
Locatiow.
Andover, Massachusetts
3
Construction Type:
Single-family
49.0
Project Type:
Addition
8
CAimate Zone:
5 (6322 HDD)
21.0
Permit Date:
0.057
9
Permit Number
120
Construction Site:
Owner/Agent:
Designer/Contractor:
North Andover, MA
132
John Lassanah
0.0
0.057
Lasanah Associates
Window 1: Vinyl Frame:Double Pane with Low -E
44
572 Boston Road Suite -20
0.320
Billerica, MA 01821
Door 3: Glass
20
978-667-5431
0.320
jlassanah@comcast.net
il- NO T
Compliance: 3.6% Better Than Code Maximum UA: 138 Your UA: 133
The % Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules,
It DOES NOT provide an estimate of energy use or cost relative to a minimum -code home.
Envelope Assemblies
Ceiling 1: Flat Ceiling or Scissor Truss
130
49.0
0.0
0.026
3
Ceiling 2: Cathedral Ceiling
345
49.0
0.0
0.022
8
Wall 1: Wood Frame, 16" o.c.
272
21.0
0.0
0.057
9
Window 3: Vinyl Frame:Double Pane with Low -E
120
0.320
38
Wall 2: Wood Frame, 16" o.c.
132
21.0
0.0
0.057
4
Window 1: Vinyl Frame:Double Pane with Low -E
44
0.320
14
Door 3: Glass
20
0.320
6
Wall 3: Wood rrame, 16" D.C.
272
21.0
0.0
0.057
16
Wall 4: Wood Frame, 16" D.C.
132
21.0
0.0
0.057
4
Window 4: Vinyl Frame:Double Pane with Low -E
60
0.320
19
Floor 1: All -Wood Joist[Truss:0ver Unconditioned Space
477
38.0
0.0
0.026
12
Project Title: Report date: 11/12/15
Data filenarne: C:\Docurnents and Settings\Owner\My Documents\REScheck\Bob—Drouin-Andover Pagel of 9
Addition-7-15-2015.rck
Compliance Statement, The proposed building design described here is consistent with the building plans, specifications, and other
calculations submitted with the permit application. The proposed building has been designed to meet the 2012 IECC requirements in
REScheck Version 4.5.0 and to comply with the mandatory requirerriOn listed in the REScheck Inspection Checklist.
A144 '7
I S ni.
Nam*� - Tifle i6 MW Date
cp
Project Title: Report date: 11/12/15
Data filename: CADocurnents and Settings\Owner\My Documents\REScheck\Bob—Drouin-Andover Page 2 of 9
Addition-7-15-2015.rck
REScheck Software Version 4.5.0
Inspection Checklist
Energy Code: 2012 IECC
Requirements: 0.0% were addressed directly in the REScheck software
Text in the "Comments/Assumptions" column is provided by the user in the REScheck Requirements screen. For each
requirement, the user certifies that a code requirement will be met and how that is documented, or that an exception
is being claimed. Where compliance is itemized in a separate table, a reference to that table is provided.
section
#
Pre-Inspection/Plan Review
I
Plans Verified
Value
I
Field Verified
Value
1
Complies?
Comments/Assumptions
1
& Req.1D
103.1,
;Construction drawings and
![]Complies
103.2
:documentation demonstrate
:0Does Not
[Pill]'
:energy code compliance for the
oNot Observable
Q)
building envelope.
EINot Applicable
103.1,
:Construction drawings and
'ElComplies,
103.2,
:documentation demonstrate
ElDoes Not
403.7
:energy code compliance for
:,lighting
E]Not Observable
[PR311
and mechanical systems.
ONot Applicable
:Systems serving multiple
:dwelling units must demonstrate
:.compliance with the IECC
:Commercial Provisions.
302.1,
Heating and cooling equipment is:
Heating: Heating:
OComplies
403.6
:sized per ACCA Manual S based
Btu/hr Btu/hr
ElDoes Not
JPR2J2
:on loads calculated per ACCA
Cooling: Cooling:
ONot Observable
Manual J or other methods
approved by the code official.
