HomeMy WebLinkAboutMiscellaneous - 31 CIDERPRESS WAY 4/30/2018 �1.�"
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�( REScheck Software Version 4.4.0
Compliance Certificate
Project Title: Meeting House Commons
Energy Code: 2009 IECC
Location: North Andover, Massachusetts
Construction Type: Multifamily
Building Orientation: Bldg. orientation unspecified
Glazing Area Percentage: 11%
Heating Degree Days: 6322
Climate Zone: 5
Construction Site: Owner/Agent: Designer/Contractor:
Building 5 Tara Leigh Development,LLC O'Sullivan Architects, Inc.
North Andover,MA 115 Carter Field Road 580 Main Street
North Andover,MA Suite 204
978-6876-2635 Reading,MA 01867
781-439-6166
eI,peai10,�J ���i"� rf �� I•
Compliance:1.1%Better Than Code Maximum UA:645 Your UA:638
The%Better or Worse Than Code index reflects how close to compliance the house is based on code trade-off rules.
It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home.
Floor 1:All-Wood Joist/Truss:Over Unconditioned Space 2948 30.0 0.0 97
Ceiling 1:Flat Ceiling or Scissor Truss 2948 30.0 0.0 103
Front Walls:Wood Frame, 16"o.c. 1296 19.0 0.0 66
Orientation:Unspecified
Double Hung:Vinyl Frame:Double Pane with Low-E 115 0.330 38
SHGC:0.30
Orientation:Unspecified
Casement:Vinyl Frame:Double Pane with Low-E 28 0.280 8
SHGC:0.27
Orientation:Unspecified
Door 1:Solid 60 0.160 10
Orientation:Unspecified
Sides:Wood Frame, 16"o.c. 2106 19.0 0.0 118
Orientation:Unspecified
Window 5:Vinyl Frame:Double Pane with Low-E 140 0.330 46
SHGC:0.30
Orientation:Unspecified
Rear Walls:Wood Frame, 16"o.c. 1309 19.0 0.0 60
Orientation:Unspecified
Window 1:Vinyl Frame:Double Pane with Low-E 236 0.330 78
SHGC:0.30
Orientation:Unspecified
Window 2:Vinyl Frame:Double Pane with Low-E 14 0.280 4
SHGC:0.27
Orientation:Unspecified
Door 3:Solid 60 0.160 10
Orientation:Unspecified
Compliance Statement: The proposed building design described here is consistent with the building plans,specific ons,and other
calculations submitted with the permit application.The proposed building has bee)theEScheck
gned to meet the 2009 C requirements in
REScheck Version 4.4.0 and to comply with the mandatory requirements listed in I s �CtIOn ec t.
Project Title: Meeting House Commons Report date: 09/08/11
Data filename:K:\Zahoruiko\Meetinghouse Commons-No Andover\Meeting House Townhouses\CD's\Building
5\Building_5.rck Page 1 of 6
REScheck Software Version 4.4.0
Inspection Checklist
Ceilings:
❑ Ceiling 1:Flat Ceiling or Scissor Truss,R-30.0 cavity insulation
Comments:
Above-Grade Walls:
❑ Front Walls:Wood Frame, 16"o.c.,R-19.0 cavity insulation
Comments:
❑ Sides:Wood Frame, 16"o.c.,R-19.0 cavity insulation
Comments:
❑ Rear Walls:Wood Frame, 16"o.c.,R-19.0 cavity insulation
Comments:
Windows:
❑ Double Hung:Vinyl Frame:Double Pane with Low-E,U-factor:0.330
For windows without labeled U-factors,describe features:
#Panes Frame Type Thermal Break? Yes No
Comments:
❑ Casement:Vinyl Frame:Double Pane with Low-E,U-factor:0.280
For windows without labeled U-factors,describe features:
#Panes Frame Type Thermal Break? Yes No
Comments:
❑ Window 5:Vinyl Frame:Double Pane with Low-E,U-factor:0.330
For windows without labeled U-factors,describe features:
#Panes Frame Type Thermal Break? Yes No
Comments:
❑ Window 1:Vinyl Frame:Double Pane with Low-E,U-factor:0.330
For windows without labeled U-factors,describe features:
#Panes Frame Type Thermal Break? Yes No
Comments:
❑ Window 2:Vinyl Frame:Double Pane with Low-E,U-factor:0.280
For windows without labeled U-factors,describe features:
#Panes Frame Type Thermal Break? Yes No
Comments:
Doors:
❑ Door 1:Solid, U-factor:0.160
Comments:
❑ Door 3:Solid,U-factor:0.160
Comments:
Floors:
❑ Floor 1:All-Wood Joist/Truss:Over Unconditioned Space,R-30.0 cavity insulation
Comments:
Floor insulation is installed in permanent contact with the underside of the subfloor decking.
