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AQProperty Record Card
Location: 27L4 ABBY LANE
Owner Name: KING, CHRISTOPHER
Owner Address: 27 ABBY LANE
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 10 - 10 Land Area: 0.61 acres
Use Code: 101-SNGL-FAM-RES -Total Finished Area: 4720 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: 1,038,000 1,043,100
Building Value: 783,300 749,800
Land Value: 254,700 293,300
Market Land Value: 254,700
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkId=2254803&town=NandoverPubAcc 3/18/2013
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Location A
No. tgt�—)q
Check #
6 6 1
Date –161 1 -�
TOWN OF NORTH ANDOVER,
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
8 �I'K' I q A
Permit NO: % -/ Date Received (' � I
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION,
P t
PROPERTY OWNER
Print 100 Year 01diStructure yes ,0�
MAP N07 PARCEL ZONING DISTRICT: Historic,District yes
Machine Shop Village yes, q6z7—>
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
11 New Building
Alone family
X�ddition
El Two or more family
[I Industrial
El Alteration
No. of units:
Li Commercial
El Repair, replacement
0 Assessory Bldg
[I Others:
Xpernolition
0 Other
Septic .0 Well,
0! -Floodplain El Wetlands
0 Watershed District,
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
(2 CK C SCfQ e r P �.vc �'Q P) Q COL L -J I WQ UJ
or Print Clearly)
1-) –70
OWNER: Name: (-�nns:bc--)uLs-- iKn� (-r- Phone: -1, Q
Address: oq-7
CONTRACTOR Narne:, Phone:
Address:
Supervis.or's-Gonstruct.ion License: Exp.. Date:
Home Improvement-Licen
.Exp. Date:
ARCHITECT/ENGI NEER— C-A� Phone:
Address: MM*v UVA _Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED cosr BASED ON $125.00 PER S.F.
Total Project Cost: $ (,POj ODD FEE: $
,.Check No.: Receipt No.: Z&P(,O- (.0
INOTE: Personscontractingwylt 'unregistered contractors do not have access to the guarantyfund
i"g signafureoUc6ntractor.
§!g!j@�yreof-A 660b�Irier
Plans Submitted P"" Plans Waived F1 Certified Plot Plan Sta.';m'ped Plans
Plans Submitted 0 Plans Waived Certified Plot Plan Stamped Plans F1
TYPE OF SEWERAGE DISPOSAL
-
I
Public Sewer El
Taming/Massage/Body Art
Swimming Pools D
well
Tobacco Sales
Food Packaging/Sales D
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
..DATE REJECTED DATE AMMOOVED
PLANNING & DEVELOPMENT 7,
z)
(7 -
COMMENTS
\./ CONSERVATION
COMMENTS
Reviewed o
61
HEALTH Reviewed on Si-qnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_..
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/ DrivewaV Permit
DPW To-wo Engineer: Signatu'r�:
Located 384 Osgood Street
FIRE 'DEPARTMENT -'Ternp Dumpster on site yes no
Located at'124 MainfStrbet
Fire Departhher'Itsignatureldate
COMMENTS
Dimension
Numbe r of Stories:
Total land area, sq. ft.:_
'—""Total square feet of floor area, based on Exterior dirnensions.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes -No
DANGER ZONE LITERATURE: Yes —No
MGL Chapter 166 Section 21 A �F and G min.$100-$1000 fine
NOTES ancl nATA — Wnr r1pn2rfmanf ncal
7)-e st e nvvilqt�'K
LJ Notified for pickup - Date
Doe.Building Permit Revised 20 10
Building Department
The foll�"Owing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofirig, Siding, Interior Rehabilitation Permits
u Building Permit Application
u Workers Comp Affidavit
u Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Li Building Permit Application
Li Certified Surveyed Plot Plan
Lj Workers Comp Affidavit
Li Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
Lj Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
• Mass check Energy Compliance Report (if Applicable)
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
u Building Permit Application
u Certified Proposed Plot Plan
Lj 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)
Li Copy of Contract
• Mass check Energy Compliance Report
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the app�,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
I)oc: Doc.Buildiing Permit Revised 2012
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 609000.00
m
$ -
$ 4,301.00
Plumbing Fee
$ 90.00
Gas Fee 100 comm.
$ 100.00
Electrical Fee
$ 90.00
Total fees collected
$ 4,581.00
27 Abby Lane
085-14 on 7/25113
remove deck and screen porch and r place with new
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ABBYLANE
L::�-�
LOT4
EEXISTING DWELLING
#27 ABBY LANE
X
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IS
7
'n
A
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BBD
YWELLING
LANE
— D
PROPOSE
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P P S --o
PROPOSED .1
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STAIRS
PROPOSED ADDITION
""OPOSEDADDITION
T-1-1
CLIENT CHRIS KING
LOCATION: LOT 4 ABBY LANE, NO.ANDOVERMA.
DATE. -6125113 SCALE:1�--40'
1�
-��AOFA44
MICHA L 0
J.
SERGI m
0
No.331 91
SS0
UR'Jei
PROFESSIONAL ENGINEERS & LAND SURVEYORS
CHRISTIANSEN& SERGI, INC.
160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830
WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX. 978-372-3960
Pictornetry Online
Page I of I
27 Abby Lane
Print Date: 06/11/2013
Image Date:04/03/2012
Level: Neighborhood
http://Pol.pictometry.comlen-uslapplprint.php?title=27%2OAbby%2OLane&date—fmt=mldl... 6/11/2013
The Commonwealth of Massachusetts
Department of IndustrialAccidints
F
Office of Investigations
600 Washington Street
Boston, MA 02111
quo www.mass.gov1d1a
Workers' Compensation Insurance Affidavit:- Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legib
Name (Business/Organization/Individual)
k,ln
Address: Lei
City/State/Zip:. CVV"— Phone#:
w A� p ,
Are you an employer? Check the appropriate box:
1. U I am a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a solo proprietor or partner-
listed on the attached sheet. I
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3. U/I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), andwehaveno
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F1 Now construction
7. E] Remodeling
8. F1 Demolition
9. R-iluilding addition
10. El Electrical repairs or additions
11. El Plumbing repairs or additions
12T] Roof repairs
13. F! Other
*Any applicant that checks box R must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they aie 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 the name of the sub -contractors and their workers' comp. policy information.
Iam an employer that isproviding workers'compensaflon insurancefor my employees. Below isthepolicy andjob site
Information.
Insurance Company Name;
Policy # or Self -ins. Lic. 9:
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 certto U. epains agilpenalties ofperjury that the information provided above is true and correct.
Simature: ?�� 4<4� Date: (,.;, / �� I I OD
Offt"cial use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract of hire,
express or implied, oral or written."
An em
ployeiis defitied as "an individual, partnership, association, corporation 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
I
owner of a dwelling house havingnot mo 'th�h tl�r;e apaRm&nt_s and who7l6ides'therain, or the occupant of the
rs
dwelling house of another who employs persons tc� do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because' of suc'h employmAt be deemed to be an employer."
MGL chapter 152, §25C(6) also states that 'every state or local I.icensing agency shall withhold ih c issuance or
renewal of a license or permit to operate abusiness or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage requ ; ired."
Additionally, MGL chapter 15 2*, §25C(7) states "Neither the commonwealthnor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s).name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that thei application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address"' the applicant should write "all locations in -(City or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is'on file for fature 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 commerc"ial venture
(i.e, a dog license or p ermit 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. ,I
The Department's address' te'le'jhone"a�nd fax number:
Tho Commonwealth of Mas' -sac _,,'bitts
Department of Industrial �,ccidents
Office of Investigations
600 Washington Strea
Boston, MA 02111
Tel, # 617-727-4900 ext 406 or 1-877rMASS
AFE
Revised 5-26-05 Fay,# 617-727-7749
__wwwmass,gov1dia
TO" OF NORTH ANDovFR
OFFICE op
BTUDYNG iDFPARTMENT
:1-60D Dskoad Str-eet Buflding 202 -SWte 2-:36
' North And0vcr, Massachusett8 01845
Gerald A. Brown.
Telephone (978) 698-9545
inspector of BL Ukdings
(978) 688-9542
140MWVNER-L1--QENSE EMM
fp fjoN
BUIDING -PF-RMT APPLICATI-o-v
Beaseprint
DATE.
JOB LOCATON.-
Map/Lot
IMMOWNEP, Ck
e Phone
—om
WorkFhone
PRESENT MAILING ADDRESS
-TLIVn
a.v
state
—9�lp Code
The current exemption for "homeown
ers- was extended to inchide owner-occdpie
10 allow subli homp-0y."Mers to C-12gage an in6ividu d d"vell"Igs to two units -or I ess and
acts a, supervisor). a"for hire Vb�O CIOCS Rot possess a license, provided that the ow:ar
StateDulfiding (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
-Pers0n(s) who
-9w,us a parcel of land on which he/she resiaes or intends to reside, on which there is,
be, a one or two faI M -1Y Stuctures. A person who constlucts mor that, ho Or is intended to
considered a homeowner. e one me in atwo-yearperi6d shall notbe
The 11ndersigned "homcdwntr-
assumes responsibilitYfOT Compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeownej,, cert
Ifies that lic/slic-,
mininaurn inspection procedures an I understands the Town of North AndoverBuilding Dep
d1requirem"p- artment
requirements, d that he/she �wvill comply with,said procedures and
110MEOVIN)ERS SIGNATUR E
APPRoVAL OP l3UlLDlNG0F.PjCjkL
Pevised 7.2009
Po— 1401—ownETs Exemptim
BOARD OF APPRAU 688-9341 CONSERVA-00N 688-9530 HEALTH 698-9540 FLAMM 689-953i
LANE
LOT 4
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MW. FROMUC-C om Jog -
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AOUNDATION LOCAZION MAN
r-' MMM ANDOVER RF_4LTy
'M'57 CERI"VXAMW IS MADE AND U*rreo
W ZMC AWVr CLoff.
LQ—"4TJ0N-- 27 ANVY L&H. NOM AWOOVO�
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PROPOSED POOL LOCATION
CUENT: CHRISTOPHER KING -
ZONING DISTRICT R-2
MIN. AREA = 21,780 S.F.
MIN. LOT WIDTH 100'
MIN. FRONTAGE 100'
MIN. FRONT SETBACK = 20'
MIN. SIDE SETBACK* 20'
MIN. REAR SETBACK 20'
THE STRUCTURE 14AY BE PLACED
UPON A SIDE LOT LINE WITHOUT A SIDE
SETBACK, PROVIDED THAT THE ADJACENT LOT
TO WHICH THE ZERO SETBACK IS LOCATED
HAS THE REQUIRED SIDE YARD SETBACK.)
THIS CERTIFICATION IS MADE AND LIMITED
TO THE ABOVE CLIENT.
LOCATION: 27 ABBY LANE, NORTH ANDOVER
SCALE: I " = 60' DA TE: 416110
CHRISTIANSENSERGI PROFFSSIONAI ENGINEERS
LAND SURVEYORS
160 SUMMER ST. HAVERHILLMA. 01830 TEL. 978-373-03FO
@2010 BY CHRISTIANSEN & SERGI INC.
"OFA4,q
MICHAEL
J.
SERGI rn
C, --1
No.33191 I
co
sslo
"'Z)SURVO
DRAWING NO. 97066010 1
Date..... ..... ....... .. ...............
TOWN OF NORTH ANDOVER ,
-PERMIT FOR WIRING
This certifies that L q or,,� tri � u, �l yAj
.....................................................................................................................
has permission to perforin ..... ....... ...