Btu/hr Btu/hr
UNot Applicable
Additional Comments/Assumptions:
111 High Impact (rier 1) 12 1 Medium Impact (Tier 2) 13 1 Low I m piict (T �ier 3�)
Project Title: Report date: 11/12/15
Data filename: C:\Documents and Settings\Owner\My Documents\REScheck\Bob—Drouin-Andover Page 3 of 9
Addition-7-15-2015.rck
12012 IECC
Foundation Inspection
Complies?
303.2.1
A protective covering is installed to
-posed -insulation
ElComplies
-El-Does
[FO11]2
protect ex exterior
Not
and extends a minimum of 6 in. below
FINot Observable
grade.
E]Not Applicable
403.8
Snow- and ice -melting system controls
ElComplies
[FO12]2
installed.
L]Does Not
E]Not Observable
E]Not Applicable
Additional Comments/Assumptions:
Comments/Assumptions
- - I
1 High Impact (Tier 1) 2 Medium Impact (Tier 2) 3 Low Impact (Tier 3)
Project Title: Report date: 11/12/15
Data filename: C:\Documents and Settings\Owner\My Documents\REScheck\Bob-Drouin-Andover Page 4 of 9
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#
Framing Rough -in Inspection Plans Verified Field Verified
Complies?
Comments/Assumptions
Value Value
& Req.ID
!402.1.1,
Glazing U -factor (area -weighted U_
U_
ElComplies
See the Envelope Assemblies
j402.3.1,
average).
[]Does Not
table for values.
402.3.3,
402.3.6,
L]Not Observable
402.5
ONot Applicable
[FR211
303.1.3
U -factors of fenestration products
ElComplies
[FR411
are determined in accordance
[]Does Not
with the NFRC test procedure or
E]Not Observable
taken from the default table.
E]Not Applicable
402.4.1.1
Air barrier and thermal barrier
ElComplies
[FR2311
installed per manufacturer's
E]Does Not
instructions.
E]Not Observable
E]Not Applicable
402.4.3
Fenestration that is not site built
ElComplies
[FR20]1
is listed and labeled as meeting
E]Does Not
AAMA /WDMA/CSA 101/l.S.2/A440
E]Not Observable
or has infiltration rates per NFRC
E:]Not Applicable
400 that do not exceed code
limits.
402.4.4
IC -rated recessed lighting fixtures
ElComplies
[FR16]2
sealed at housing/interior finish
E]Does Not
and labeled to indicate :52.0 cfm
E]Not Observable
leakage at 75 Pa.
E]Not Applicable
403.2.1
Supply ducts in attics are R-
R-
ElComplies
[FR12]1
insulated to �!R-8. All other ducts R-
R-
E]Does Not
in unconditioned spaces or
E]Not Observable
outside the building envelope are
E]Not Applicable
insulated to 2t[1-6.
403.2.2
All joints and seams of air ducts,
OComplies
[FR13]1
air handlers, and filter boxes are
E]Does Not
,41
sealed.
FINot Observable
E]Not Applicable
403.2.3
Building cavities are not used as
ElComplies
[FR15]3
ducts or plenums.
E]Does Not
FINot Observable
Applicable
403.3
HVAC piping conveying fluids R-
--.E]Not
R-
OComplies
[FR17]2
above 105 LIF or chilled fluids
E]Does Not
U I
below 55 QF are insulated to 2:R-
E]Not Observable
3.
E]Not Applicable
403.3.1
Protection of insulation.on HVAC
DComplies
[FR24]2
piping.
E]Does Not
F-INot Observable
E]Not Applicable..
403.4.2
Hot water pipes are insulated to R-
R-
ElComplies
[FR18]2
>—R-3.
E]Does Not
E]Not Observable
E]Not Applicable
403.5
Automatic or gravity dampers are
DComplies
[FR19 ]2
installed on all outdoor air
E]Does Not
intakes and exhausts.
