HomeMy WebLinkAboutMiscellaneous - 3, 5, 7, 9 Ciderpress WayDate..!�/ ...................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ll..C,
........ .. .................................................................................
has permission to perform ............ ��:v ...........
winn:r in the buildin of
9 ... �M. ... �Lec�� ......................
at C'
..........................
.......... . N rth Andover, Mass.
Fee ...... ...... Lic. No.
ELE&RwAL INSPECrOR
Check # / / L/-5—/
9
<Ll\ Official Use. Only
Commonwealth of Massachusetts
Permit No.
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev- 1/071 (leave blan1c)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 12.00
6r
31,527 CMR
(PLEASE PRIAT IN)YK OR TYPE ALL JXFORAM TIOA9 Date: L3
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) IPA:
OwnerorTenant
Owner's Address C4 --t
Is this permit in conjunction with a building permit? yes El
Purpose of Building
Existing Service — Amps volts
New Servic Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No.
- -1k
No L!J- (Check Appropriate Box)
Utility Authorization No. I -t q LL( 0 -�
OverheadEl Undgrd 0
Overhead [:1 UndgrdF]
No. of Meters
No. of Meters
Cnmnh,tinn nl'Ap -fn7lAw;—f�A1, — A,, A. T.—,f— �rWi—
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
Jo. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above Ei In- E]
Rrnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN"o. of Zones
0 of Sv
No. FofSyiitches
No. of Gas Burners
No. of Detection and
Initiating Devices
,_ f
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
P--- ............ "]
I Tons
............
I KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalEl Municipal 0 Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
KW
Heaters I
�No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
rNo. of Motors Total IIP
Telecommunications Wiring:
No. of Devices or Equivalent
=0THER, I
EstimatedValueo ElectricalWork: 0C Attach additional detail ifdesired, or as required by the Inspector of M. res.
L,, _X:)- (When required by municipal policy.)
Work to Start: - 6 1 It � Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCIf C kA�G]E: 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 operation7' coverage or its substantial equivalent. The
undersigned certifies that such cover!p . .
,,ps in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE E9 ---BOND n OTBEREI (Specify:)
I certify, under the ams andpenalfies ofperjury, thatthe infoTmation on this application is true and complete.
FIRM NAME: LIC. NO.: -2m ff--rA
Licensee: &,k ignaturkk
LIC. NO.:
ffapplicabl�, enter "exempt" in the nse number lineJ Bus. Tel. No.: 1-,nJ 1� 8: Z--2,7�9
ress:
Add 2r Alt. Tel. No.: T2 6: 3
*Per M.G.L c. 147, s. 57-6 1, security work requires Department of Public Safety "S" License: Lic. No. -
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) D owner 0 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
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, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not pro gressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses 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 0
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass EN
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Commen'ts,
=7
44
Inspectors Signature:
Date:
PARTLU ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
DEBWEINHOLD ...TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
�Lx The Commonwealth ofMassachusetts
Department ofIndustriqlAccidints
Office of Investigations
600 Washington Street
Boston., MA 02111
vww.mass.gov1d1a
Workers' Compensation Insurance Affidavit: BuUders/ContractorsfFle,ctricians/Plumbers
Applicant Information Please rrint Legibly
Name (Business/Organization/Jndividual): R etl=-=� I
Address: -4-0 457
City/State/Zip: �)TDLA_) ,k)\Ik 0'�W,�_Phone#: .3 -?6_-0`Y67
Ar yo"n employer? Check the appropriate box: -
Typo of project (required):
1. ;"I/am a employer with (�e
4. El I am a general contractor and 1
6. Lgliee_w c6ikstruction
employees (fiffl and/or part-time).*
2.0 1 am a solep'roprietor orpartner-
have hired the sub -contractors
listed on the attached sheet. t
7. 0 Remodeling
ship and'have no employees
yorking for me in any capacity.
These sub -contractors have
workers' comp. insurance.