.............................................
wilring in the building of .......... ki..� . . ...............................................................................
at ............. 2-j orth Andover, M
..........................................................................................
ree
.... Lic. No.7!��J!10).r�
INSPECTOR
Check # 66� -
118 C." 0 � e C)F- 14 vl-�. I 111;- 1(3
OffidalUseOnly
Commonwealth of Massachusetts
4% Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] Geaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRI(;AL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 12.00
(PLEA SE PR17VT IN HK OR TYPE A LL I NFOR M-4 TION) Date: 7eA; � 7 i
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 2—'7 I -Q �C4
Owner or Tenant Cker/ 4> � -1,, " 7 / Telephone No.
Owner's Address
Is this permit in'conjunction wivil a building permit? Yes fff No El (Check Appropriate ]Box)
Purpose of Building_ a ofoff-7,10 r--, Utility Authorization No.
Existing Service')O 10 Amps 2L,' Z �6Volts OverheadEl Undgrd E' No. of Meters
New Service Amps Volts OverheadEl Undgrd El No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Onmnfptinn nfth,, fn7h?whia M91P mau he waived hv the In -vector of Wires.
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
No. of To-tal
Transformers KVA
No. of Luminaire Outlets 67
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above [j In-
Swimming Pool grnd. grad. El
N o,- of Emergency Lighting
BaUtery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS I
No. of Zones
No. of Switches
No. of G2s Burners
No. of Detection nud
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat]Pump
Totals:
I.KW ... . ......
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
-1 Municipal F1 Other
Local El Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
No. of No. of
Data Wiring:
Heaters
signs Ballasts
. No. of Devices or Equivalent
No. Hydrom2ssage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
10. THER:
1 9 Atiach additional detail i(desired or as required by the Inspector of Wires.
Estimated Value of 1317ctrtgel Work: (When required by municipal policy.)
WWk to Start: 3 Inspections to be requested in accordance with NMC Rule 10, and uponc'ompletion-
INSURANCE COVERAGE: Unless waived b� the owner, no permit for the perforniance, of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operatiorf 'coverage or its substantial equivalent. The
undersigned certifies that such c9v5age is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE 9 BOND F1 OTBER El (Specify:)
I certi plete.
fy,undetthepainsandpenalt' !f. gerjury, thatthe information on this application is true and com
Lic. No.: -2,bLIM17
FIRM NAME:
Licensee: beerja,d Signature- LIC. NO.:
(Ifapplicable-unter "exempt" in the license number li" Bus.Tel.No.-
Address: 39- 1414)U, Alt. Tel. No.: -
Ver M.G.L c. 147, s. 51-61, security work requires Departmeirt of Public Safety "S', License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by la -w. By my signature below, I hereby waive this requirement. I am the (check on,,) n owner [I owner's agent.
Owner/Agent
Signature Telephone No. Ept:i��iFEE.-$
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, mid applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3 L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
El The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
• Rule 8 — Permit/Date Closed: Note: Reapply for new permit El
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed Id
Re- inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass n?
Failed M
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTILAL ROUGH INSPECTION:
Pass n?
Failed IN
Re- Iffspection Required 0
Inspectors Comments.,
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass F?1 V
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
,7
Date:
FINAL INSPECT,16N:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments�,�
A-
4
A
Inspectors Signalre:
—V
Date:
DEBWEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusetts
Department oflndustriqlAccld�izts
Office of Invesfigations
600 Washington Street
Boston, MA 02111
if wwwmass.govIdia
Workers' Compensation Insurance Affidavit: Buuders/ContractorsfFle,etricians/Plumbers
Applicant Information Please Print Legib
NaMe (Business/Organization/Individual):_
Address:
City/State/Zip: q ICA) 0-, In,4 Or-� 5 0 Phone q-7 -C;1/ 6
Are you an employer2 Check the appropriate box- -
Typo of project (required):
I - D I am a employer with
4. El I am a general contractor and 1
6. E] New coqstruction
(fall and/or part-time).*
have ned the sub -contractors
listed on the attached shoot. I
7. Remodeling
2. Prmployees
i am a sole proprietor or partner-
ship and'have no employees.
These sub -contractors have
8. Mmolitioa
working for me in any capacity.
workers' comp. insurance.
I
9. Building addition
[No workers' comp. insurance
5. DWe are a corporation and its
lo.p9loctrical repairs or additions
r quked.]
1 am a homeowner doing all work
3. [1e
officers have exercised their
right of exemption per MOL
I QJ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, §1(4), andwebavano
12.E] Roofrepairs
insurance required.) t
employees. [No workers'
13. Fi Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensation policy information.
i Homeowners who submit this affidavit indicating they Ere doing all work and then hire outside contractors must submit allow affidavit indicating such.
tantractors that check this box must affached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
.Taman employer that isprovi(fing workers'compensation insuranceformy employees. Below isthepollcy andjobsite
information.
Insurance Company N
Policy # or Self -ins. Lie. ExpirationDate.
Job Site Address: 7 b Pity/State/Zip:
Attach a copy of theworkers' compensation policy ileclaration page (showing the policy number and expiration date).
Faihiro)to secure coverage, as requiredunder Section 25A of`MGL o. 152 can lead to the imposition of criminal penalties of a
fme u� to $1,500.00 and/or oner-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 fonvardedto the Office of
Invesftations of the DIA for insurance coverage verification.
Idoh erebycert!ly?y derthepainVsanad nalties ofperjury that the informationprovided above is t eandcorrect
Date:
Official use only. Do not write in this area, to be completedby city ortown official
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactPerson: Phone
Information and Instruction -_8
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 employeiis defined as "an individual, partnership, association, corporation 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 be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or lo'cal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to constiruct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage requ.1red."
Additionally, MGL chapter 152', §25C(7) states "Nuithertho 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 fin out the workers, compensation affidavit completely, by chocking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone nutriber(s) along with their cortificate(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 anLLC orLLP does have
employees, a policy is. required. De 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.retumedto the city or town that thie 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. Solf-iusured companies should enter their
seY-itisuranco license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printchogibly. Thu 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
Pleas.e 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 pernrit/license applications'Mi any given year, need only.'submit one affidavit indicating current
Policy information (ifneoessary) and under "Job Site Addross7' . 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 ii on file for future permits or licenses. Anew affidavit must be filled out each
year. More a homeowner or citizen is obtaining a license or*pormit not related to any business or comm ercial venture
(i.e. a dog license or �ermit 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 Comm n
0 m-alt1l of M@.ssa
,r�h-v
Depaxtment oUndustrial Accidents
Office of luvestigations
600 Wkaington, sfm�t
BomnMA02111
Tol, # 617-727,4900 ext 40 6 or 1 -877 -MASS
-A FF,
Revised 5-26-05 Fay, W 617-727-7749
0
P�
l:0);:..COMMONW LTH OF MASSACHUSETTS'
C N
ld..EtE:CTRI IOS:
-,ISSUES THF FOLLO WING LitENSC A.S., V
rIT
L E C -T
fi..ISTRED M.A..STED,,..-.. VC
LiEON I ARD P SULLIVAN I I I
lz
39 MAGNAVISTA DR.-
-:;:7AA 01
.-A AV E R H 11 L. 830-2.28
0 6801
20 1 *1
5
2 1) 0 C, 17
D ri G -1 11 a P
nq ne c r no Phone 978,465,6436
-ix Line 978.465,5160
Daniel%L. Geliras P.E. FL
579A N orth End Blvd.
Salisbj zy,MA 01952-1738 email darilgelinas@,adel 1-�ia.net
J..P
September 28, 2006
Carroll Construction
jim Carroll
cell 978.479.2776
Mand Road fax 978,475.0942
163 HiRl
Andover, MA 0 18 10
phone 979-623,3386
SUBJECT. Lo 7 Abby Lane North AndOIMT
Dear.Mr. Carroll:
As Per Sile Observation on Wednesday, September 27,21006, The Framing was as is on Dra In's d
an
conforms to Massachusetts Bldldiva Code.
Plewe �;all. all with zaiy ques-tions.
ZI
�Ter)! truly yo tirs;
Daniel T- Gelinas, P.E.
ty
J lcftcr rrport 27 AbLy Ln N A-rdovcr.do�
A�
1%.
9466 Date...
... .... ... 6 .. ...... ..
'40
0 TOWN OF NORTH ANDOVER
.0 PERMIT FOR WIRING
CMU5
This certifies that ........ ; //.. -1.!2
........... Z.7 .......................
has permission to perform fflzf ...... ......
wiring in the building of ..... -7 . ....................................
at ........ ..... .. .................. . dovel ass.
............ Nort
Lic
,�LE I L i��PECM
Check # 3
61
11
C0 mmonwealth of Massachusetts umcial Use Only
Department of Fire Services Permi,No.
I
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Fev.- 1/07]
(le e blank�
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL"
7 WORK
All work to be performed in accordance with the Massachusetts Electical Code (biE
(PLE,4SEPMTflVM oR TYPE Aa fl�rFORM_4TJOA9 Date: 1� . 5 52,7 -CMR 12.00
— 6, 3,11d
City or Town of. NORTH ANDOVER To the Inspector of Wi
By this application the undersigned gives no e of hi res:
Location (Street & Nurnber) 01 J perform the electrical work described below.
Owner or Tenant
(4 Telephone No.
Owner's Address 2-7 e / CA IA
Is this permit in conjunction w a building permit? Yes R�' No
Purpose of Buildi�g <I " 1i (Check Appropriate Box)
E3isting Service 3!22_ Amps (20 /2t,�IOVolts Utility Authorization No.
New —Service Amps Overhead Undgrd 2— No. of Meters
_____�_Volts Overhead Undgrd El No. of Meters
Number of Feeders and. Ampacity
Location and Nature of Proposed Electrical Work. 71 C4 14%,_
7—.
A
No- of Recessed Luminaires
the ^ollowin
No. of CeiL-Susp. (Paddle) Fans
table may be wa
No. of Ltuninaire Ou dets
No. of Hot Tubs
0
TranSffirmpre T,"Y,
No. of Luminaires
001 Aboy in
swimming p El
G�ner*rs KVA
17,
1101, 1!111 1 9
1111 tir i�� 1 ig
No. of ReceDtacle Outlets Id
gmd. d.
ers
atte Units
No. of Switches
FIRE ALARTVIS Ne. of Zones
i
No. of Gas Burners
No..of Detec i n and
No. of Ranges
No. of Air Cond. otal
IDitiatin Devices
No. of Waste Disposers
Tons
eat Pump
No. of Alerting Devices
. .... .... . .... , , �
No. Of Dishwashers
Total—
�, � ��
i't! ff. ( - —1 1111 11 E 11 ��
Detection/Aler ' g Devices
tin
Space/Area Heating KW
ocal [I Mum i al
ElOther
No. of Dryers
Heating Appliances KW
Conn tion
Security S te
0. of ater
Heaters KW
No. of
No. of Devices or Equivalent
S1 s Ba sts
Data Wiring:
No. of Motors To HP
No. of Devirm nr
uzvuulu��Uuj�auon W -
S wing:
OTRER:
XT
11—ces or Equivalent
Estimated Value % Flecirical Work: e2 76� 00 Attach additional detail if desired, or as required by the Inspe ______J
Work to Start b, 0 . — . (when requimd by municipal policy.) Ctor of Wires.
I-J-Z�_ Inspections tIO be requested in accordance with MEC Rule 10, and upon completion.