E]Not Observable
E]Not Applicable
Additional Comments/Assumptions:
1 'High Impact (Tier 1)
2 Medium Impact (Tier 2)
3 Low Impact (Tier
3)
Project Title:
Report date: 11/12/15
Data filename: CADocuments and Settings\Owner\My Documents\REScheck\Bob—Drouin-Andover Page 5 of 9
Add ition-7-15-2
015. rck
1 High Impact (Tier 1) 2 Medium Impact (Tier 2) 3 Low Impact (Tier 3)
Project Title: Report date: 11/12/15
Data filename: CADocurnents and Set'Lings\Ow,)er\My Documents\REScheck\Bob—Drouin-Andover Page 6 of 9
Addition-7-15-2015.rck
Section
# Insulation Inspection
& Req.ID
303.1 All installed in sulation is labeled
[IN13]2 or the installed R -values
provided.
Plans Verified Field Verified Complies? Comments/Assumptions
Value Value
402.1.1, Floor insulation R -value. R- R-
402.2.6 F1 Wood Wood
[IN1]1 E] Steel Steel
V11
303.2,
Floor insulation installed per
402.2.7
manufacturer's instructions, and
[IN211
in substantial contact with the
4),
underside of the subfloor.
402.1.1,
Wall insulation R -value. If this is a
R-
R-
402.2.5,
mass wall with at least 1/2 of the
n Wood
n Wood
402.2.6
wall insulation on the wall
Mass
Mass
[IN331
exterior, the exterior insulation
Steel
E] Steel
,I-) I
requirement applies (FR10).
ElComplies
E]Does Not
[]Not Observable
EINot Applicab le
ElComplies See the Envelope Assemblies
E]Does Not table for values.
E]Not Observable
E)Not Applicable
ElComplies
E:]Does Not
E]Not Observable
ONot Applicable
11com-p-lie—s— S e e t h -e -E -n v -e-1 o --p e- A s s- e- m- b I i e -s
ElDoes Not table for values.
ONot Observable
E]Not Applicable
303.2 Wall insulation is installed per []Complies
[IN4]1 manufacturer's instructions. DDoes Not
U, ONot Observable
E]Not Applicable
Additional Comments/Assumptions:
1 High Impact (Tier 1) 2 Medium Impact (Tier 2) 3 Low Impact (Tier 3)
Project Title: Report date: 11/12/15
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Addition-7-15-2015.rck
Section
# Final Inspection Provisions
&-Req.ID
402.1.1, Ceiling insulation R -value.
402.2.1,
402.2.2,
402.2.6
[FI111
303.1.1.1, Ceiling insulation installed per
303.2 manufacturer's instructions.
[F1211 Blown insulation marked every
300 ft'.
402.2.3 Vented attics with air permeable
(F122]2 insulation include baffle adjacent
to soffit and eave vents that
extends over insulation.
402.2.4 Attic access hatch and door R__
[F1311 insulation 2:11 -value of the
adjacent assembly.
Plans Verified
Value
R-
n Wood
[] Steel
402.4.1.2 Blower door test @ 50 Pa. <=5 ACH 50
[FI17]1 ach in Climate Zones 1-2, and
44) <=3 ach in Climate Zones 3-8.
402.4.2 Wood -burning fireplaces have
[F[8]2 tight fitting flue dampers and
Itt outdoor air for combustion.
403.2.2 Duct tightness test result of <=4 cfm/100
[F1411 cfm/100 ft2 across the system or ft2
<=3 cfm/100 ft2 without air
handler @ 25 Pa. For rough -in
tests, verification may need to
occur during Framing Inspection.
403.2.2.1 Air handler leakage designated
[F12411 by manufacturer at <=2% of
design air flow.
403.1.1 Programmable thermostats
[Flg]2 installed on forced air furnaces.
Q)
403-1.2 Heat pump thermostat installed
[FIJ0]2 on heat pumps.
403.4.1 Circulating service hot water
[FIJJ]2 systems have automatic or
_U accessible manual controls.
403.5.1 All mechanical ventilation system
[F125]2 fans not part of tested and listed
HVAC equipment meet efficacy
and air flow limits.
Field Verified
Value
Complies? Comments/Assumptions
R-
GComplies See the Envelope Assemblies
Wood
E]Does Not table for values.