8. El Demolition
9. E] Building addition
[No workers' comp. insurance
5. El We are a coiporation and its
10.n Electrical repairs or additions
required.]
3.EN am a homeowner -doing all work
officers have exercised their
right of exemption per MGL
ILEI Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
12.Q Roofrepairs
insurance required.]
employees. [No workers'
1311 other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they ire doing all worle and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this b ox must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
1am an em pensaflon insurancefor my employees. Below is Mepolicy andiob site
ployer that isproviding workers I coin
information.
Insurance Company Name:. A/0 J erLAL (, A,6
Policy # or Self -ins. Lie. M IDTIration Date;
Job Site Address: P A�o _%— - _,C1ty/State/Zip:.. WO, -A At4
Attach a copy of the workers' compensation -policy declaration pagel(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of -MGL o. 152 can lead to the impos ition of criminal penalties o ' f a
fine up to $1,50 0.00 and/or one�year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do h ereby ceriffimil der th e F ains an dp en alfles ofp erju ry th at th e information pro vided ah o ve is tru e an d correct.
Sim re: V�x - Date: �, 1 3
Phone 0: 1 �- � ? �- - C) �- G Z__
Official use only. Do not write in this area, to he completed by chy or town official
City or Town:
Permit[License 0
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
0 8-Y S—
Information and Instruction's
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract ofhirc,-
express or implied, oral or written."
An employeils defined as "an individual, partnership, association, corporation or other legal entlty� 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, assoriation or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage requ.ired."
Additionally, MGL chapter 152', §25C(7) states "Neither the commonwealth nor any of its political subdivfsions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, S-UPPIY sub-contractor(s) name(s), address(es) andphone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirm]ationof insurance coverage. Also be sure to sign and date'the affidavit. ihe affidavit should
be returned to the city or town that ffi'e 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 nurnber listed below. Self-insured companies should enter their
self-insurance license number on the appropriate Eric.
City or Town Officials
Please be sure that the affidavit is complete and printedlegibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pleas * e be sure to fill in 6e permit/lic e*nse number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applicationsmi any given year, need only. *submit one affidavit indicating current
Policy information (ifnecessary) and under "Job Site Address" . the applicant should write "all locations in -(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit ii on file for future permits or licenses. A now affidavit must be fLflqd out each
year. Where a home owner or citizen is obtaining a license or'permit not related to any business or commercial -venture
(i.e. a dog license orp` ermit to burn leaves etc.) said person is NOT required to complete this affidavit.'
The Office of Investigations* would like to thank you in advance -for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The COMMonmalth of Massachusetts
Depaftejat of ladusWal Accidonts
Office of kv0stigation's,
600 Wasbingtoli Strc:et
BostQnMA02111
TQL # 617-727,4900 oxt 406 or 1-877,:MASSAFE
Revised 5-26-05 Fax 4 617-727-7749
Date -Oh ...................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... :
............................................................................................
has permission to pe------- ............................................... ................
wiring in the building of ...... I ........................ I .............
.......... ...... . . .... .........
North Andover, Mass.
fit .... ..... ...... .. ........... i ....... ....... -*-**a .. , t * I
Fee .... la.;� ... ... ....... g ......
.................. Lic. No.
LEcTRicAL INspEcrOR
Check #
Commonwealth of Massachusetts
Department of Fire Services
1ARD OF FIRE PREVENTION REGULATIONS
Official Use Only
PemiitNo. J& �F
Occupancy and Fee Checked
,[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (h1EC 7 CMR 12.00
13),52
(PLEASE PRINTININK OR YYPEALL INFORUATION) Date: C., It -�?