INSURANCf COVERAGE: Unless waived by the owner, no permit for the Pefformance 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 Jtr_'�OND [I OTHER 0 (Specify:)
I certify, under thq Pains an penalties ofperiury, that the informado
FERMNA'.LMEE: �edAdx, V 00 cl� I !6c -n n on this application is true and coTplete-
Licensee: LIC. NO.:
(If applica Signature
ble,'6nter "exempt " in the license number line.) LIC. NO.:
Address: Bus. Tel. No_V-��'7�,6
'Fer M.G.L c. 147, 8' 57-6 1, securi work requires Dep Alt. Tel. No.:
3-) A,- ver ILI 14
artrnent of Public Safety "S" Licen—se: Lic. No.
VNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coveragt normay
ON
required by law. By my Signature below, I hereby waive this requirern
Owner/Aggent ent. I am the (check one) 0 owner [I owner�s agent —
Signature Telephone No.
&- /,0.- 1-0 P -A7
�o - � .-- /,� Al
41
v
I
ne CommOnweizith ofAlassachusetty
Department of _rnduslrial Accidents
officc Of Irn reszigarions
.600 Kasizin6aton Street
B0ST0Pz,,M,102111
WWW.iftzzSS.g0V1dia
Workers' Compensation Insurance AjTldavit: Rudlders/COntractors/Electricij
x3ficant Tnfny-mai�__
------------
Name (Business/organization/ldi,�idml):_ I
Ad&ess: �2 0 A"',
City/S�ate/Zip:. MCI 0 Iq ?C)
Pbone#:_ � 2�>i;q 9 r/ 5 11 - K��l
Are you am empioyer? Check the appropriate box - :
1 am a =PloYer with
-part-time).
4.7 1 am a o, contractor
employees (full and/or
2. 1 am a sole
general and I
have hired the sub -contractors
proprietor or partacr-
ship and have no emplovCcs
listcd oil the attached sheet I
w0rldng for me in any capacity.
Th" -se sub�-Mntractors have
workers' COMP. insurance,
[No work=' comp. insurance
We are a corporation
required-]
am a homeowner doing all
and its
officers have -exercised their
work
myself. [No workers' comp.
ri�gt of -exemption per MC
- TL
c. 152, 61(4),. and we have no
insurance required-] t
employees. [No workers'
comp. inaur-,
Type of project (required):
6- New constructin
7. R=odzh,,,
8. Demolition
9. Building addition
Electrical repairs or additions
I -ED Plumbing repairs or additions
12.[] Roof repairs
13.7 Other
�PPli _U_J
- —t that checla� box must alo a, no
1 Homeown=
e!_v� _0. w M4,
who submit this affidavit indicatin C:o
th", at d_;_ -anditil=hmoutsi M--�,"mP---,c,.=:5a—_-zorL
2Cont.crtors thatch=k this box mun ._�. - --9 all work d, ll;u_-t
an additional sheet showin., the submit a new affidavit indizatin.g such.
am an Mployer th4g - - name of the su1D'-cGaU7aCTM and their woTk=' comt- DOii � information.
infornurgioyL 'SProv'dEn�- workers' cOmpensaxiolz
'n'"rancefor mj' cmPloyees� Below' is thepOliCy andjob site
Insurance Company Name:
Policy # or Self -ins. Lic.
Expiration Date:
------------
Job Sit� Address:
Attach a copy of the workers' compensation policy declaration p e City/state�zip:
a (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL C. 152 ran lead to the m2position of criminal pertalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as r-ivil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a cDpy of this stat-ement may be forwarded to the Office of
Investigations of the DIA for misurance covel-age verification.
I do herchY cerdfi, under the pawAfidpendfies ofp,
erJ4*r"h4r`t the information provided above 7e and correct-
Si!znaturc P7 K7
-
Ph e #: 6
Official use oldy. Do not write ij7 this area, to be completed bj, ci"J, Or town officiaL
City or Town: 1ermitucense #
S -R9 Authority (circie one):
1. Board of Health 2. Building Department 3. Citv�TOWIU Clerk 4. Electrical Inspector �z. plumbir,
6. Other Inspector
Contact Per&39n:
lDhone #:
✓ ��
i �
/��
/ � V
R
M
r
Date ........ ......
... .. ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
A U
This certifies that ....... 44�V�4b ............ 5ZIZ I— f I
............................................
has permission to perform .. Y, '45 7- z /,q:�� ...........................
............................
wiring in the building of .................. .................................
at ..... ...................................... . Northfiodover, Mass.
Fee. Lic. No. ................
ELEcrRICAL 9NSP'EC,-T0R
Check #
"cr-wsamusetts
011,y
Department of Fire Services -permit No. 01,67
OccuPancy and Fee Ch:ecked.
BOARD 0 . F FIRE PREVENTION REGULATIONS 3
v. 1/07]
L[P-eVC7
(leave blank
J__
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordnce with
MECK,-527 CMR 12.00
PEALL WORAL4TJON) Date:
(PLEASE PPW N EX OR TY the Mnss=husefts Electrical Code
City or Town of. NORTH ANDOv]Ep
By this application the undersigned gives ..Tothe nspectoroffires-
notice Of his or he, ���on �Op,,&,
Location (street &,�Nuxnber) electrical work, descn*bed below.
Owner or Tenant ale r
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes D No J��
Purpose of Building (Check Appropriate Box)
.E -listing Service Utility Authorization No.
4 Ove�head I])', '1Undgrd'2-'-
ew Service Amps
No.'of Meters
Number Of Feeders and Ampacity ---L—VO .1ts -Overhead 11 Udg-rd No. of Meters
Location and Nature of -proposed Electrical Work.
e117
5WIITC�e 0 V/-
No.� of �Recess
sed Luminaires
es
N 0 of
o. of Lmminaire Outlets
a. of Lurninlires
JNo- of Receptacle Outlets /
r of-�:=
o:
No. of
a. of Waste Disposers
o. of Dishwashers
of Dryers
Heaters- KW
[N!atl�lydromassage Bathtubs
of CeL-Susp. (p —
addle)-Fam
of Hot Tubs
wimnAng pcb.1 "ove
�d-
0. of Oil Bu,imers
a. of Gas Burners
Ud. ot',
a. Of 7C...4 ��
'Area Reating KW —
.9 AppHances 1CW
1,40.01
Ba&ft,
'No.of Motorn
a, of M
�I �� Total E[�P
7 7y
� table may be wa
E, �'.. 6 ived thel�ector of Rres,
f
A 0. 0 To
Transformers KVA
Generators KVA
ttel; I ung
FUM No.�o Zones
0. of etectioll and
Initia , Devic
'40, of Alerting Devices
0. of S -Contained
)etection/Alerfi-
;-----_MDe-Aces
,ocal E] Mumc'PRI
Connection 0 Other,
�ecuntY Systems:*
. No. of Devic t
�ata Wiring..
No. of Devices or E uivaleut
elecomm . ca"
No. of
— ces or Enivivni^-+
. .. . .. .... ...... .. ...
Estimated Value Of Electrical Work: / 00 0 0 a
I , 1 if desired, or as required bY the Inspector of w,=.
Work to start, o�/,4Y., S,- (When required by municipal policy.)
INSUp Inspections to be requested in accordance with IVSC R
CE COVERAGE: Unless waived by the o ule 10, and upon completion.
wneT, no Permit for the performan,, of
the lic=sw Provides Proof of liability insurance includin - electrical work may issue.uniess
9 cOmp.leted OPer-ation"' coverage or its substantial
und='gn'd certffles th& sucb C�0�e is in force, and has
CHECK ONE: ImSURANCE =hib��d proof of same to the permit iss g o 'qui'Oent T!he
i!f BOND E] OTHER C] (Spe Uin
,c�) frice.,
rce7wfy, underthe pains andpenaides ofp_jury, tjjat the in
f
FnM NAMM: , t&mald to _$Zt Or7nation on dzis aMlication is true and complete
LIC. NO.:
(If applicable, ter in the lice S dftl--
uj7zbr-r line.) ------------------- Z=:=-_ LIC. No.:
Address: 3 Rf' 5 7er/ 1 tordl? 1 %, - Bus. Tel. N
*P= M -GI c. 147, s. 57-61, security wo "ki
rk reauire Deparrment pu c AIL TeL No.:
O'VirNEIVS ]INSURANCE WAr-17ER: I am mxare th Of bli Safety 'IS,, License: Lic. No.
required by law. By MY signature below, at the Licensee does not have the ,ability
Owner/Agent I 1'=by waive ths requirement- lamthe(check..e """"eragenormay
Signature Teleplione No. owner 0 ovmer's a-ent
'�
i
Co�n"Ieaft of Afarsirchuseft
Of Ad=trialA=�,,,,
r
F
Qffwe Of
600 Warhinton S&eet
Bovopl, MA
us
WWW."2a.M&ov
Workers, cOMPermation Idia
A, Ji lmhranee AHidavit: JarLiWers/Con
k kant rnformation b-aetorsm
ecticians/Plumbers
Please Prr't Lt-bh
Nain:e.fBcsi.n=sVOrP�iza6ar�4ndividuW), lewllan�
Addmss:' 9c3
- - --------------------- A -
CilyStae/zip. Me -A—eN 1-m4
. . - ' "-- , "
Are 0
0 qcl
" - A
Phone 7c
--------
y en'
you an e1M*YW? Check the app, -
'A Y ar' Cite ck e approp�
Mprmte,bo=
arn
I Eim a arnployer
7
with
;MP 'o .
iOYem (fig or pa� tttnc
2 . 7
2. 21, aTMn..asole
e�
4,
4.7 1 arn jL g==.al r Type -of Project (required):
onrraaor and I
have: hirted the stio- 6. 0 New constructim
0011buctors -
c'or
proprietor or partner.
or p =2�
shi e
ship and have no employees
no
On the aftched shcc�L 7.0 Remode
7be= su&contractm have . I ling
W n M
working for me in any capacity,
e any cap=v,
0 Wo
[No Workers, cOMP. fimranc'e
. cornp. �cc
workem, co Dernoiftion,
Mp. Msurance.
S.
S. M W -e a corporation 9. Building addition
req
required.]
3. El ah M . -
3 0 1
'aiR a homeowner doing
M �"
and its
offio=s have e,x=cked their Ia. Electricaj MPaim or
all work
7 W crl�
It
se N or"crs
!Myselc. [No -work=' comp.
7 7� P.
insurance
11surance
right of additions
'exernM1011 Per MCIL Plumbing Tzpaim or addition,
1(4) *and we have
required.]
no koof
-OMPloyeer, Wo workers! rep aim
*AnyftPPh=t1harch `0TnP- insurarice roquirej) 13-0.0ther
t Romeo caks bm:,# I Mog' Rig') fffl out the =cmor[ below ghowing thcir workat, 66mPoosatifi
—ft who itir this affW"it _idim2iog
4C4MUUftM &fft ch -k ai5'bo;c dwd - addifionai sh=rsh.,,,g Policy informofiom
they an domg all w0tk and thm him,outs
"IL"IMM
61c M1M* of fim b-cunnj='tM ftluSt sUbmit A RCW Mffidatit indica* suck
M god th*
am an emp4w &az_iS.PrVVkfinr:W0r1,=P work= I =mp� Policy infumaon.
infOrMado,L "Pt"J2.,62swuncefor im. Mrlaye=
I---
i,. AePOficy zoadjob sh,
pany Narne:
Policy g, Or Self -ins. Lic. P
F.�.iraii� n__
Job Sift Address.* --------- —
C.