E] Steel
E]Not Observable
E]Not Applicable
OComplies
E]Does Not
E]Not Observable
ONot Applicable
OComplies
E]Does Not
ONot Observable
E]Not Applicable
R- ElComplies
E]Does Not
E]Not Observable
E]Not Applicable
ACH 50 ElComplies
E]Does Not
E]Not Observable
F-1 Not Applicable
ElComplies
E]Does Not
E]Not Observable
E]Not Applicable
cfm/100 ElComplies
ft2 E]Does Not
[]Not Observable
ONot Applicable
ElComplies
DDoes Not
E]Not Observable
E]Not Applicable
ElComplies
E]Does Not
E]Not Observable
E]Not Applicable
ElComplies
E]Does Not
E]Not Observable
E]Not Applicable
ElComplies
E]Does Not
ONot Observable
E]Not Ap plicable
ElComplies
DDoes Not
E]Not Observable
ONot Applicable
1 High Impact (Tier 1) 2 Medium Impact (Tier 2) 3 Low Impact (Tier 3)
Project Title: Report date: 11/12/15
Data filename: CADocuments and Settings\Owner\My Documents\REScheck\Bob—Drouin-Andover Page 8 of 9
Addition-7-15-2015.rck
_�-�C_t_ion
#
. Final Inspection Provisions Plans Verified
& Req.ID
Value
403.9.1
Readily accessible switch on
[FI12]3
heaters for swimming pools or
ii,
permanent in -ground spas.
403.9.2 Timer switches on heaters and
[Fllg]3 pumps serving pools and
permanent spas.
Field Verified Complies? Comments/Assumption
Value
E]Com plies
E]Does Not
nNot Observable
E]Not Applicab le
ElComplies
E]Does Not
FINot Observable
[]Not Applicable
403.9.3 Heated pools and permanent ElComplies
[F120)3 spas have a vapor retardant ODoes Not
,L� cover. ONot Observable
404.1 75% of lamps in permanent
[F1611 fixtures or 75% of permanent
fixtures have high efficacy lamps.
*0 Does not apply to low -voltage
lighting.
404.1.1 Fuel gas lighting systems have
[F123]3 no continuous pilot light.
401.3 Compliance certificate posted.
[F17]2
303.3 Manufacturer manuals for
[FI18]3 mechanical and water heating
_9 I systems have been provided.
Additional Comments/Assumptions:
E]Not Applicable
ElComplies
E]Does Not
E]Not Observable
ONot Applicable
ElComplies
E]Does Not
E]Not Observable
E]Not Applicable
ElComplies
E]Does Not
FINot Observable
E]Not Applica . ble.
ElComplies
E]Does Not
FlNot Observable
E]Not Applicable
1 High Impact (Tier 1) 2 Medium Impact (Tier 2) 3 Low Impact (Tier 3)_
Project Title: Report date: 11/12/15
Data filenanne: C:\Documents and Settings\Owner\My Documents\REScheck\Bob—Drouin-Andover Page 9 of 9
Addition-7-15-2015.rck
150 )
150'
FND 1. PI�E "I BARKER STREET
JOB NAME: DRAWN BY: RWC CHECKED BY: LBW
ANDREW & ELIZABETH
I I
McDEVI SCALE: 1 of =40'
LOCAT10i:
266 BA�KER ST DATE: 3/28/2016
NORTH i ANDOVER, MASS JOB NUMBER SHEET
DESCRIPMON: 16-08 1 OF 1 A
PROPOS!'ED ADDITION
ENDRD:
OFND 1.
t'
PIPE
'150)
DEED BK 9412 PG 218
7
PLAN #3:506
0)
LOT 2
44,000
SF
)FND
cli
LEO C�.