Air Leakage:
Project Title: Meeting House Commons Report date: 09/08/11
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LI Joints(including rim joist junctions),attic access openings,penetrations,and all other such openings in the building envelope that are
sources of air leakage are sealed with caulk,gasketed,weatherstripped or otherwise sealed with an air barrier material,suitable film or
solid material.
Air barrier and sealing exists on common walls between dwelling units,on exterior walls behind tubs/showers,and in openings between
window/door jambs and framing.
Recessed lights in the building thermal envelope are 1)type IC rated and ASTM E283 labeled and 2)sealed with a gasket or caulk
between the housing and the interior wall or ceiling covering.
Access doors separating conditioned from unconditioned space are weather-stripped and insulated(without insulation compression or
damage)to at least the level of insulation on the surrounding surfaces.Where loose fill insulation exists,a baffle or retainer is installed
to maintain insulation application.
Wood-burning fireplaces have gasketed doors and outdoor combustion air.
Air Sealing and Insulation:
Building envelope air tightness and insulation installation complies by either 1)a post rough-in blower door test result of less than 7
ACH at 33.5 psf OR 2)the following items have been satisfied:
(a)Air barriers and thermal barrier:Installed on outside of air-permeable insulation and breaks or joints in the air barrier are filled or
repaired.
(b)Ceiling/attic:Air barrier in any dropped ceiling/soffit is substantially aligned with insulation and any gaps are sealed.
(c)Above-grade walls:Insulation is installed in substantial contact and continuous alignment with the building envelope air barrier.
(d)Floors:Air barrier is installed at any exposed edge of insulation.
(e)Plumbing and wiring:Insulation is placed between outside and pipes.Batt insulation is cut to fit around wiring and plumbing,or
sprayed/blown insulation extends behind piping and wiring.
(f) Corners,headers,narrow framing cavities,and rim joists are insulated.
(9)Shower/tub on exterior wall: Insulation exists between showers/tubs and exterior wall.
Sunrooms:
L] Sunrooms that are thermally isolated from the building envelope have a maximum fenestration LI-factor of 0.50 and the maximum
skylight LI-factor of 0.75.New windows and doors separating the sunroom from conditioned space meet the building thermal envelope
requirements.
Materials Identification and Installation:
Materials and equipment are installed in accordance with the manufacturer's installation instructions.
U Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R-value.
Lj Materials and equipment are identified so that compliance can be determined.
0 Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided.
Insulation R-values and glazing U-factors are clearly marked on the building plans or specifications.
Duct Insulation:
Lj Supply ducts in attics are insulated to a minimum of R-8.All other ducts in unconditioned spaces or outside the building envelope are
insulated to at least R-6.
Duct Construction and Testing:
Lj Building framing cavities are not used as supply ducts.
Lj All joints and seams of air ducts,air handlers,filter boxes,and building cavities used as return ducts are substantially airtight by means
of tapes,mastics,liquid sealants,gasketing or other approved closure systems.Tapes,mastics,and fasteners are rated UL 181A or
UL 181 B and are labeled according to the duct construction.Metal duct connections with equipment and/or fittings are mechanically
fastened.Crimp joints for round metal ducts have a contact lap of at least 1 1/2 inches and are fastened with a minimum of three
equally spaced sheet-metal screws.
Exceptions:
Joint and seams covered with spray polyurethane foam.
Where a partially inaccessible duct connection exists,mechanical fasteners can be equally spaced on the exposed portion of the
joint so as to prevent a hinge effect.
Continuously welded and locking-type longitudinal joints and seams on ducts operating at less than 2 in.w.g.(500 Pa).