City or Town of. NORTH ANDOVER To the Inspe'ctorof Wires:
By Us application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) N:J� C-('6 6-L-Lp j4 oe,!5 L,4/AJ
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service — Amps volts
PLew Service Amps volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Yes F1
No. 2)& bk-7-2Z3-5—
No �(CheckAppropriate Box)
Utility Authorization No. ( q ? I �f 0 � -A�-
Overhead [I UndgrdE] No. of Meters /1//-V 6-3
OverheadEl UndgrdF] No. of Meters
I Completion ofthe followin table mav be waived hv the ector nf Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
::c
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei In- Ej
Swimming pool Lyrnd. grnd.
No. of Emergency Lighting
BatteKy Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. of Zones
No. of Switches
No. of Gas Burners
Nor. o Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
IAP.Mhe.r
....
I Tons
I——
I KW
I- ' *
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Mun'c'pPl El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. qf Water
Heaters KW
No. of No. of
SiLyns Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications W! * -
�1119-
No. of Devices or quivalent
FOTHER,
113 Attach additional detail ifdesired, or as reqzdred by the Inspector of 97res.
Estimated Value - o E trical. Work: 2-,000. - (When required by municipal policy.)
Work to Start: b
,b I J� 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 operatioie' coverage or its substantial equivalent. The
undersigned certifies that such co!v5w is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE [�r BoND El OTEER 0 (Specify:)
I certify, under thepains andpenalties ofperjury, thatthe information on th4 gpplicat;'kn is true an com
d plete.
FIRM NAME: .)P),,,.L M AT— LIC. NO.
Signature'--- LIC. NO.: /--� lily
(Ifapplicable, enter "exempt" in the license nzimber line) Bus. Tel. No.:
Address: -04A
L�--, Alt. Tel. No.. 7:2 ic 3 Ir -0
-4 — S
*Per M.G.1, c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one)EI owner 1:1 owner's agent.
Owner/Agent
Signature - Telephone No._ ARMIT FEE: $
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, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may bedeemed 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.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
D Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass X
Failed
Re- Inspection Required 0
Inspectors Comment
A
V
Inspectors Signature:
Date:
PARTLU ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass R1
Failed M
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusetts
_CX
Department ofIndustriqlAccidints
Office of Investigations
600 Washington Street
Boston., MA 02111
www'-mass.govIdia
Workers' Compensation Insurance Affidavit: Buflders/ContractorsfElelctricians/Plumbers
Applicant Information Please Frint LeLyib
NaMe (Business/Organization/Individual):
Address:
City/State/Zip:_ P\A4-JjP"J e A/H 63qhCone#: Wo Z_
Are yo I er? Check the appropriate box:
4.El I contractor and 1
f r fect (required):
Typo 0 0j
70W
1 . am a employer with 0
am a general
6. 01 con.straction
employees (fall and/or part-time).*
211 1 am a sole, proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. I
7. El Remodeling
ship fmd'have no employees
for in
These sub -contractors have
workers' comp. insurance.
8. E] Demolition
9. E] Building addition
w�Ug me any capacity.
[No workers' comp. insurance
5. El We are a corporation and its
10.El Electrical repairs or additions
required.]
3. El I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11. E] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
12.Q Roofrepairs
insurance required.] t
employees. [No workers'
1311 Other
comp. insurance required.]
'Any applicant that checks box9l must also fill out the sectionbel6w showing their workers' compensation poliryinfonnation.
T Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a now affidavit indicating such.
TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. polloy information.
I am an employer that isproviding workers'com
pensation insurancefor my employees. Below is thePORCY andi0b site
information.
Insurance Company Name%
Policy # or Self -ins. Lie.
Is
Expiration Date;
Job Site Address: N -j-) t t�, _A4 11 0 kY 5-
1) 6-r, 0c_ 5- �--O A—P Fity/state/Zip: A.20 AZ_J(�CO t
Attach a copy of the workers' compensation -policy declaration pale (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one�year imprisonment, as wellas civil penalties in the form of a STOP. WORK ORDER and a fine
ofup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
'Investigations of the DIA for insurance coverage verification.