WHITE
No. 29641
-/slE
ZONE: R2
i
REQUIRED: t LASO
of
FRONTAGE 150'
44.9'
FRONT SE�IBACK 30'
SIDE SETBACK 30'
,REAR SETBACK 30'
.6
EXISTING: 1
25.5'
20-r
52.r
FRONTAGE 1150'
FRONT SETBACK 98.5'
�_
DaST SINGLE FAMILY HOME
SIDE SETBACK 25.5'
36.2'x6.l* POROi
REAR -SETBACK 147.2'
20*
- 31�:
16.9 50.2'
PROPOSED1
I
FROIN TIAGEA 50'
FRONT S ACK 98.5'
SIDE SETB K 25.5'
C
REAR SE ACK 142.9'
to
0-)
06
0)
N
150 )
150'
FND 1. PI�E "I BARKER STREET
JOB NAME: DRAWN BY: RWC CHECKED BY: LBW
ANDREW & ELIZABETH
I I
McDEVI SCALE: 1 of =40'
LOCAT10i:
266 BA�KER ST DATE: 3/28/2016
NORTH i ANDOVER, MASS JOB NUMBER SHEET
DESCRIPMON: 16-08 1 OF 1 A
PROPOS!'ED ADDITION
W Boise Cascade Quadruple 1-3/4"x 11-7/8" VERSA-LAM02.031005P Floorl3eam\F501
Total Horizontal Product Length = 32-00-00
Reaction Summary (Down / Uplift) (lbs)
Dry 12 spans I No cantilevers 10/12 slope March 31, 2016 08:52:22
BC CALCO Design Report
Build 4516
File Name: BC CALC Project
Job Name: MCDEVITT
Description: Designs\FB01
Address: 266 BARKER ST.
Specifier:
City, State, Zip: NO. ANDOVER, MA
Designer:
Customer:
Company:
Code reports: ESR -1040
Misc:
Total Horizontal Product Length = 32-00-00
Reaction Summary (Down / Uplift) (lbs)
Bearina Live
Dead
Snow
Wind Roof Live
BO, 5-1/4': 2,117/716
1,397/0
1,759/0
131, 5-1/4' .7,045/0
7,027/0
7,045/0
B2, 5-1/4" 2,9051151
2,746 / O�
2i829 / 0
Live
Dead Snow VAnd Roof Live
Trib.
Load Summary
Tag Description Load Type
Ref. Start
End 1000/0
90% 115% 160% 125%
1 Standard Load Unf. Area (lb/ftA 2)
L 00-00-00
32-00-00 30
10
07-00-00
2 wall Unf. Un. (lb/ft)
L 00-00-00
32-00-00 0
80
n/a
3 ATTIC Unf. Area (lb/ftA2)
L 00-00-00
32-00-00 20
10
07-00-00
4 ROOF Unf. Area (lb/ftA 2)
L 00-00-00
32-00-00
15 50
07-00-00
Controls Summary Value
% Allowable Duration Case
Location
Pos. Moment 25,827 ft -lbs
52.8%
115% 12
23-11-01
Neg. Moment -29,625 ft -lbs
60.5%
115% 13
13-00-00
Neg. Moment -29,625 ft -lbs
60.5%
115% 13
13-00-00
End Shear 5,800 lbs
31.9%
115% 12
14-02-08
Cont. Shear 8,674 lbs
47.8%
115% 13
14-02-08
Total Load Defl. U314 (0.711
76.4%
n/a 12
23-01-14
Live Load Defl. U496 (0.451
72.6%
n/a 27
23-01-14
Total Neg. Defl. U999 (-0.108")
n/a
n/a 12
08-10-08
Max Defl. 0.711
71.1%
n/a 12
23-01-14
Span / Depth 18.8
n/a
n/a 0
00-00-00
% Allow % Allow
Bearing Supports Dlrn. (L x W) Value
Support
Mernber
Material
Bo Post 5-1/4" x 7" 4,305 lbs
n/a 15.6%
Unspecified
131 Post 5-1/4" x 7" 17,594 lbs
n/a 63.8%
Unspecified
B2 Post 5-1/4" x 7" 7,047 lbs
n/a 25.6%
Unspecified
Notes
Design meets Code minimum (U240) Total load deflection criteria.
Design meets Code minimum (U360) Live load deflection criteria.
Design meets arbitrary (1 ") Maximum total load deflection criteria.
Calculations assume Member is Fully Braced.
Design based on Dry Service Condition.
Deflections less than 1/8" were ignored in the results.
Fastener Manufacturer:Simpson Strong -Tie, Inc.