Lj Duct tightness test has been performed and meets one of the following test criteria:
(1)Postconstruction leakage to outdoors test:Less than or equal to 235.8 cfm(8 cfm per 100 ft2 of conditioned floor area).
(2)Postconstruction total leakage test(including air handler enclosure):Less than or equal to 353.8 cfm(12 cfm per 100 ft2 of
conditioned floor area)pressure differential of 0.1 inches w.g.
(3)Rough-in total leakage test with air handler installed:Less than or equal to 176.9 cfm(6 cfm per 100 ft2 of conditioned floor area)
when tested at a pressure differential of 0.1 inches w.g.
Project Title: Meeting House Commons Report date: 09/08/11
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5\Building_5.rck Page 4 of 6
(4)Rough-in total leakage test without air handler installed:Less than or equal to 117.9 cfm(4 cfm per 100 ft2 of conditioned floor area).
Temperature Controls:
Thermostats exist for each dwelling unit(non-dwelling areas must have one thermostat for each system or zone).A manual or
automatic means to partially restrict or shut off the heating and/or cooling input to each room is provided.
Electric Systems:
Separate electric meters exist for each dwelling unit.
Heating and Cooling Equipment Sizing:
Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code.
For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2009 IECC Commercial
Building Mechanical and/or Service Water Heating(Sections 503 and 504).
Circulating Service Hot Water Systems:
Circulating service hot water pipes are insulated to R-2.
Circulating service hot water systems include an automatic or accessible manual switch to turn off the circulating pump when the
system is not in use.
Heating and Cooling Piping Insulation:
HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-3.
Swimming Pools:
Heated swimming pools have an on/off heater switch.
Pool heaters operating on natural gas or LPG have an electronic pilot light.
n Timer switches on pool heaters and pumps are present.
Exceptions:
Where public health standards require continuous pump operation.
Where pumps operate within solar-and/or waste-heat-recovery systems.
0 Heated swimming pools have a cover on or at the water surface.For pools heated over 90 degrees F(32 degrees C)the cover has a
minimum insulation value of R-12.
Exceptions:
Covers are not required when 60%of the heating energy is from site-recovered energy or solar energy source.
Lighting Requirements:
❑ A minimum of 50 percent of the lamps in permanently installed lighting fixtures can be categorized as one of the following:
(a)Compact fluorescent
(b)T-8 or smaller diameter linear fluorescent
(c)40 lumens per watt for lamp wattage—15
(d)50 lumens per watt for lamp wattage>15 and—40
(e)60 lumens per watt for lamp wattage>40
Other Requirements:
Snow-and ice-melting systems with energy supplied from the service to a building shall include automatic controls capable of shutting
off the system when a)the pavement temperature is above 50 degrees F,b)no precipitation is falling,and c)the outdoor temperature is
above 40 degrees F(a manual shutoff control is also permitted to satisfy requirement's').
Certificate:
A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R-values;window
U-factors;type and efficiency of space-conditioning and water heating equipment.The certificate does not cover or obstruct the visibility
of the circuit directory label,service disconnect label or other required labels.
NOTES TO FIELD:(Building Department Use Only)
Project Title: Meeting House Commons Report date: 09/08/11
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Project Title: Meeting House Commons Report date: 09/08/11
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U L.
Ceiling Roof 30.00
Wall 19.00
Floor/Foundation 30.00
Ductwork(unconditioned spaces): -----
....................
—----------------
Window 0.33 0.30
Door 0.16 NA
Heating System:_---------------- --- ---
Cooling System:__ —--------- ----
Water Heater:
............
........................ ...................
Name: Date:
Comments:
aa. Massachusetts-Department of Public SafCty
Board of Building Regulations and Standards
Construction Supervisor L icens-
License: Cs 55417
Restricted to 00.