Attach a copy of the Workerst,cont
Pensidion P*liy decl�ration p1tv
.e (Showing
the Por
FMIUM to secure coveme HA JMY 111hera e
fine- up to $I required undw Section 25A of'MGL r ad Xpi
�50UO and/or one, -year im 152 can lead tD the imposition If C73*
Of UP to S250M a day gait&,the viol prmonment, as well as civil penalties in t1te form of Mnal peral�= of a
Investigations of tii, ator- Be advised that a copy of tWs statetnent a S7"P 'VC)P-K C)P-DER Md a fine
e DIA fbr irmnance coveTup verf
cation. Mly be fOrward'd to the
office of
I I I do Amby
— �CVVVMY n da
Si MMIM
Lh, , e 4�.- (
the and
of P-dary J*ar ax informadon pro
qded aiwve ts fte
Md corram
L00 S/
Date- 40�/
z---------
Dv not
are4, 6,be conplated 0 city or town 0
City or Town:
Lqsuing Authority (circle one): Permit/License
6. Other -fiafth 2- lau'klin nePurtment 3. C
I Sun rd of 'WTOwn Cierk 4- Electrical Ing
Pector S. Plumbing inspector
Contact Person:
phone#..
Inf6mation a nd Instructions
Massachusetts Genemi Laws chapter 152 requires all empo loyers to provide workers' compensafion for their employees.
Pursuant to this stattitt, an employee. is defined as "...cvcry person in the =rvilce of another under any cont:ract oftirt,
express or impiied,.Dral or wrimmm"
An employer is defined as "an individual., pwtnership, am<nciation, corporation or other legal entity, or any two or more
oftht'foregoing engaged in a joint anbm-prist, and includirig the legal rmp=crTtativ= of a deccasad employer, or the
re=iver or tuste—e-of an individuaLpartneirship, associatialn,: or other legal entity, empi0yingerpi0yees. *Howevzrthe
owner. of a dwelling house having not more thah -three apaxtrntrits and who resides thereirt, or . the occupant of the
dwelling house of another who employs pemns to do mu-iTilanance-, construction or ' wciik on such dweliing-houst
repar
or on the gmunds: or building aWurtenerxt themto shaU not because of sucb employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states *W "every state %ir local fiediving agency shall withhold the issuance or
renewal of a license or permit to operate a busless or ite construct buildings in the commion.wealth for any
appricant who has �ot produced acceptable avidenee.t4'empliance with the insumneeeoverage mquired."
AdditiDnak.- MOL chapter 152, §25C(7) states "Noifficr tbc cornmonwealth-nor any of its -political subdivisions Shan
ente, ftrto any contract far the perhormence of public wMic until-acceptabic mviLen= of cornpli ` with the i '
]H= nsumce
requirements of this chapter have been presented to the carlbmnting authority."
Applicants
Pless fill out the workers' compciisadmn. affidavit complem-tely, by checking the bw= that apply to your situation and, if
necessary, supply sub-contradzir(s) narne(s� address(es) amd phone ntanber(s) along with tmir certificate(s)'of
insumm Limited Liability Companies .(LLC) or Limited Liability Partnerships (LLP) with no employees other than the
membars or partners, are not-mquimd to carrY workem' c4nkrripensation insurance. If an LLC or LLF does have
employ=, a policy is =qi&cd. Be ad:vised fi= this afficlavit.may be Submitted to the Depeatmed of 1ndustrW
Acciderits for wrifirmation of insurance covarzge. Also'he sum to sign and date the affideviL The affidavit should
be re==d to the city. or town that the application for the painift or licartse is being requested, nort"the Department of
Industrial Arcidents. Should you hm E;�y quesdons regar-ding the law or if youart requimd to obtain a workcrs�
ooMpensation polioy,plunse-ca.11 the Department at the nuwnbcr. listed below, Salf-insurcd cougmies should entcrtheir
aUMOCT on tho*RpWopriate 41H*=
City or Town Officials
Piz= be sure that the affidavit is complete and printe-d legibly. T6 Department his provided'a space at the bothin
of the: afficlavtt for you to fill out in the event the Office of Investiptions; has to con= you regarding the applicarrL
Plem be sure to fill in the permit/liccrise number which %%-M bt used as a reference number. In addition, an applicant
tkw. must sai5mit multiple.Permit/license applialtions in any given year, need only submit one -affidavit indicating,cUrrent
policyinformafion (if necessary) and under "Job Site. Addre=- the applicant sho
uld write 'Idll locations in city or
tDwn)." A copy of -be affidavit that has bczio 0MCiallY Stamped or marked by the city' town ffW be provided to the
I or
applicarit as proof that a valid affi- davit is on file for fiMm - permits or licerism A new affidavit must be Med out
each
year. When a home owner or citizen i's obtaining a license or permit not related, to any businem or commercial venture
dog license or pemit to burn leaves atc.) smd persim_. 'is NOT required to-,camplcte this affidtvit
Tbc Offim of Investigations would I&z to ffimk ymu in ad-Vanct fur Your coopbration and should
picam do no I t. hesitate to give us a call.. you have any questi I ons,
The Dcpmtrnant's address, telephone anct fax nuinbzr.
The CQmm0T1wC:EL1th of Massachusetts
Dcparftmiat of Industdal Ac6d=ts
Offim of'- tweatigrations
600 Washington St�:�
MA 0211 *1
TeL 4 617-7274900 6x -t 406 or 1-977-M.ASSAFE
P_-viscd 5-26-05 Fax,* 61 7-727-77449�
wwwznass.gov/dia
0
Date .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
S CHUS
This certifies that ........ h�A/ .... ..............................
has permission to perf I orm .......... A ... ... V .... /-/
wiring in the building of ...... ...... ........................
at ...... A.7 .... ?W. c,/ .... ................................ . North Andover, Mass.
Fee.?U ........ Lic. No.,,
..........................
Check# ELEcrRICAL INsPEc-ro
6962
C
Commonwealth of Massachusetts Offlcial Use Only
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/051
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Codq (MEQ, 527 CMR 12.00
(PLEASE PRINT.IN. INK OR TYPE ALL JNF-ORM,4 TION) Date: 4 —0 6-
\' \ '�' 4,, 1, r
City or Town of-. To the Inspector of Wires.,
By this application the undersigned gives notice of his her intention to perform the electrical worK described below.
Location (Street & Number) 1-9 � M 4 01 W - -0'Y2-7
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a b ilding permit? Y I es No F-1 (Cheek'Appropriate Box)
Purpose of Building_A/��w = Utility Authorization No.
Existing Service Amps Volts
New Service cr
Amps 1-2VO Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead F�, - Yndgrdj-�
Overhead 0 Undgrd ��
N6.,of Meters
No. of Meters
Completion of thefollowing ble n7av be vvaived by the In ector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets 70
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above n In-
Swimming Pool grnd. grnd.
[No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets //6 b
No. of Oil Burners
FIRE ALARMS
JNo. of Zones
No. of Switches A/V
No. of Gas Burners I--
No. of Detection and
Initiating Devices
No. of Ranges
ToFal—
No. of Air Cond. Tons
—
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
umber
Ton
N"o—.of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
_] Municip
F ? 1 0 Other
Local Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Felecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: 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 [I BOND [] OTHERE] (Specify:) I
1 cert�ry, under the pains andpenalties oj�,erjury, that the information 00 t1isapplicatin
is true and complete.
FIRM NAM 0.3 -P 5� -2-
;E:d
�� c/) I' (�'41 , 6 ��l . LIC. NO
Licensee e.#v bl,d C,&Z/"3 Signature LIC.NO.03f-9Z-
(If applicable, enter "exem t " in the license numbe line.) Bus. Tel. No.: I/
Address: 10 "n ? Alt. Tel. No.:
*Security System Contractor License required for this work; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [:] owner E] owner's agrent
Owner/Agent JV
Signature Telephone No. FPERAHT FEE.- $
0 q., VA
SACHUS
TOWN OF NO
PERMIT
Date 73. �' - /?- - eo- -
ANDOVER
R PLUMBING
This certifies that / ...................
has permission to perform ... ................
plumbing in the buildings of . ( .................
at. . . 2- :7. . '047 � ............... I Nor-th Andover, Mass.
10 -
Fee. Lic. No. . ....... . . * ' ' ' --11% �- -------
P'L M BING INSPECAOR
Check# 3,31 3
7120
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLU�MBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Buildin., Location �Ulylm3e- - OwnersName CA't'Qu Date P ->L -OL
Q Permit It—
Type Of Occupancy Amount S-A� -2. --
Now 121 Renovation Replacement 1:1 Plans Stibmitted Yes 13 No
VTV9rTT,niry
(Frint or type)
Installing Company Name CDrA(--o
Check one: Certificate
ElCorp.
Partner.
Firrn/Co.
.Name of Licensed Plumber:
Insurance Coverage: Indicate—the type of inSUrance coverage
0 by checking the appropriate box:
Liability insurance policy E3 Other type of indemnity E3 Bond
n
Insurance Waiver: 1, the Undersigned, have been made aware that the licensee of this application dces not have any one ofthe above
three insurance
Signature Owner Agent
I hereby certify 1hat :ill of the details and information I have SUbmitted wir cntored) in abovc.,tppjic�jtiojj are true and 'ICCLJratc� to the
i)cst of my knowledge and thUt 'Ill PlUrnbill I I work and installations PC"Formied Linder Permit Issued jor this application will he in
-,ornpliancc with ,ill p,-n-tinent provisiow, ot"the MassachLISCUS State PlLirnbina C()dF and Chapter 142 ot the Gencral
By:
Signature ,1 U"71�uu rjun,57
Title T',Pe
,�f Plumbing License
CityiTown It -4 -�
Eicense 71777776c�r Master TOLIMCklman
U APPROVED (OFFIC-E USF ONLY
40R
0
'3SAcmUS
Date ...
TOWN OF NORTH
PERMIT FOR GAS INSTALLATION
This certifies that
4.<- el
..................
has permission for gas installation tl!� 17 .........
......................
in the buildings of .... (1591A
at
North Andover, Mass.
Fee.lk� Lic. No.. ......
GAsINSPECTOR
Check # '3 3
5733
NIASSACHUSErIS UNEFORMAPPUCATONFORPERWrTODO GAS Frr]nNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
L -P-" Q -
Owner's Name C4"� 11
Now El Renovation Replacement Plans Submitted
Date 6� - -Z-(, -0 (,
-) 3->
Permit #
Amount $
(Print or type) Check one: Certificate Installing Company
C'n", P-0�( —k I\_0
Name cc� F0 1 Corp.
Partner.
Firm/Co
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check onp:
I have a current liability Insurance policy or it's substantial equivalent. Yes [Z] No
If you have checked.yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy n Other type of indemnity 1:1 Bond 0
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 E] Agent El
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 State Gas Code and Chapter 142 of the General Laws.
�h - - , - - I\- — -I -
By:
Title
City/Town
I APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
r--3 Plumber ( I -�S-,!;-
Gas Fitter License Number
Master
r7 Journeyman
CA
Cn
U
�-4
U
z
E-4
Z
0
U
z
U
El
z
0
.4
U
9
0
SUB -B A SEM ENT
B A S E M E N T
IST. F L 0 0 R
2 N D F L 0 0 R
3 R D F L 0 0 R
4 T H F L 0 0 R
5 T H F L 0 0 R
6 T H F L 0 0 R
7 T H F L 0 0 R
8 T H F L 0 0 R
(Print or type) Check one: Certificate Installing Company
C'n", P-0�( —k I\_0
Name cc� F0 1 Corp.
Partner.
Firm/Co
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check onp:
I have a current liability Insurance policy or it's substantial equivalent. Yes [Z] No
If you have checked.yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy n Other type of indemnity 1:1 Bond 0
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 E] Agent El
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 State Gas Code and Chapter 142 of the General Laws.