W 13d"Cateft QUadrupiel-3/4"xll-7/8"VERSA-LAMU2.031005P F1oorBeaMTB01
BC CALCO Design Report Dry 12 spans I No cantilevers 10/12 slope March 31, 2016 08:52:22
Build 4516 File Name: BC CALC Pmiect
Job Name: MCDEVITT Description: Designs\FB01
Address: 266 BARKER ST. Specifier:
City, State, Zip: NO. ANDOVER, MA Designer:
Customer: Company:
Code reports: ESR -1040 Misc:
lConnection.-Diagram
___j " I_ . I , 1, Disclosure
-- :�:7
T . I
Completeness and accuracy of input must
i —, I
a
be verified by anyone who would rely on
—0
output as evidence of suitability for
particular application. Output here based
C
on building code-aocepted design
properties and analysis methods.
Installation of Boise Cascade engineered
wood products-must.be in aocordance.with
current Installation Guide and applicable
building codes. To obtain Installation Guide
a minimum = 1-1/2% = 8-7/8"
or ask questions, please call
b minimum = 6" d = 24"
(800)232-0788 before installation.
e minimum
BC CALC*, BC FRAMER&, AJS-,
Beams 7 inches wide will be assumed to be either top -loaded only, or equally loaded from
ALLJOISTO, BC RIM BOARDTm, BCI8,
each side.
BOISE GLULAMTm, SIMPLE FRAMING
Install Screws with screw heads in the loaded ply.
SYSTEMS, VERSA-LAM8, VERSA -RIM
PLUS8, VERSA-RIM8,
Member has no side loads.
VERSA-STRANDO, VERSA -STUDS are
Connectors are: SDW22634
trademarks of Boise Cascade Wood
Products L.L.C.
The Commonwealth ofMassa chusettv
Department ofIndustrialAccidents
I Congress Street, Suite 100
Boston, AM 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElQc.tricians/Plumbers.
TO BE FILED WITH TRE PERAUTTING AUTHORITY.
NaMe (Business/Organization/Individual): 0 cb)q fW e– fcl-1 , Lvl—
Address: �,6 . S� Y � �nul�
City/State/Zip:,
. 01—,_( Phone #:
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit Us affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must -attached an additional sheet showing thq name of the sub -contractors and state whether or not those entities have
employees. if the sub-c6n6c6s 6� v! e'mploy'ees, ley must provide their workers' comp. policy number. ' � I . . -
I am an employer that ispiovidihg workers' compensation insurancefor my empl6yees.' Below is thepolicy andjob site
information.
Insurance Company
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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 thepains andpenalties ofperjury that the information provided above is true and correct
J\ _J _ CA_
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
n employer? Ch'e�k&eappir`op'riate box:
Type of project (T�quired):
7eyou
1. 1 am a employer with mployces (full and/or part-time).*
I am
7. El New construction
2. [] I am a sole proprietor or partnership and have no employees working for me in
8. E . I Remodeling
any capacity. [No workers' comp. insurance required.]
9. F1 Demolition
3.FJ I am a homeowner doing all work myself. [No workers' compAnsurance required.] t
10 ��uilding addition
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
11. Electrical repairs or additions
prop ! ri etors with no employees.
12.F] Plumbing repairs or additions
5. F1 I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
1�.[J Roof repairs
Thesb,s�b-contractors, hai'.e` em"pl9ye9s; and have workers' comp. insuranceJ
6.FJ We are a corporat�qn pod its- officers , have exercised their right of 'exemption per MGL c.
14.El Other
152, § 1(4), and we have no. jamploye(,n. [No workers' comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit Us affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must -attached an additional sheet showing thq name of the sub -contractors and state whether or not those entities have
employees. if the sub-c6n6c6s 6� v! e'mploy'ees, ley must provide their workers' comp. policy number. ' � I . . -
I am an employer that ispiovidihg workers' compensation insurancefor my empl6yees.' Below is thepolicy andjob site
information.
Insurance Company
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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 thepains andpenalties ofperjury that the information provided above is true and correct
J\ _J _ CA_
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires aH 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 contralt"o'-fIffire,
expres's or implied, oral or written." I
An employer is defined as "an individual, partners�ip, association, corpoTation or other legal entity, or' any two or more
of the foregoing engaged in ajoint 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 b6 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-'contractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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 Depattment. of Ifidustrial
Accidents fbi 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 r6qu�ired to obtain a Workers'
compensatioli �olicy, please call the Department. at the number listed below. Self-insur6d companies sh,ould'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
pol" information (if necessary) and under "Job Site Address" the applicant should write "all locations in
ICY _(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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
MCCAC01 OP ID: BW
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMtDDIYYYY)
1 03/30/2016
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 HOLDER.