THOMAS W ZAHORUIKO
115 CAR tEROEW RD - a
N ANDOVER mA,U'1845 � .
c—
�y�. -` Expiration: 41SM2
C`a+nmisshiner Tr-": 21090
77ie Commonwealth of 1Vmassachuseits
Department of industrial_accidents
Office Oflnvestioations
600 W'Whi oaton Street
Boston, M4 02111
H Wx'-Mas&gov/dia
Workers' Compensation Insurance Affidavit'.Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print 14,5bly
Nameusiuessl r
(B Orgaruzation/Individual):
Address: J
City/State/Zip .-A Phone#. 3 ✓
Are You an employer?Check the appropriate bo=
1.❑ I am a employer with 4. ❑ 1 am a enerai Type of project(require:
g contractor and I
employees(full and/or part-time)-* have hired the sub-contractors 6 New construction
2.® I am a sole proprietor or parmar- listed on the attached sheet 1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. works' comp,insurance.
[No workers'comp.insurance 5. ❑ We are a corporation and its 9. ❑Budding addition
reqs-] officers have exmrised their I O-El Electrical repairs or additions
3.❑ I am a homeowner doing all work right of=cMPtiom per MGL .1 LEI Plumbing rept or additions
myself[No workers'comp. C.
152'
I(4),and we have no 12.[]Roof repairs
required.]t employees- [No workers'
comp.!!� regtrired I3-❑Other
i=_1W ap t�iLaz sh-_ L box- ?must eho jM out fl--=cum=or showing lc Wow'�M*
Homeowners who submit fids affidavit' defier€at!w�and tion hin ��conasct�m�
indicating dhi submit a mew afmdavk mdi=4ng such:. _
•Conttaetors that cbrl this bins must attached an additioaal sheet showing the name of tin
sob-cna�ctom and tbea workers'comp-poficY iaforantim
r am an inforn�on.foyer t is providi>tg workers'co safion iirsrQance f�myemployees Below is the pobcy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.*:
- Fapirafion Date:
Job Site Address:
Cray/Statel7ip:
Attach a copy of the workers'compensation policy declaration page(showing liceo
Farlwe to sexnrE P cy number and expiration date
coverage under Section 25A ofMGL c. 152 can lead to fire imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year inprisomanent,as well as civ il penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the ante cop
fir Be that a
Investigations of this statement may be forwarded to die Office of
. gations of fire DIA�fior insurance " cation. _
I do here4 carvj,ung �a� - 0fP6jWY�t the
in provided is true and correct
Sienature:
- Dam-. U
O. icial use only. Do nnf write in this area, to be compiled by cry or tonin off7d
City or Town: Per�mitucense#/
Issuing Authority(circle one):
L Board of Health Z Bru7dinb Department 3.City/To
wit Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone;
' Date.......��.-..Jlo �..f.
,aORTp
" TOWN OF NORTH ANDOVER
°
PERMIT FOR WIRING
�, 1111.......
�Ss�cHUS� NN •
This certifies that ........./ . ....................... l/
......c .............................
has permission to perform .........l...sw` ... fa. '.....................
wiring in the building of / l�'1,.� 4bc..S".... '� ,
.... 1.111. —1
at1111.3... ....G�o ?.fi�. =. "�....��/,/ Y.... ,North Andover,Mass.
oo
' —Lic.No ....Q.......6 /. .�,
Fee. .✓`� K �� ................ .
LECTRICAL IN
Check Jim
�� 0479
Commonwealth wealth or-Massachusetts Official Use Only
Department of Fire Services Pe�itNo.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
• [Rev. 1/07] -----
Ieave blank
APPLICATION FOR PERMIT TO PERP®RM ELECTRICAL WOR
All work to be pedormed in accordance with the Massachusetts Electrical CodeC),52 CMR 12.00
(PLEASE PMNTIN.INK OR TYPEALL INFO
City or Town o£ TION) Date: l �� S � l�
By this application the undersi ed gives no ' e of his orher'ntention perform the electrical wk d16 the_Tnspector of escribed below.
Location(Street&Number) 3 Cl & - -—S
Owner or Tenantt�
Owner's Address � � LLC_ Telephone No.
Is this permit in conjunction with a building permit? yes O. V
Purpose of BuildingNo ❑ BLDG PERMjT##
_keS t �Iq�- Utility Authorization No.
Existing Service Amps _ / _volts Overhead
❑ Undgrd 0 No.of Meters
New Service Amps /
Number of Feeders and Ampacity --volts Overhead❑ Undgrd 0 No. of Meters
` Location and Nature of Proposed Electrical Work:
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires �3 No.of Ceil:Sus . No.of
p (Paddle)Fans Total.