I do hereby cert! fperjury th at the information provided above is true and correct.
fy�nder thepains andpenaldes o I
Phone 4: '1 ') /5� S __� �� -tD S� je-) _Z
Official use only. Do not write in this area, to be completed by cl(v or town offlcW
City or Town: Permit/Ucense 0
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. rJumbing Inspector
6. Other
Contact Person:- Phone
Information and Instruction's
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract ofhiro,-
express or implied, oral or written?,
An em
ployeils 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 local 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.ired."
Additionally, MGL chapter 152', §25C(7) states'Weither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers, compensation affidavit completely, by checking the boxes that apply to your situation and., if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are notrequired to carry workers' compensation insurance. If anLT—C orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date'the affidavit. the affidavit should
be retained to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate Eno.
City or Town Officials
Please be sure that the, affidavit is complete and printedlegibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of lavestigations has to contact you regarding the applicant.
Pleas * e be sure to fill in 6c 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 Addre&the applicant shouldwrite "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. A now affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or -permit not related to any business or commercial venture
(i.e. a dog license or �cmiit 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 CommoJuMalth of Moss�.rhus,._tts
Department ofladwtdal Accidents
Office of 11westigatims
600 Wasbington, Stroet
Boston, MA 021 It
Teel, # 617-727,4900 oxt 406 or 1-877,MASSAFF,
Revised 5-26-05 Fax 4 617-727-7749
U
GCAW - � % Lf"
LAWRENCE H. OGDEN, P.E.
198 EAST MAIN STREET
GEORGETOWN, MA 01833
978-352-8318 fax 978 —352-2858
cell: 978-502-5921
June 9, 20 10
Mr. Thomas Zahoruiko
Meeting House Commons LLC.
115 Carter Field Road
North Andover, Ma. 0 1845
RE: Meeting House Commons LLC., North Andover, Ma. 0 1845
MA tds 3) ct C %, jerpwt WV
Dear Mr. Zahoruiko
As you requested I visited the site 6/4/10 to review the installation of the
Engineered Materials consisting of LVLs and Steel Beams utilized in the framing of the
above project for Building One units 3,5,7,and 9.. These are shown on plans prepared
by O'Sullivan Architects Dated 12-17-09 with the framing sheets certified by me 12-17-
09
Based on the above site visit and based on what I could visibly see I can certify
that to the best of my knowledge the of LVLs and Steel Beam members utilized in the
framing as shown on the drawings are installed properly and meet the loading conditions
of the Massachusetts State Building Code for 1&2 Family ResidencesWith the
following exceptions:
The LVL members should be connected together with Fasten Master
Trusslok screws as shown on the drawings sheet AO.1 1. The 10d gun nails used are
not recommended by the LVL manufacturer and are insufficient. You could use 16d
Common nails(. 162 * 3 1/2 ") these are not gun nails, at some locations for some 2 & 3
member boams, 4 member ILIV—Is would still have to be screwed or bolted together. I can
recheck and specify the 16d common nails patterns if you want but I think this would
lead to confusion as some beams will require screws and 16d commons would have to be
hand nailed -
As we discussed at the site Simpson LST20 Twist straps should be added at the
post in the garage at Unit type B where the specified ECCQ caps were left out. For future
framing the ECCQ caps should be used as shown.
I reviewed the 3-2*6 header at the dormer at the bed room for Unit type A for the
4ft window this is acceptable. ( This was David O'Sullivan's item 1. 19,.4/8/10 report).
Also as discussed the garage headers must extend over the wall panels and the
sheathing nail pattern must be followed as shown on drawing AO.9.
This certification assumes that all other framing requirements of the drawings and
code, including but not hmited to materiais, nading schectuies, Mocking, connections and
other details were properly complied with by the licensed construction supervisor
responsible for the project.
Should you have any questions please do not hesitate to call.
Yours truly,
�4wrenc�eH �Ogden P.E.
Cc. David 0' Sullivan
Structural 27765
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