�h - - , - - I\- — -I -
By:
Title
City/Town
I APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
r--3 Plumber ( I -�S-,!;-
Gas Fitter License Number
Master
r7 Journeyman
Location
No. Date
'A011701 TOWN OF NORTH ANDOVER
0
jffin i �Mj j �& f -
i MPIPMW
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check# t&q-z,
19620 tL4---,
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION 001100*11--! ORT"
, 1. �00
0
Permit NO: Date Received
c c*
c
0
Date Issued: 4�-V'
I IMPORTANT: Applicant must complete all items on this naue I
LOCATION- e -
Print
PROPERTY OWNER Nr)ri-�l AAA nV top P0 A 1.1 V GP
MAP NO.: &6- PARCEL: o)q Print
TYPE AND USE OF BUILDING
L % Y C�
ZONING DISTRICT:
MST0R1C'n1qTR1('T VEQ F1
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
E Addition
)<Alteration
Xone family
U Two or more family
No. of units:
11 Industrial
11 Connnercial
El Repair, replacement
Ll Demolition
El Assessory Bldg
— El Moving (relocation)
L Other
11 Others:
— El Foundation only
I I
DESC iFTI N OF WORK TO BE PREFORMED
]GnAsk Roqgann2r)-4- Lji4k
�Trf
I / 0 Y 5, Q r- T -
Identification Please Type0or Print Clearly)
OWNER: Name: )+14 6;, Phone: 9-�� 557(o U,-?
Address:
CONTRACTOR Name: OLr4 4n&9e2 QeAU�j &hone: ct-18
Address:
%J
Supervisor's Construction License: 35-03 Exp. Date:--7/-ny/07
Home Improvement License: Exp. Date:
ARCHITECT/.ENGINEER Ly�o Name:Phone: !279 GR:?Jt�;'8
Address: -&A),r,, RA , iS �.Aovpo Reg. No.
FEE SCHEDULE: BULDING P,,ERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost S 3-4) xl2.00=FEE:$ W --
Check No.:—/j-y7--- Receipt No.: ( � w-&
Page I of 4
r-
TYPE OF SEWERAGE DISPOSAL
I&/
Tanning/Massage/Body Art
Swimming Pools
Public Sewer
E
Tobacco Sales
Food Packaging/Sales El
Well
Permanent Dumpster on Site El
Private (septic tank, etc.
Electric Meter location to
proj ect
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyjuna
Signature of Agent/Owner "\s cw"� Signature of contractoL�"
- U
Plans Submitted Plans Waived Certified Plot Plan Yamped Plans El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT I,--] J]
[]Water Shed Special Pcrmit
El Site Plan Special Permit
Other
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
n 11
DATE REJECTED
11
DATE APPROVED
11
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer connection/Si2nature & Date Driveway Permit
Temp Dumpster on site yesi no_ Fire Department signature/date
Building Setback ( -)
Front Yard Side Yard Rear Yard
RequireEl Provided Require=dProvides Required Provide
do - I -Sc" , I Iq C;O' 60 E�
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
NUILS and UAIA—
Page 3 of`4
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC. Jart.2006
j
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be
obtained.
Rooring, Siding, Interior Rehabilitation Permits
• Building Permit Application
• Workers Comp Affidavit
• Photo Copy Of H.I.C. And/Or C.S.L. Licenses
• Copy of Contract
• Floor Plan Or Proposed Interior Work
Addition Or Decks
u Building Permit Application
u Surveyed Plot Plan
o Workers Comp, Affidavit
Lj Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
• Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
• Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
Li Building Permit Application
Li Certified Proposed Plot Plan
u . Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
zi Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Copy of Contract
Li Mass check Energy Compliance Report
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the
Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds.
One copy and proof of recording must be submitted with the building application
Doc: INSPECTIONAL SERVICES I)EPARTMENT:BPFORM05
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Work=' Compensation Inm== Affidavit
APPLICANT D�qFQRMATIQN Please PRINT Ledibly.'
Name:
Telephone
1 am, a homeowner performing all work myself.
:3 1 am sole proprietor and have no one working in my capacity
am an employer providing workers' compensation for my
Company Name:
Address:
s working on this job
A + . V 6W
8,? q
City: Telephone
Insurance Co3mp=y: &i�Ltj4N J�Velt�? 6-4gQ2�W Policy M LIP -A01 322 03
I am (cirde one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following
wofkers' compensation policies:
Company N=e:
Address:
City:
Insurance Company:
Company Name:
Address:
City:
Insurance Comp
Telephone
Policy M
Telephone M
Policy IF
Attach additionual sheet if necessary
Failureto securf-- coverage as requiredund—er Section 25A of MGL 15B can lead totheimposition of criminal penalties of afineupto S1,500-00
and/o7oncycars' imprisonment as well as civil penalties intheformof a STOP WORK ORDERand afte of�S100.00 a day againstme. I
understand that.a copy of this statement may be forwarded to the Office of Investigations of the DU for coverage verification.
.1 do hereby !Srttft under the dpenaldes ofperjury that the information above is true and correct
Date:
-q I ;?G
PnntName�--Iqlhl� V cptrrd ) . Phone # 5-12 CS& C18 3 Y
Mcial Use 0N1,Y - DD not write in this Rre2
City or Town-. Permit/License
0 Check If IrnmBdiste response is required
o Building Department
0 Licensing Board
o Selectmen's Office
13 Health Department
o Other
F�'�Itl 'N.P. P�J-Frt!L
FI;X :19736--:�3,-3i47 0 6 0 Zif I F'l
CERTIFICATE
�PFZODLIIIEP
DATE �mf&[Vfy �yy'l
OF LIABILITY INSURANCE
OLAIN'SMAU."
--'
1 -
THIS CERTIFICATE IIS WSLIED A MATTER OF INF0PJ4AA7'!0N
14. P. ROBERTS ONLY
INSURANCs AGz.wc.,y
INC, ANO CONFERS NO RIGHM U�ON THE CERTIFICATS
osr�,coD STRUT
HOL��ER. THIS CIFIR11FICATE DOES NOT AMENO, SXTiND OR
OEM L AC�-�r��GA TE L�AT AP:`�IES f'LP.:'
IRO
L ALTER THE qoVkMrE AFFOROED BY THE POLICiES BEi O\N.
NORTH ANDOV—rR KA 01$45
i��' 4L-.-
INSURERS AFFORE)ING COVERAGE
1
NORTH ANDOWR REAL,r'y
NAIc;4
coRp. �-P-ENA:
JIM CARROLL
ANY �\JTQ
459 LAST BROADroMY
Wbrry�.D SINGi.E LVVIT
(E'; I
RhVERRILL, Mh 01830
N8L:RL:R* 'L A`�ZEA;XAN SQMr ASSURkNCE INSj
INSURER E
COVERAGES
(Put �emn;
'LYINJURY
ThE POLIC.Z8 OF iNaURANGF i 1$7ED BELOW HAvE BEEN FO THE IN5jREr) NAMED ABOVE FOR 'THC- '-"OLICY PCP.�CC, NDI',�TF:D N07','vI7H5:1AI`,IDINc,
ANY REQIJIREM�NT TFRIO OWCONDIMON U ANY CONTRO��T OR (11 HER D0<',VMEN-,' VATI-I
MAY PERTAIN, TK INISUAANCE AFFORDED BY THE
RESr"Ecl F0 WH414 TH18 (;&RTi�l'�ATE MAY Ele K58UE3 OR
POLICIES DESC.MiKD HERr..IN:.I SUBJECT TO ALL TEMMS, EX�Lisforis A.No :;ONDIMOII.� -i -I
POLICIES AGGR��T;: LIMITS S HOWN MAY HAVE BEEN
OF SX
REDUCED BY PAC CLAA1.5.
0A WORD!
Poluo 'cjml]I�R r), -'�i
GCNI�RAL 'LIABILITY
EACH 7:
"ONVERCIAL GFPJFP.Ai. LABILIT'i
OLAIN'SMAU."
L�;,� EXF (AnY oi or, ramop)
P� AL -V I NjUfty
-,.RbONAI-
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(Put �emn;
'LYINJURY
AUTC'S
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V�'�
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PR09EIRT,' D�,MAGE
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4WALIT D
CCUR CLAIIASMADE
LCLUCTLGI-F�
EZF7 �Q I' -.'N s
vvoR'KcRs';--w.rEN3� AND
IX PROVf VONS �alov
OTI,ER
�E-C-p -iii 0 N OF 0 �'FRAFIO AV- ICLES 'E1,0LUMN,� ADDED DY 5PECG-':.
FAX: 978- -9942
'ER71FICATE HOLDER
-- -CANCELLATION
G rl�tc..p THAN EA ACIC�! s
I AUJOUNLY
! LtfH OCCURR'�IqC-=
GLF
�E
E
E.- Q15FAISF. - CA 000 1
Fi MIA��-PQL'CYLRA17
TOWN OF NORTH ANDOVER
DkTF THZ�Z�E()F, THIE tSSU;NC INSUR.Er ?JIL4 DIOCAVOR 7 C, 'wL C:AY-, V'/-Z!TMI
400 Q3000J.) N' 0 r]C,- 10 THE URTWIGATR HQ1 M -R 100AW r0THE LrJ-T, EVI FAt:�'JRF TO L)Q ';0 L;l ',LL
Impos; NO 00LIGA'NON ��R LIAQ:JTy QF WY KIN'-� Upllr4 T�:[ INSV.RER T6 A�3F',!T�'i (.4
NORTH Alf0OVZR, HA 01845 REPREiFNTATI'VES
I [ALJTIIL)P[Zr, PrPRGS,'�HrA71V1'. m lot k.) A,-) a
kcoRD 25(200�;M)
MACORD CORPO
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 063503
Birthdate: 07/19/1965
Expires: 07/19/2007
Restricted: 00
JAMES V CARROLL
163 HIGHLAND RD
ANDOVER, MA 01810
Tr. no: 14926
Commissioner
Location
C, --r—
No. 59-7-
Date
TOWN OF NORTH ANDOVER
0 Aa��
Certificate Occupancy $
of
CHU
Building/Frame Permit Fee $ 59W;
Foundation Permit Fee $ 1147a - C;*
Other Permit Fee $ -6-� .
15
TOTAL $ 4/ o
Check #
(lob
�1 52
Building Inspector
,AORT#1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
CHU$
Permit NO: '4;7�z Date Received:
Datelssued:
IMPORTANT: Applicant must complete all items on this page
LOCATION D-7 nllvb�l LAI\)z LZ T L1
PROPERTY OWNER BoOtB t�620�0!� ke4t4-1
Print I
MAPNO.: (95 PARCEL: D4 ZONING DISTRICT:
TYPE AND USE OF BUILDING
� 0-1
HISTORIC DISTRICT VFN n
TYPE OF IMPROVEMENT
PROPOSED USE
R6§idential
Non- Residential
VNew Building
0 Addition
0 Alteration
1?"One family
0 Two or more family
No. of units:
0 Industrial
D Repair, replacement
0 Demolition
0 Assessory Bldg
11 Commercial
1-1 Moving (relocation)
11 Other
0 Others:
0 Foundation only
DESCRIPTION OF WORK TO BE PREFORMED Cog r,)e-4 in c0a 4w/,xi L-4
V
D',AJE d'rlj;� 1J14 C.W" 0A1.Qq-. ::::jc�TaL -SQ1A2%9
0 V V
q -7s -(o
Identification Please Type or Print Clearly)
OWNER: Name:
�M=
N , aos 0i930
CONTRACTOR Name: NWrl. 0,dow A�A-� Gr12 - —,YAo6 4 C401 / Phone: q7q
I I
Address: 3 MA , 016 (0
Supervisor's Construction License: CS OCo3 -,50 3 Exp. Date: 7 - N - XO -7
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Brulyc, As-coc Name: Phone: ctl e 116- 3
Address: &C k) 9L�f &JAJ I N. t4o 04ee av -Rea. No. 3 3 q`R
I
FEE SCHEDULE: BULDING PERAHT- $M00 rg $1000.00 OF THE TOTAL ESTIMA TED COSTBASED ON $125.00 PER S.F
Total Project Cost :$ 5'1 q, 500 x]0.00=FEE:$ 51-Y'; "
Check No.: C. — I I 0c;1 ReceiptNo.: 004�z,
Page I of 4
TYPE OF SEWARGE DISPOSAL
Tanning/Massage/Body Art
Swimming Pools
Public Sewer
F1
Tobacco Sales Ll
Food Packaging/Sales 0
Well
1-1
Permanent Dumpster on Site F�
Private (septic tank, etc.