No.of Luminaire OutletsTransformers KVA
/3 No.of Hot Tubs Generators KVA
Ej
No.of Luminaires { 3 Swimming Pool Above in- o, 131 mergency
nd. rnd. El Batte Units Ig tmg
No. of Receptacle Outlets 0 No.of Oil Burners
FIRE ALARMS No.of Zones
No. of Switches YS' No.of Gas Burners No.of Detection and
No. of RangesInitiatin Devices
No.of Air Cond. Total
L Tons 3 No.of Alerting Devices
No. of Waste Disposers I Heat Pump Number Tons
Totals: .............................
K W No.of Self-Contained
....................... .. . ........
DetectLn-Alertin Devices (p
No.of Dishwashers L Space/Area Heating KW Local❑ Municipal
No. of Dryers r Connection El Other
rY Heating Appliances KW Security Systems:
No. of Water No.of No.of Devices or Equivalent
Heaters KW Si No.of Data Wiring:
Signs Ballasts No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of MotorsTotal HP Telecommunications Wiring:
•
OTIMR: No.of Devices or E uivalent
Estimated Value o(Ele trical Work: °p (When required by municipal policy.)
Attach additional detail if desired, or as required by the Inspector of Wires.
Work to Start: 11 1 S 1 Inspec''ons to be requested in accordance with AMC 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 cove e is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER
I'cert, under th pains and penalties o er'u that the information on this application is trace and complete-
FIRM NAME: fP aY,
L
Licensee:���,���� nA LIC.NO.
� /N� l�.r; Signature ej��
(If applicabje, a er exem t' in the license number line.) LTC.NO.: Z
Address: IMiS Bus.Tel.No.:
"Per M.G.L. c.1 s.57-61,s curity work requires Department of Public Safe S Licen Alt'Tel.No..
OWNER'S INSURANCE WAIVELTC
R: I am aware that the Licensee does not have the liability insurance coverage normally.
required by law. $y my signature below,I hereby waive this requirement. I am the
Owner/Agent (check one)[]owner ❑owner's agent.
Signature Telephone No. PSE
RMIT FEE: $
ELECTRICAL PERMIT NO. INSPECTION REPORT: '
ELECTRICAL INSPECTOR-DOUG SMALL
1.ROUGH INSPECTION:
Passed– Failed–[ ] Re-inspection required($50.00)-j ]
Inspectors'comments:
r-
(Inspectors'#gnature 4no initials) Date
2.FINAL INSPECTION:
Passed– Failed–[ ] Re-inspection required($50.00)-j ]
Inspectors'c mments;
(Inspectors'S' natur no initials) Date y
3.UNDER GROUND INSPECTION: :—
Passed–[ ] Failed–[ ) Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials) Date
4.INSPECTION–SERVICE:
DATE CALLED NATIONAL GRID: NAME:
Passed–[ ] Failed–[ ] Re-inspection required($50.00)-[ ]
Inspectors' comments:
(Inspectors'Signature-no initials) Date
5.INSPECTION-OTHER:
Passed–[ ) Failed–[ ] Re-inspection required($50.00)-[ )
Inspectors' comments:
(Inspectors'Signature-no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
L
The Commonwealth ofMassachusetts
Department of Industrial'.Accidents
Office of-Investigations
600 Washington Street
Boston,MA 02111
UV
www.mas..govldia
Workers' Compensation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.Applicant Information. Please Print L' eaibly
NaMO(B.usiness/Organization/individual): A 0.4&j4c to
Address:
City/State/Zip: 4A./�,�O-J _ Al%4 03 f fr Phone#: Z p
A,re�u an employer?Check the appropriate box: FO
-ect(required):
1•Lv� 1 am a employer with�o _ 4. ❑ I am a general coniractox and Iconstruction
employees(full and/or part time). have hired the sub-contractors
2.❑ I am a solepxoprietor orpartnex- listed on the attached sheet.? deling .
ship an l have no employees These sub-contractors have lition
working forme in any capacity. workers'comp.insurance. ing addition
' [No workers'comp,insurance 5. ❑ We axe a corp oration and its
required.] officers have exercised their ical repairs or additions
3.❑I am a homeowner doing all work right of exemption per MGL ing repairs or additions
myself,[No workers'comp. c.152,§1(4),and we have no 12.❑Roofrepairs
insurance required.]i employees.[No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box 41 must also fll out the section below showing their workers'compensation policy information.