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 require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such enclorsement(s).
PRODUCER
Francis Provencher Insurance
Agency, Inc.
530 Rogers Street
Lowell, MA 01852
CONTACT
NAME:
FA -454-9343
M. Extl: 978-459-8681 (AIXC Nl)� 978
E-MAIL
ADDRESS'
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: Preferred M utual Insurance Co. 15024
INSURED McCarthy Contractors Corp.
INSURER B: SAFETY INSURANCE
PO Box 594
Dracut, MA 01826
INSURER C:
DAMAGE 10 REN I ED
PREMISES (Ea occurrence) S 50,000
MED EXP (Anyone person) S 10,000
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.
INSR I ADDL SUBR ___l5OL1_CYEFF__Pb1_1CYEXP I
LTR TYPE OF INSURANCE POLICYNUMBER (MMIDDNYYYI (MMIDDIYYYY) LIMITS
A
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
FIV -1
CLAIMS -MADE OCCUR
BOP0100721665
12/0912016
1210912016
DAMAGE 10 REN I ED
PREMISES (Ea occurrence) S 50,000
MED EXP (Anyone person) S 10,000
PERSONAL & ADV INJURY S 1,000,000
GENT AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE S 2,000,000
F—] PRO -
POLICY JECT F� LOC
PRODUCTS - COMP/OP AGG S 2,000,000
S
OTHER
AUTOMOBILE LIABILITY
BINED SINGLE LIMIT
(CEOamaccdent) S 1,000,000
BODILY INJURY (Per person) S
B
ANY AUTO
6227181
01/2212016
01122/2017
BODILY INJURY (Per accident) S
ALLOWNED SCHEDULED
AUTOS F)( AUTOS
PROPER DAMAGE
(per c.,Z I) S
NON -OWNED
HIREDAUTOS AUTOS
E
s
UMBRELLA LIAB
H
OCCUR
EACH OCCURRENCE $
AGGREGATE S
EXCESS LIAB
CLAIMS -MADE
DED I I RETENTION $
S
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
PER H_
S ATITE EORT
E.L. EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? r
N/A
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE S
E.L. DISEASE - POLICY LIMIT S
If yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
"CERTIFICATE FOR WORKERS* COMP COVERAGE WILL BE ISSUED DIRECTLY FROM THE
COMPANY WITHIN 2 BUSINESS DAYS"
L"il i� 03 AIR OF101 I L-1 0
NANDOVE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of North Andover
120 Main Street AUTHORIZED REPRESENTATIVE
N. Andover, MA 01845
(D 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
0-3 3/17/2016 4:42:57 AM PAGE 2/002 Fax i5erver
r.FRTIFlr.ATF OF I 1AR11 ITY IfURI]RAKIr-F DATE (M.MIDDr�i
!U=TIFACATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE' HOLDER. THI'S...
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
ER.
IMPORTANT- If the certificate holder is an ADDITIONAL INSURED, the policypes) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to
the uertificitite holder in lieu of such endarsement(s).
PRODUCER
CONTACT
NAME!
PHONE
FAX
FRANCIS E PROVENCHER INS
530 ROGERS ST
(A/C, No, E -a):
(AIC, No):
E-MAIL
LOWELL, MA 01852
ADDRESS:
26F9G
INSURER($) AFFORDING COVERAGE NAIC#
INSURED
INSURER A: TR7VELERS INDEMNTf-Y comPANY or AMERICA
MCCARTHY CONTRACTORS C ORP
INSURER 8:
INSURER C:
INSURER D:
PO BOX 594
INGURERE:
DRACUT, MA 01826
INSURER F;
COVERAGES CERTIFICATE NUMER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIESOF INSURANCE LISTED BELOWHAVE BEEN =M TO THE INSURED NAMED ABOVE FOR THE FOLICYPERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DDCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN. THEINSURANCE
AFFORDE13 BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDIT IONS OF SUCH POLICIES. LONTS SHOWN MAY HAVE BEEN REDUCED BY
rAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADD
L
ISUB
It
POLICY NUMBER
POLICY EFF DATE
IMMrQMYYYY0
POLICY EV DATE
(MmIzow"
LIMITS
ERA
GENERAL LIABILITY
E_ACI I OCCURRENCE $
I
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE [D OCCUR.
DAMAGE TO RENTED $
�REMISES (Ea occurrence)
MED EXP (Any one person) $
z
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER
GENERAL AGGRFGATE S
71 POLICY [:] PROJECT LOC
PRODUCTS - COMP/OP AGG $
AUTOMOBILE LIABIUTY
ANY AUTO
COMBINED SINGLE
LIMIT (Ea accident)
ALL OWNED AUTOS
BODILY INJURY
SCHEDUI,EAUTOS
(Per person)
BODILY INJURY $
HIRED AUTOS
NON -OWNED AU rOS
(Per accident)
PROPERTY DAM AGE
(Per accident)
UMBRELLA LIAB
M
OCCUR
EACH OCCURRENCE $
EXCESS LIAB _
LJ
CLAIMS -MADE
AGGREGATF $
DEDUCTIBLE
RETENTION $
A
WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN
UMG03954A-1 5
05M WWI 5
05/1912016
X
I VVC1 91 ATU f-ORY
LIM T5
OTHER
ANY PROPERITOWPARTNER/EXECUrIVE
OFFICERIMEMBER EXCLUDEU?
E. L EACH ACCIOENT $ 100,000
(MUndellarY Ih NHJ
if Yes, describe under
E.L. DISEASE - EA EMPLOYEE S 100,000
I
E.L. DISEASE - POLICY LIMIT Is 500'U00
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPOtATIONa/LOCATlCNaAfB4lCLESIREMTRICTIONSIBPECIAL ITEMS
REPLAC29 ANY PRIOR CURTWICATE L13SU13D TO THE C13RTMCATE MILDER AFTEC�G WORKERS COM -P COVERAGE -
CERTIFICATE HOLDER
CANCELLATION ------------
TOWN OF METHUEN
SHOULD ANY OF; THE ABOVE D193CRIBSO POLICIES BE CANCELLED
41 PLEASANT ST STIE 313
BEFORE THE EXPIRATION DAYS THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE YAT)i THE POLICY PROVISIONS,
ME-MUFN, MA 01844
AUTHORIZED REPRESENT4VVE
--------------
-U- -1 - I -u MUF Ku OF #%L.VMLJ 'IVt%U-ZU1U AGORD CORPORATION. All rights reserved.
Ofric, of Consumer Affairs & Busines's Regulation
ME IMPROVEMENT CONTRACTOR
gistration: , f49258
Type:
xpiration: :111b/2018. Individual
ROBERT J MCCARTHY
ROBERT MCCARTHY
81 LONGMEADOW DR.
LOWELL, MA 01852
Undersecretary
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Location
No.?-4� - 7 -
Date 0d) v -;z ��
.e
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXANIINATION " 10
Od--7- —00
/7
Permit NO:— Date Received rap
Date Issued: 09 07-M2� CHU
I IMPORTANT: ADDlicant Must COMDlete all items on this Daae I
LOCA
PROP]
MAP NO.: (V W1 PARCEL:
TYPE AND USE OF RIT11,DING
Pnnt
ZONING DISTRICT:
MgTnRic niqTRICT V1F.V4 r-1
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
ddition
0 Alteration
0 One family
0 Two or more family
No. of units:
0 Industrial
0 Repair, replacement
0 Demolition
0 Assessory Bldg
0 Commercial
0 Moving (relocation)
0 Other
0 Others:
0 Foundation only
I 9J W6701 I'A I W I Lei kq KJSJ WAY143 1114 %140 LON lab] a W %"A a 01 Iil LVA 1:101
Identification Please Type or I
OWNER: Name:
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License:C� - 0 Exp. Date: /C)
Home Improvement LicenseJ �jq Yxp. Date:
ARCI-HTECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF TBE TOTAL ESTIMA TED COSTB,4SED ON $125.00 PER S. F
Total Project Cost:$ 6 —xl2.00=FEE:$ �360-00
Check No.: &—, I b
Receipt No.:.
Page I of 4
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