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owne"')o Signature of ContractoA�
Plans Submitted P� U Plans Waived D Certified Plot Plan 2� Vamped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
[]Water Shed Special Permit
El Site Plan Special Pen -nit
11 Other
CO
DATE jL'4---JECTED DATE APPROVED
CONSERVATIOI!����
COMMENTS
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition
Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Water & Sewer connection signature & date
Temp Dumpster on site ye�Jno . - Fir
Building Permit Approved and Issuec
Page 2 of 4
DATE REJECTED DATE APPROVED
F1 F1
1.09
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required
Provided Required
Provides Required
Provided
L
po
I
-77
DIMENSION -7 '�- L�756
Number of Stories: r- Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.: ;) (C� i S-5'7
NOTES and DATA — (For department use)
Page 3 of 4
Doc: INSPECTIONAL SERVICFS DF.PARTMF.NT RPFORM05
Created JMC. Ian 2006
Building Department
The following Is a list of the required forms to be filled out for the appropriate permit to be obtained.
Rooring, Siding, Interior Rehabilitation Permits
• Building Permit A' lication
pp
• Workers Comp Affidavit
• Photo Copy Of H.I.C. And/Or C.S.L. Licenses
• Copy of Contract
• Floor Plan Or Proposed Interior Work
Addition Or Decks
• Building Permit Application
• Surveyed Plot Plan
Li Workers Comp Affidavit
Li Photo Copy of H.I.C. And C.S.L. Licenses
Li Copy Of Contract
u Floor/Crossection/Elevation Plan Of Proposed Work With S�rinkler Plan And Hydraulic
Calculations (If Applicable)
Li Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
Lj Building Permit Application
Li Certified Proposed Plot Plan
L3 Photo of H.I.C. And C.S.L. Licenses
Li Workers Comp, Affidavit
Lj Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
L3 Copy of Contract
u Mass check Energy Compliance Report
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of
Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and
proof of recording must be submitted with the building application
Doe: INSPECTIONAL SERVICES DEPARTMENT:BPFORMOS
Page 4 of 4
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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Buflding Permit Number 592 (3/24/06) Date: December 11, 2006
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 27 Abby Lane
MAY BE OCCUPIED AS Sinple Family Dwelfina INACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY "PLY.
Certificate Issued to: North Andover Realty Trust
27 Abby Lane
North Andover MA 0 1845
P-1 --4//,
BuildiAg Inspector
Ilk
Too
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 592 (3/24/06) Date: December 11, 2006
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 27 Abby Lane
MAY BE OCCUPIED AS Sinale Family Dweffinp- 'IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: North Andover Realty Trust
27 Abby Lane
North Andover XIA 01845
Building Inspector
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BOISE'. Quadruple 1-3/4"xll-7/8"VERSA-LAM@2.03100SP FloorBeam�F!301
BC CALCO 9.2 Design Report - US 4 spans I No cantilevers 10/12 slope Thursday, March 23, 2006 07:42
Build 141
6
BO, 1-3/4" B1, 3-1/2" B2, 3-1/2" B3, 3-1/2" B4, 1-3/4"
LL 2772 lbs LL 6082 lbs ILL 13132 lbs ILL 12618 lbs LL 3456 lbs
DL 1335 lbs DL 1900 lbs DIL 5064 lbs DL 6133 lbs DL 1454 lbs
Total of Horizontal Design Spans = 32-05-00
Load Summary
File Name: nar 060323.BCC
Job Name: Plan #29421
Description: FB01
Address:
Specifier: Gregory R. Doyle
City, State, Zip: Andover, MA
Designer: Gregory R. Doyle
Customer: North Andover Realty
Company:
Code reports: ESR -1040
Misc:
6
BO, 1-3/4" B1, 3-1/2" B2, 3-1/2" B3, 3-1/2" B4, 1-3/4"
LL 2772 lbs LL 6082 lbs ILL 13132 lbs ILL 12618 lbs LL 3456 lbs
DL 1335 lbs DL 1900 lbs DIL 5064 lbs DL 6133 lbs DL 1454 lbs
Total of Horizontal Design Spans = 32-05-00
Load Summary
Value
% Allowable
Duration
Live
Dead Snow Wind
Roof Live
Tag Description
Load Type
Ref.
Start End
100%
90% 115% 133%
125% Trib.
1 Standard Load
Unf. Area
Left
00-00-00 32-05-00
40 psf
10 psf
08-00-00
2
Unf. Lin.
Left
00-00-00 32-05-00
0 plf
80 plf
n/a
3
Unf. Area
Left
00-00-00 32-05-00
30 psf
10 psf
08-00-00
4
Unf. Lin.
Left
00-00-00 32-05-00
0 plf
80 plf
n/a
5
Unf. Area
Left
00-00-00 32-05-00
30 psf
10 psf
08-00-00
6
Conc. Pt.
Left
17-00-00 17-00-00
6071lbs2161lbs
Max Defl.
n/a
Controls Summary
Value
% Allowable
Duration
Load Case
Span Location
Pos. Moment
21959 ft -lbs
51.6%
100%
14
3 - Internal
Neg. Moment
-19930 ft -lbs
46.8%
100%
22
3 - Right
End Shear
-3610 lbs
22.9%
100%
16
4 - Right
Cont. Shear
9776 lbs
61.9%
100%
20
3 - Left
Uplift
1216 lbs
n/a
22
1 - Right
Total Load Defl.
U853 (0.148")
28.1%
14
3
Live Load Defl.
L/1 128 (0.112")
31.9%
14
3
Total Neg. Defl.
-0.039"
7.7%
14
4
Max Defl.
0.148"
14.8%
14
3
Span / Depth
10.6
n/a
3
Cautions
Uplift of 1216 lbs found at span 1 - Right.
Notes
Design meets Code minimum (L/240) Total load deflection criteria.
Design meets Code minimum (U360) Live load deflection criteria.
Design meets arbitrary (1") Maximum load deflection criteria.
Minimum bearing length for BO is 1-1/2".
Minimum bearing length for B1 is 3".
Minimum bearing length for B2 is 3-1/2".
Minimum bearing length for B3 is 3-5/8".
Minimum bearing length for B4 is 1-1/2".
Entered/Displayed Horizontal Span Length(s) = Clear Span + 1/2 min
1/2 intermediate bearing
Page 1 of 2
end bearing +
Disclosure
Completeness and accuracy of input must
be verified by anyone who would rely on
output as evidence of suitability for
particular application. Output here based
on building code -accepted design
properties and analysis methods.
Installation of BOISE engineered wood
products must be in accordance with
current Installation Guide and applicable
building codes. To obtain Installation Guide
or ask questions, please call
(800)232-0788 before installation.
BC CALCO, BC FRAMERS, AJSTM,
ALLJOISTO, BC RIM BOARDTM, BCIG,
BOISE GLULAM-, SIMPLE FRAMING
SYSTEMS, VERSA-LAM6, VERSA -RIM
PLUSa, VERSA-RIM0,
VERSA -STRAND-, VERSA-STLIDO are
trademarks of Boise Wood Products,
L.L.C.
Reise. Quadruple 1-3/4"x 11-7/8"VERSA-LAM02.0 3100 SP FloorBeam\1=1301
BC CALCO 9.2 Design Report - US 4 spans I No cantilevers 10/12 slope Thursday, March 23, 2006 07:42
Build 141
File Name: nar 060323.13CC
Job Name: Plan #29421 Description: FBOI
Address: Specifier: Gregory R. Doyle
City, State, Zip: Andover, MA Designer: Gregory R. Doyle
Customer: North Andover Realty Company:
Code reports: ESR -1 040 Misc:
Connection Diagram
a minimum = 2" c = 7-7/8"
b minimum = 2-1/2" d = 24"
r son
al
Connection design assumes point load is 'top -loaded'. For connection design of 'side -loaded' point loads,
please consult a technical representative or professional of Record.
Member has no side loads.
Concentrated loads are not considered in side load analysis.
Connectors are: 1/2 in. Staggered Through Bolt
Page 2 of 2
Boisw Triple 1-3/4" x 11 -7/8" VERSA -LAM@ 2.0 3100 SP Floor Beam\F1302
BC CALC@ 9.2 Design Report - US 4 spans I No cantilevers 10/12 slope Thursday, March 23, 2006 07:40
Build 141
BO, 1-3/4" B1, 3-1/2" B2, 3-1/2" B3, 3-1/2" B4,1-3/4"
LL 6071 lbs LL 16271 lbs LL 15543 lbs LL 16271 lbs LL 6071 lbs
DL 2161 lbs DL 6286 lbs DL 5107 lbs DL 6286 lbs DL 2161 lbs
Total of Horizontal Design Spans = 32-00-00
Load Summary
File Name:
nar 060323.BCC
Job Name: Plan 429421
Description:
F1302
Address:
Specifier:
Gregory R. Doyle
City, State, Zip: Andover, MA
Designer:
Gregory R. Doyle
Customer: North Andover Realty
Company:
1 Standard Load
Code reports: ESR -1 040
Misc:
00-00-00 32-00-00
BO, 1-3/4" B1, 3-1/2" B2, 3-1/2" B3, 3-1/2" B4,1-3/4"
LL 6071 lbs LL 16271 lbs LL 15543 lbs LL 16271 lbs LL 6071 lbs
DL 2161 lbs DL 6286 lbs DL 5107 lbs DL 6286 lbs DL 2161 lbs
Total of Horizontal Design Spans = 32-00-00
Load Summary
Value
% Allowable
Duration
Live
Dead Snow Wind
Roof Live
Tag Description
Load Type
Ref.
Start End
100%
90% 115% 133%
125% Tri b.
1 Standard Load
Unf. Area
Left
00-00-00 32-00-00
40 psf
10 psf
17-00-00
2
Unf. Lin.
Left
00-00-00 32-00-00
0 plf
80 plf
n1a
3
Unf. Area
Left
00-00-00 32-00-00
30 psf
10 psf
17-00-00
4
Unf. Lin.
Left
00-00-00 32-00-00
0 plf
80 plf
n/a
5
Unf. Area
Left
00-00-00 32-00-00
30 psf
10 psf
17-00-00
Controls Summary
Value
% Allowable
Duration
Load Case
Span Location
Disclosure
Pos. Moment
14192 ft -lbs
44.5%
100%
14
1 - Internal
Completeness and accuracy of input must
Neg. Moment
-17343 ft -lbs
54.3%
100%
18
1 - Right
be verified by anyone who would rely on
End Shear
5696 lbs
48.1%
100%
14
1 - Left
output as evidence of suitability for
Cont. Shear
9007 lbs
76.0%
100%
18
1 - Right
particular application. Output here based
Total Load Defl.