T HomeoWners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
-1,77n an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: cU . I A)S
Policy#or Self-ins.Lie.#: Expiration Date:
lob Site Address: G tlb6 w S City/State/Zip: IVO , k.✓��t.(/�
Attach a copy of the workers'compensation policy declar ion 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
fma up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA.for insurance coverage verification.
Ido hereby cert y under the pains andpenaldes ofperjury that the information provided above is true and correct.
Si ature: Date:
Phone#:
Official use ox y Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
-Issuing Authority(circle one):
:L Board of$realth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.I'lumbingImpector
6.Other
C ontactPerson: hone 4:
Date././/7X/ . . . . ..... .
NORTH
o� °•° TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
. y
SACHUSESS ~
This certifies that . . �e . . '�� � . . . . . . . . . . . . . . . . . . . . G
has permission for gas installation ��/ '�✓.�-�'S. f��� .•. . . . . . .
in the buildings 9f . e-�l�.%�!�`�� . .<<C-. . . . . . . . . . . . . . .
at . . . . . . . . . . . , Z:rth� ndover, Mass.
Fee./W P�?. Lic. No.�> JS 7 � H? ''�7. .
GAS INSPECTOR
Check#
7909
91 V7 Date.
40R'M TOWN OF NORTH ANDOVER
Of�„'D ,•1�0
PERMIT FOR PLUMBING
-Ts US
�f 7
This certifies that . . !.'.�/��. . . eILC��//. . . . . . . . . . . . . . . . . . . . .
has permission to perform . .1211w. r�. .!�''?`'�',r�. . . . . . . . . . . . . .
plumbing in the buildings of . /'�'� � �'�'-� ICC
at. . ..�� . ��'/��?f SSS. . . . . . . . / , North Andover,Mass.
Fee!,P� ,5�7.Lic. No—B /S7 . hI�c/ .!/�r<if>r� '. . . . .
/Oc� PLUMBING INSPECTOR
Check 'I �G
G'
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: 1? , MA. Date: Permit#
J` Buildin Location: ✓es-s
9 �� � �l sQ Owners Name: r L'
V
Type of Occ pancy: Commercial E] Educational F] Industrial Instituttonal Residential
New:of
❑ Renovation: Re
❑ Replacement:ent: ❑ Plans Submitted: Yes❑ No❑
FIXTURES
do co co
1�. Ix
Z w co
HN L) =
m = O W w 00 to H O = = w
O Z Z p tY w w w O i— p
Lu W UJ m 0 F- W O Q F'
to V WQ' 0 Lu in 0 LLI C3 = Ii
ZW
Z w Q' t/) =1 Q Q m W O Z O 1- F— W F- FW, W
V o o I=i CW7 = _ O a W - > > > O
SUB BSMT. e
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
6 FLOOR
6 FLOOR
7 FLOOR
8 FLOOR
Installing Company Name:
Check One Only Certificate#
�/y
❑Corporation
Address: City/Town: h State:
❑Partnership
Business Tel: ��U.3` E3—/,?Z� Fax:
❑Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes u-<o❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 1:1 Agent ❑
By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
[APPROVED
�� �� Type of License: ,l
❑Plumber
le VMaster s Fitter Sign ure of Licensed Plumber/Gas Fitter
City/Town ❑Journeyman License Number: f� /,� 7
OFFICE USE ONLY ❑LP Installer
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office oflnvestigations
600 Washington,Street
Boston,MA 02111
pV
www mass gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
_Applicant Information
Please Print Legibly
Name(Business/Organization/individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
1•❑I am a employer with 4. Type of project(required):
❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6 El New construction
2.❑ I am a sole proprietor or partner- listed on the attached shgget.t 7. ❑Remodeling
ship and have no employees These sub-contractors have S. [)Demolition
working for mein any capacity, workers'comp,insurance.