U951 (0.101
25.2%
14
1
on building code -accepted design
Live Load Defl.
L/1208 (0.08")
29.8%
14
1
properties and analysis methods.
Installation of BOISE engineered wood
Total Neg. Defl.
-0.04"
8.0%
14
2
products must be in accordance with
Max Defl.
0.1011,
10.1%
14
1
current Installation Guide and applicable
Span / Depth
8.1
n/a
1
building codes. To obtain Installation Guide
or ask questions, please call
Notes
(800)232-0788 before installation.
Design meets Code minimum (L/240) Total load deflection criteria.
Design meets Code minimum (L1360) Live load deflection criteria.
Design meets arbitrary (1") Maximum load deflection criteria.
Minimum bearing length for BO is 2-1/8".
Minimum bearing length for B1 is 5-3/4".
Minimum bearing length for B2 is 5-1/4".
Minimum bearing length for B3 is 5-3/4".
Minimum bearing length for B4 is 2-1/8".
Entered/Displayed Horizontal Span Length(s) = Clear Span + 112 min
1/2 intermediate bearing
User Notes
Beam B. Center Girder
Page 1 of 2
end bearing +
BC CALCO, BC FRAMERS, AJSTM,
ALLJOISTO, BC RIM BOARDTM, BC10,
BOISE GLULAMTM' SIMPLE FRAMING
SYSTEMO, VERSA-LAMD, VERSA -RIM
PLUS@, VERSA -RIM@,
VERSA-STRANDTM, VERSA-STUDO are
trademarks of Boise Wood Products,
L.L.C.
ROiSE- Triple 1-3/4" x 11 -7/8" VERSA -LAM@) 2.0 3100 SP Floor BeamkFB02
BC CALCO 9.2 Design Report - US 4 spans I No cantilevers 10/12 slope Thursday, March 23, 2006 07:40
Build 141
d
a
c
e 0 0 0
a minimum = 2" c = 7-7/8"
b minimum = 3" d = 12"
e minimum = 3"
Member has no side loads -
Connectors are: 16d Sinker Nails
Page 2 of 2
File Name: nar 060323.BCC
Job Name: Plan #29421
Description: FB02
Address:
Specifier: Gregory R. Doyle
City, State, Zip: Andover, MA
Designer: Gregory R. Doyle
Customer: North Andover Realty
Company:
Code reports: ESR -1 040
Misc:
Connection Diaaram
d
a
c
e 0 0 0
a minimum = 2" c = 7-7/8"
b minimum = 3" d = 12"
e minimum = 3"
Member has no side loads -
Connectors are: 16d Sinker Nails
Page 2 of 2
BOISE- Double 1-3/4" x 9-1/4" VERSA -LAM@ 2.0 3100 SIP Floor BeamX171303
BC CALC(5 9.2 Design Report - US 1 span I No cantilevers 10/12 slope Thursday, March 23, 2006 07:46
Build 141
File Name: nar 060323.BCC
Job Name: Plan #29421 Description: FB03
Address: Specif er: Gregory R. Doyle
City, State, Zip: Andover, MA Designer: Gregory R. Doyle
Customer: North Andover Realty Company:
Code reports: ESR -1 040 Misc:
j,
'4
. ...............
11-00-00
60,1-3/4" B1, 1-3/4"
LL 1403 lbs LL 1403 lbs
DL 958 lbs DL 958 lbs
Total of Horizontal Design Spans = 11 -00-00
Load Summary Live Dead Snow Wind Roof Live
Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% Trib.
1 Standard Load Unf. Area Left 00-00-00 11-00-00 30 psf 10 psf 08-06-0-0
2 Unf. Lin. Left 00-00-00 11-00-00 0 plf 80 plf n/a
Controls Summary
value
% Allowable
Duration Load Case
Span Location
Pos. Moment
6490 ft -lbs
48.9%
100% 1
1 - Internal
End Shear
1998 lbs
32.5%
100% 1
1 - Left
Total Load Defl.
L/431 (0.306")
55.7%
1
1
Live Load Defl.
U725 (0.182")
49.6%
1
1
Max Defl.
0.306"
30.6%
1
1
Span / Depth
14.3
n/a
1
Notes
Design meets Code minimum (L/240) Total load deflection criteria.
Design meets Code minimum (U360) Live load deflection criteria.
Design meets arbitrary (11 ") Maximum load deflection criteria.
Minimum bearing length for BO is 1-112".
Minimum bearing length for B1 is 1-1/2".
Entered/Displayed Horizontal Span Length(s) = Clear Span + 1/2 min. end bearing +
1/2 intermediate bearing
User Notes
Beam C. Rear Wall, 2nd Floor Framing. NOTE: BEAM D REQUIRED ABOVE
Connection Dia
b
a
c
X
a minimum = 2" c = 5-1/4"
b minimum = 3" d = 12"
Member has no side loads.
Connectors are: 16d Sinker Nails
Page 1 of 1
Disclosure
Completeness and accuracy of input must
be verified by anyone who would rely on
output as evidence of suitability for
particular application. Output here based
on building code -accepted design
properties and analysis methods.
Installation of BOISE engineered wood
products must be in accordance with
current Installation Guide and applicable
building codes. To obtain Installation Guide
or ask questions, please call
(800)232-0788 before installation.
BC CALCO, BC FRAMER@, AJSTM,
ALLJOISTO, BC RIM BOARDTm, BCI(@,
BOISE GLULAMTM, SIMPLE FRAMING
SYSTEMO, VERSA-LAM8, VERSA -RIM
PLUSO, VERSA-RIMOD,
VERSA-STRANDTM, VERSA-STUD(5 are
trademarks of Boise Wood Products,
L.L.C.
BOiSE- Triple 1-3/4" x 9-1/4" VERSA -LAM@) 2.0 3100 SP Floor Beam\F1304
BC CALCO 9.2 Design Report - US 1 span I No cantilevers 10112 slope Thursday, March 23, 2006 07:45
Build 141
11 -DO-DO
BO, 1-3/4" B1, 1-3/4"
LL 4208 lbs LL 4208 lbs
DL 1478 lbs DL 1478 lbs
Total of Horizontal Design Spans = 11 -00-00
Load Summary Live Dead Snow Wind Roof Live
Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% Trib.
1 Standard Load Unf. Area Left 00-00-00 11-00-00 30 psf 10 psf 08-06-0-0
2 Unf. Area Left 00-00-00 11-00-00 30 psf 10 psf 17-00-00
Controls Summary
Value
File Name: nar 060323.13CC
Job Name:
Plan #29421
Description: F1304
Address:
78.5%
Specifier: Gregory R. Doyle
City, State, Zip:
Andover, MA
Designer: Gregory R. Doyle
Customer:
North Andover Realty
Company:
Code reports:
ESR -1040
Misc:
11 -DO-DO
BO, 1-3/4" B1, 1-3/4"
LL 4208 lbs LL 4208 lbs
DL 1478 lbs DL 1478 lbs
Total of Horizontal Design Spans = 11 -00-00
Load Summary Live Dead Snow Wind Roof Live
Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% Trib.
1 Standard Load Unf. Area Left 00-00-00 11-00-00 30 psf 10 psf 08-06-0-0
2 Unf. Area Left 00-00-00 11-00-00 30 psf 10 psf 17-00-00
Controls Summary
Value
% Allowable
Duration Load Case
Span Location
Pos. Moment
15634 ft -lbs
78.5%
100% 1
1 - Internal
End Shear
4813 lbs
52.2%
100% 1
1 - Left
Total Load Defl.
1_1268 (0.492")
89.4%
1
1
Live Load Defl.
L/363 (0.364")
99.2%
1
1
Max Defl.
0.492"
49.2%
1
1
Span / Depth
14.3
n1a
1
Notes
Design meets Code minimum (L/240) Total load deflection criteria.
Design meets Code minimum (L/360) Live load deflection criteria.
Design meets arbitrary (1") Maximum load deflection criteria.
Minimum bearing length for BO is 1-1/2".
Minimum bearing length for B1 is 1-1/2".
Entered/Displayed Horizontal Span Length(s) = Clear Span + 1/2 min. end bearing +
1/2 intermediate bearing
User Notes
Beam D. Rear Wall, CIg Joist Framing
Connection Diagram
, -� b �-- �--d -
a
C 0
c
J_
e 0 0 0 77
I— It 7" 77
a minimum = 2" c = 5-1/4"
b minimum = 3" d = 12"
e minimum = 3"
Member has no side loads.
Connectors are: 16d Sinker Nails
Page 1 of 1
Disclosure
Completeness and accuracy of input must
be verified by anyone who would rely on
output as evidence of suitability for
particular application. Output here based
on building code -accepted design
properties and analysis methods.
Installation of BOISE engineered wood
products must be in accordance with
current Installation Guide and applicable
building codes. To obtain Installation Guide
or ask questions, please call
(800)232-0788 before installation.
BC CALCO, BC FRAMERO, AJSTM,
ALLJOISTO, BC RIM BOARD T- , BC10,
BOISE GLULAMT-, SIMPLE FRAMING
SYSTEMID, VERSA-LAMO, VERSA -RIM
PLUS0, VERSA-RIM0,
VERSA -STRAND TM, VERSA -STUD@ are
trademarks of Boise Wood Products,
L.L.C.
BOISE- Double 1-3/4" x 16" VERSA -LAM@ 2.0 3100 SP Simple Hip\SH01
BC CALC@ 9.2 Design Report - US 2 spans I Left cantilever 17.1/12 slope Thursday, March 23, 2006 07:47
Build 141 01-00-00 Tributary
File Name: nar 060323.BCC
Job Name: Plan #29421 Description: SH01
Address: Specifier: Gregory R. Doyle
City, State, Zip: Andover, MA Designer: Gregory R. Doyle
Customer: North Andover Realty Company:
Code reports: ESR -1 040 Misc.-
12
Notes
Design meets Code minimum (Ull 80) Total load deflection criteria.
Design meets Code minimum (L/240) Live load deflection criteria.
Minimum bearing length for B1 is 3".
Minimum bearing length for B2 is 2-3/4".
Entered/Displayed Horizontal Span Length(s) = Clear Span + 1/2 min. end bearing +
1/2 intermediate bearing
User Notes
Beam E. Hip Rafter
Connection Dia
- b d
a
,,--e v
NEWS
--i_
a minimum = 2" c = 12"
b minimum = 2-1/2" d = 24"
Member has no side loads.
Connectors are: 1/2 in. Staggered Through Bolt
Page 1 of 1
BC CALCO, BC FRAMERS, AJSTM,
ALLJOISTO, BC RIM BOARDTM , BC10,
BOISE GLULAMTM, SIMPLE FRAMING
SYSTEMD, VERSA-LAMV, VERSA -RIM
PLUSO, VERSA -RIM@,
VERSA -STRAND-, VERSA-STUDV are
trademarks of Boise Wood Products,
L.L.C_
B1, 3-1/2"
B2,1-3/4"
0
DL 2084 lbs
DL 3241 lbs
SL 2333 lbs
SL 3889 lbs
d = 16-00-00
o = 02-00-00
Total of Horizontal Design Spans =
25-05-08
Load Summary
Live Dead
Snow Wind Roof Live
Tag Description
Load Type Ref.
Start
End
100% 90%
115% 133% 125% Trib.
1 Equivalent Load
Trapezoidal
Left
00-00-00
0 plf
0 plf n/a
25-05-08
352 plf
489 plf n/a
Controls Summary
Value
% Allowable
Duration
Load Case
Span Location
Disclosure
Pos. Moment
32555 ft -lbs
75.8%
115%
3
2 - Internal
Completeness and accuracy of input must
Neg. Moment
-202 ft -lbs
0.5%
115%
3
1 - Right
be verified by anyone who would rely on
End Shear
-7130 lbs
58.3%
115%
3
2 - Right
output as evidence of suitability for
Cont. Shear
4229 lbs
34.6%
115%
3
2 - Left
particular application. Output here based
Total Load Defl.
L/205 (1.54")
87.9%
3
2
on building code -accepted design
Live Load Defl.
L/379 (0.832")
63.3%
3
2
properties and analysis methods.
Total Neg. Defl.
-0.622"
82.9%
3
1 - Cantilever
Installation of BOISE engineered wood
products must be in accordance with
Span / Depth
17.0
n/a
2
current Installation Guide and applicable
building codes, To obtain Installation Guide
Slope and Cut Length
Slope Facia
Depth Horiz. Length
Product Length
or ask questions, please call
Plumb Cut with Hanger to dbl. top plate 7.1/12 4"
25-05-08
29-08-10
(800)232-0788 before installation -
Notes
Design meets Code minimum (Ull 80) Total load deflection criteria.
Design meets Code minimum (L/240) Live load deflection criteria.
Minimum bearing length for B1 is 3".
Minimum bearing length for B2 is 2-3/4".
Entered/Displayed Horizontal Span Length(s) = Clear Span + 1/2 min. end bearing +
1/2 intermediate bearing
User Notes
Beam E. Hip Rafter
Connection Dia
- b d
a
,,--e v
NEWS
--i_
a minimum = 2" c = 12"
b minimum = 2-1/2" d = 24"
Member has no side loads.
Connectors are: 1/2 in. Staggered Through Bolt
Page 1 of 1
BC CALCO, BC FRAMERS, AJSTM,
ALLJOISTO, BC RIM BOARDTM , BC10,
BOISE GLULAMTM, SIMPLE FRAMING
SYSTEMD, VERSA-LAMV, VERSA -RIM
PLUSO, VERSA -RIM@,
VERSA -STRAND-, VERSA-STUDV are
trademarks of Boise Wood Products,
L.L.C_
REScheck Compliance Certificate
2000 IECC
RES checkSoftware Version 3.6 Release I
Data filename: C:\Program Files\Check\REScheck\PL2942 Lrck
PROJECT TITLE: PLAN NO 29421
CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: Single Family
WINDOW / WALL RATIO: 0. 16
DATE: 03/22/06
DATE OF PLANS: 5-30-00
PROJECT DESCRIPTION:
COLONIAL HOUSE
DESIGNERICONTRACTOR:
BRUNO ASSOC.
28 BERKELEY ROAD
N. ANDOVER, MA 0 1845
COMPLIANCE: Passes
Maximurn UA = 455
Your Home UA = 361
20.7% Better Than Code (UA)
Ceiling 1: Flat Ceiling or Scissor Truss
Wall 1: Wood Frame, 16" o.c.
Window 1: Vinyl Frame:Triple Pane with Low -E
Door 1: Glass
Basement Wall 1: Solid Concrete or Masonry
Wall height: 8.0'
Depth below grade: 7.0'
Insulation depth: 4.0'
Permit Number
Checked By/Date
Gross Glazing
Area or Cavity Cont. or Door
Pe R -Value R -Value U --Fact UA
1680 30.0
30.0 29
2512 13.0
13.0 101
360
0.330 119
39
0.330 13
1680 19.0
19.0 99
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 2000 IECC requirements in RES checkVersion 3.6 Release I (formerly MECcheb� and to comply with the
mandatory requirements listed in the RES checkinspection Checklist.
Builder/Designer A/ 3 — :z 3 —a4off
��21&ewtol— Date
REScheek Inspection Checklist
2000 IECC
REScheckSoftware Version 3.6 Release I
DATE: 03/22/06
PROJECT TITLE: PLAN NO 29421
Bldg.
Dept.
Use
Ceilings:
1. Ceiling 1: Flat Ceiling or Scissor Truss,
R-30.0 cavity + R-30.0 continuous insulation
Comments:
Above -Grade Walls:
1. Wall 1: Wood Frame, 16" o.c., R-13.0 cavity+ R-13.0 continuous insulation
Comments:
Basement Walls:
I . Basement Wall 1: Solid Concrete or Masonry, 8.0'ht/7.0'bg/4.0'insul,
R-19.0 cavity + R-19.0 continuous insulation
Comments:
Exterior insulation must have a rigid, opaque, weather -resistant protective covering that
covers the exposed (above -grade) insulation and extends at least 6 in. below grade.
Windows:
1. Window 1: Vinyl Frame:Triple Pane with Low -E, U -factor: 0.330
For windows without labeled U -factors, describe features:
# Panes Frame Type Thermal Break? I I Yes No
Comments:
Doors:
1. Door 1: Glass, U -factor: 0.330
Comments:
Air Leakage:
Joints, penetrations, and all other such openings in the building envelope that are sources of air
leakage must be sealed.
Recessed lights must be 1) Type IC rated, or 2) installed inside an appropriate air -tight assembly
with a 0.5" clearance from combustible materials. If non -IC rated, the fixture must be installed with a
3" clearance from insulation.
Vapor Retarder:
Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors.
Materials Identification:
Materials and equipment must be installed in accordance with the manufacturer's installation instructions.
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 and glazing U -factors must be clearly marked on the building plans or specifications.
Duct Insulation:
Ducts in unconditioned spaces must be insulated to R-5.
Ducts outside the building must be insulated to R-6.5.
Duct Construction:
I I All joints, seams, and connections must be securely fastened with welds, gaskets, mastics (adhesives),
mastic -plus -embedded -fabric, or tapes. Tapes and mastics must be rated UL IS IA or UL 18 1 B.
Exception: Continuously welded and locking -type longitudinal joints and seams on ducts
operating at less than 2 in. w.g. (500 Pa).
The HVAC 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.
Service Water Heating:
Water heaters with vertical pipe risers must have a heat trap on both the inlet and outlet unless the
water heater has an integral heat trap or is part of a circulating system.
Insulate circulating hot water pipes to the levels in Table 1.
Circulating 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 105 OF or chilled fluids below 55 T must be insulated to the
levels in Table 2.
Tahle 1: Mmbnum Insulation rhicknessfor Circulating Hot Water Pipes.
Insulation
Thickness
in Inches
by Pipe Sizes
Heated Water Won -Circulating
Runouts
Circulatine
Mains and
Runouts
Te==ture ( E) lip to I It
J�R to 1.25"
1.511 to
2.011 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
Table2: Minhnum Insulation 7hkknessjbrHVACP4ws.
Fluid Temp.
Insulation Thickness
in Inches
-b_y Pipe
Sizes
Piping SyaWm Ines
Raugg ( F)
2" Runouts
V and Less
1.25" to 2" 2.5 '1 to 4"
Heating Systems
Low Pressure/Temperature
201-250
1.0
T.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)
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ALDRD- CERTIFICATE OF LIABILITY INSURANCE
.�PPODLICEP. 2LIL! 2 0 Qj
I THIS CERTIFICATE iS I$SUED AS A MATTER OF WFORPAA710N
14,P.90BERTS TWSURANCE AGENCY INC, ONLY ANO CONPER6 NO R
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1060 OSGOOD STIRF= HOL.^VER. THIS -FRIIFICATE DOES NOT AMr:N�), EXT 'I'lo OR
ALTER THE COVEPACF AFFORDED BY THE POLICiE$ OELOVJ.
NORTH ANDQV-rR MA ()J�45
MURERS AFFORDING COVERAGE
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HhVERHILL, UX 01g3o
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7flE �70LIC'S OF 4�URANCE. 1.1,97ED BEL,)klV HAVE BEEN _T0 IHE _IN5_JREj) —NA'------'—
AN� REQIJIREM�NT NED ABOVE Z;ORTHP�01L�CY P[PIOCNIDGATF.0 N07WITHSTANDiNG
rl�RM OR CONDMON U ANY CONTPL0,0TOR 01I<F(OOCvNiEN,- ��JJTJJ RESr"EoT TO WHICH THIS CERTiRQ,�rE MAYB6 f,",UED OR
MAY PEVAIN, THE NISUAANCE AFFORUEO BY THE POLiCims DEVVIRED HERIPWS SURJECT TO �44L -.�'F TEnrviS. EXC.,L)sjorjs A.No ��ONDM011.5 OF
P01-It'lE S. AGGREGAT�_: L)MlTz SHOWN MAY HAVE HEN REDUCED FIYPA�D CLAM$,
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07�,ER
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FAX: 978- 75-0942--1
'ERTIFICATE HOLDER CANCELLATION
TOWN OF NOATH A"OVER -HOULD ANY Ql� Y�-FAUOVE DESCRIUCID P OLII' IrN RF C;m�cv.u.fV BECoIlC, 1-1 �E t7.y,PliiA I vr�
Di,,TF THF. ISGUINC iNSUPEr VALL DIDGAVOR 10 YA:L 10 OAY�� V/177CN
Noric, �0 THE CE4rwicfTP H(lI!)f-..R �MMIIO TO THE LEFr, BVI V.QJRE TO DQ �;O UhlLL
400 Q3000D STREET
lmn�; No 08LICA'TION (jP LM�,.n �)F �W KIN`, IjPlot� THE INSURLP. To A:WAT,� 0.�
NORTH AgDTSR, +1A 01845 RIEPRESRINTATIVES
I ALITI ORVP.� REPRES"HtAlIVE.
k C,'O R D 2 5 (12 0 01 0J) G)ACORD CORPORATION 1985
f
oepxvnem of -r=aStddA=iL
Off= of Investva=U
600 WxaWun SM4
W 02111,
'WoTkmt'Compmsatioulnsm-a=AfEdMt
Please P= Letbly
APPLICANT INFORMATION
Name:
Locatiow.
C1 Telephone, #:
0 fata a homeowner performing 4 work nfyself
0 1 am sole proprietor and have no I one world�g 'may MP —Wily
91—a—Man employer providing workers' compensation for my cmploYces worldng on this job
Re A.
C omp a=e:—'
any N
. '. :' ;.1 .. 11, 0, P. -. !, , 97
Address�
C),
City: Telephone :#-�
Insurance Company tCA4 VO&C &4SA,,z_,e �Policym
13 1 am (circle one) sole proprietor, general contractor or homeowner and have, hired the contractors listed below who have the following.
workers' compensation policies:
:_'Z
Company Na=e:
Address:
city. Teleph�pne M
Insurapet Company: Policy
Company NaTnt-:
Address:
City-. Telephone M
Insurance CoxnP Policy M
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to S1,500,00
ORDER and a fine, oi$ 100-00 a day against me, I
and)or oneyears' imprisomnJent Rs -well as civil -Penalties in the foxm of a STOP WORK -
understand that.a. copy of this statement may be forwarded to the Office of Investigations of the DIA. for co,v=gt verifiCatiDn.
I do hereby cerzYfy under the pains andpenalties ofperjury that the information 4bove is'true and c6 I rriact.
I - v G
Signature: Date: 3 --;21 .
Print Name: Jqme Phone # q7 6' -47q- P770
OfLcial'Use ONLY -Do not write in this area
Olty or Town: ParmIt/Licanse M
0 Check If Immediate response Is required
o Building Department
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