[No workers'comp,insurance 5. ❑ We are a corporation and its 9. ❑Building addition
required.] .officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1111 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no
insurance required.]t employees. 12.❑ocheRoorepairs
[No workers
comp,insurance required.) 13.[]Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#:
Expiration Date:
Job Site Address: ,
City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA,for insurance coverage verification.
t do hereby certify under thepains andPenalties ofperjury flnt the information ,
provided above is true and correct.
Signature,
Bate:
?hone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town CIerk 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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall'withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers;compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,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�s a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
Policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a homeowner or citizen is obtaining a license or permit not related for any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOTrequired 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:
xlze Coon;%�eaitla,of l�assacl�tzsetis '
Department of Industrial Accidents
Ofce of Investigations
600 Washington Street
Boston;MA,02111
Tel-#617-727-•4900 ext 406 or 1.-877-MAMA.FE
Revised 5-26-05 Fax#617-727-7749
WWW-Mass.g-ov/dia
r Date. /?Z //?.. . . . . ... ..
NOFTN
4,
TOWN OF NORTH ANDOVER
• . PERMIT FOR GAS INSTALLATION
,SSACMUSEt
,�/
This certifies that .l. l��./.1.�'�e r. . . . . . . • • •LL• • • • • • • • • • •
has permission for gas installation . .
in the buildings of ./. . . ... hrd. . . . . . . . . .LC-
at . . . . . • . • • • • • , North yA�ndo/ve}; Mass.
J�ee'.A1P.!� Lic. No/S/s7. . . ,. . . . . . . .
GAS INSPECTdR
Check#
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTNResidential
City/Town: /�, MA. Date: / Permit#
Building Location:�. P„ lie Owners Name:
Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional ❑New: Alteration:❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Y
FIXTURES
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Address: ' (�► City/Town: State:
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Business Tel:_�v C�� -- �S'� —/�S � Fax:
Name of Licensed Plumber/Gas Fitter:
�� El Firm/Company
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No El
you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of indemnity ElBond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
By checking this box I];I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License: l(Jr
❑Plumber
Title ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter
❑Master
City/Town ❑Journeyman _
APPROVED OFFICE USE ONLY. ❑LP Installer License Number:__/ -� 7
i
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA. Date: / (�
Permit#
Building Location:
Owners Name:
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New:❑Alteration:❑ Renovation:
❑ Replacement:❑ Plans Submitted: Yes❑ No❑
FIXTURES
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Address ) City/Town: l El Corporation
.� State:��
7 —/ El Partnership
Business Tel:-_ ['- � /��S Fax:
El Firm/Company
Name of Licensed Plumber:
INSURANCE COVERAGE:
I have a current Iia�Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑
If you have checked Yes,please indicate the-type of coverage by checking the appropriate box below.
A liability insurance policy. Other type of indemnity E] Bond
OWNER'S INSURANCE WAIVER:I am aware that the licensee does Ve the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Si nature of Owner or Owner's A ent Owner ❑ Agent ❑
1 hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and fo R
Knowledge and that all plumbing work and installatlons Performed under the permit issued for' application wil!be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. accurate to t.,�bast o,my
3y
Type of License: �� l
"itle X
❑plillmber Signage of Licensed Plumber
Ity/Town Master
PPROVE (OFFICE USE ONLY] ❑Journeyman License Number: ��J�
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
5�
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsXlectrlicians/Plumbers
.Applicant Information
Please Print Le�biy
Name(Business/Organizationgndividual):
Address:
.City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
1.❑I am a employer with 4. LEW
project(required): -
❑I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractorsew construction
2.[] I am a sole proprietor or partner- listed on the attached sheget.temodeling
ship and have no employees These sub-contractors have B. emolition
working for me in any capacity. workers'comp.insurance.
[No workers'comp.insurance 5. ❑ We are a corporation and its ilding addition
required.] .officers have exercised their ectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL umbing repairs or additionsmyself.[No workers' comp. c.152, §1(4),and we have noinsurance required.]T em to ees. ofrepairsP y [No workers'compinsurancerequired.] her
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
lam an employer that is providing workers'compensation insurance
information. for my employees Below is tlae policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine UP to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
t do hereby certify under the ains and en o j ry
P P fper u that the information provided above is true and correct.
Signature-
?hone
i ature:?none#:
Official use only. Do not write in this area,to be completed by city or town official. •
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/T9"Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person:
Phone#: