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Miscellaneous - 316 RALEIGH TAVERN LANE 4/30/2018
316 RALEIGH TAVERN LANE - 316 RALEIGH TAVtKN LAM 210/107.A-0129-0000.0 n Lane 210/107.A-0129-0000.0 - Date....,., .. ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHUSE a i This certifies that .... .. .r. - k...... .................................................................. has permission for gas installation �r, n�., K�/, ................. inthe buildings of.. ............................................................ ...................................... at.,: q..1 .................... .., 9rth Andover, Mass. ......... ...... Fee,3(:. P.. Lic. No. /...4../ .. .:_ L..................................... GRAS INSPECTOR Check#�.�.� �r (�/ n � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE 3/17/16 PERMIT# JOBSITE ADDRESS LEIGH TAVERN RD OWNER'S NAME I JOSH LOBEL GOWNER ADDRESS I SAME TEff 917-968-6953 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALE] PRINT CLEARLY NEW:O RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO[] APPLIANCES-1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .._ - I .1 ems,_-1 i.—_ - N BOOSTER CONVERSION BURNER _ COOK STOVE X ,m I_�' � 1 T __. =A DIRECT VENT HEATER �I�"' DRYER -- �— v--_ FIREPLACE FRYOLATOR — FURNACE GENERATOR PP I� _� �I = _-- GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER1^ -- --� — ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _ . ==jj = �- a ��I _ '� UNVENTED ROOM HEATER v �- OR I -_ —� WATER HEATERTHE � INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 complian with all en rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I MIKE NOVICK 1 LICENSE# Q_2F"/ SIGNATURE MP© MGF 0 JP❑ JGF 0 LPGI CORPORATION D# 147C PARTNERSHIP❑# LLC❑#� COMPANY NAME: HOLDEN OIL INC. ADDRESS 191 LYNNFIELD STREET CITY I PEABODY STATE MA ZIPJ 01960 ITEL 978-531-2984 FAX 978 5314321 CELL EMAIL MARKL@HOLDENOIL.COM ,r„ -, 4 I I I I I � �l1 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations r 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): HOLDEN OIL INC Address:91 LYNNFIELD STREET City/State/Zip: PEABODY MA 01960 Phone#:(978)531-2984 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 45 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no GAS FITTING employees. [No workers' 13.X Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:HDI GERLING AMERICA INSURANCE CO. Policy#or Self-ins. L`ic. #:EWGCD000014516 Expiration Date: 12/31/2016 '1 Job Site Address:., Cc. 1291—d) ,�-(-1 7� V?_6J RA 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA fo insurance coverage verification. I do hereby ce . and e p ins d penal ' s o perjury that the information provided above is true and correct. Simature: Date: a Phone#: 9785312984 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1 i Iy is as3:COMMONWEALTH OF MA$' ACHUSF`1'"i' 1`< BOARD Of PLUMBERS >AND GASEITTERS +> I SSUES. THE FOLLOWING L LCE_NSE 'CEN_ LI CENSFD AS AN LPG>AS INSTALtER EL �ry 4 B L A I R 7EIt FEA'BOi3Y:»' MA 01:960-51,d li?79 05/01/1F 228f; i P, 1 Communication Result Report ( Dec. 14. 2015 2: 33PM ) 1) Town of North Andover 2) Community Development Date/Time : Dec. 14. 2015 2: 22PM File Page No. Mode Destination Pg (s) Result Not Sent ---------------------------------------------------------------------------------------------------- 6243 Memory TX 817819423800 P. 30 OK ---------------------------------------------------------------------------------------------------- Reason for error E. 1) Hangup or line fail E. 2) Busy E. 3) No answer E. 4) No facsimile connection E. 5) Exceeded max. E-mail size E. 6) Destination does not support IP-Fax Commonwealth of Massachusetts Sheet Metal Permit Datc:On+ z$ LS Pemrit$��� BsSmaledJob Cost PemutFee:$ Plans S.b M&YES_NO✓ Plans M%m-ed:YES_NO— Bus'ruess License#— Applicant License# Business lnfonnstion: property 0wnerl7ob Lomtionh&—afl n- Namel od�1 1 w AL2_ Name• SZan, .�l'�I rJ Sheet:•;tln RAk,Al TqQ--YY 12 City/r.":V�,a n�,1&!a] City/1..: n)�ekv� Telephone-l.scl-qq4-1030 Telephone: '7$1-3'i5-(o'l48 Photo I.D.nqui,ed/Copy of Fboto I.D.attached YES ✓ NO Butt7diug Type: Ftc4deadd; 1-2 faniliy i Multi family_„ Condo I To=houms_ . conunetciaL'officc^ Bctail— Industrial— Eduratid— Instiueflonm_ Buildiug Cubic Foptege: under 35,000 a,.ft.— over 35,000 cu.R. 6hoet nrehduork to be completed New Virork:-j,- Renovafioa: HVAC, McWRoofmg_ Kitohw BabaustSysbem_ CA,imney/yams_ . Pmvide Wddescripdon of workto be done: . �T W J Date........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 'his certifies that ....I......i................................................ has permission for gasallation ... ..................... inthe buildings of...........IP ..0.. ............................................................................... at........3A.LP..Pr'SS ......k.6 0 O.North Andover, Mass. k:vp Fee..60......... Lic. P . .... I...... ..................................................................... GASINSPECTOR Check# 2 62 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kw�o�j V 240 V`! CITY N ANDOVER MA DATE 10/27/15 PERMIT# JOBSITE ADDRESS 316 RALEIGH TAVERN ROAD OWNER'S NAME I RONN COLTIN G OWNER ADDRESS SAME TEC NIA FAx N/A TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:Q RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NOQ APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR N FURNACE 1 1 GENERATOR G1 GRILLE �1 INFRARED HEATER LABORATORY COCKS. MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTEDROOM HEATER WATER HEATER OTHER. . ,J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT , 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bLest of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com li ith Wertin ision the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Michael J Guida Sr. LICENSE# 15091 E MP[] MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 3643 PARTNERSHIP❑#0 LLC❑#1 COMPANY NAME:j Cooling Unlimited INC. ADDRESS 1,565 A Main St CITY Reading STATE Ma ZIP 101876 TEL 781-944-1030 FAXI I CELLI 781439-0788 EMAILmguida@coolingunlimited.com 1 d` ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apulicant Information. Please Print Leeiblv Name(Business/Organization/Individual):COOLING UNLIMITED INC Address:565 A MAIN ST City/State/Zip:READING MA 01876 Phone#:781-944-1030 Are you an employer?Check the appropriate box: Type of project(required): 1.O I am a employer with 15 employees(full and/or part-time).* J. New COristruCtlori 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.a I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions proprietors with no employees. 12.R]Plumbing repairs or additions 5.a I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ASSOCIATED INDUSTRIES OF MA Policy#or Self-ins.Lic.#:WMZ8008005492013A Expiration Date:6/22/16 Job Site Address:316 RALEIGH TAVERN RD City/State/Zip: N ANDOVER MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer der th d pen I' of perj that the information provided abov is trued correct Si nature: AylDate: Phone#:781- 4'103Y 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/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 4 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 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 as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia i film Pi leol • e e BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLU GING CORP ° MICHAEL J GUIDA SR COOLING UNLIMITED INC 18 NEWTON ST W EVERETT MA 02149 pS/ .1/lb QZK7 • . q. COMMONWEALTH OF MASSACHUSETTS • • e e BOARD'OF PLUMBERS ,AND GAS.FITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTER P UMBltR:'} 'Commonwealth of Massachusetts ' r ,r r v Departnierit - Pubilc Safety M 1 CHAE.L' J GUIDA SR License PM-29812': 0 18 NEWTON ST PE�ie#fitter Master pp r;y MICHAEL J GUIDA;S© �~ EVERETT MA 02149-1722 18 NEWTON ST Everett MA 02119 ,' 19 COMMONWEALTH OF.MASSACHUSETTS BOARDOF SExpiration: ' PLUMBERS' AND GASF ITTERS 03/20/2017 Commissioner . ISSUES THE FOLLOWING LICENSE LICtNSED AS A MASTER GASFITTER liICk1d1EL J GUIDA SR 18 NEWTON ST. �: + EVE RETT MA 02149{-1722 _ LCOMMONWEALTH OF MASSACHUSIETTS MIN • e , • e BOARD pp , PLUARERS AND GASP ITT'ERS ISSUES THE FOLLOWING •LICENSE 1 L I C.-ENS'ED AS A JOURN�EY'MA'V UML S' I � . H�i'C►iAEL 'J GUI DA SR 18 NEWTON ST i ERIE°RE"TT MA 02149-1.72\.2`yl' y i Date.... . ............ O ,k0AT#j '� TOWN.OF NORTH ANDOVER PERMIT FOR WIRING sSACHU This certifies that .......... . .. ............................................................. has pe scion to�eifb.... ..—, ............ ............................ ........ ........P........ wiringin the building of ........................................................................................ at ....�Ap...... ...... ..................North Andover,Mass. Fee...`�P7.........Lic.No. Y.A .................................................................................... ELECTRICAL INSPECTOR Check It 2 Q0 3 3 /� 00// i l.ommonwealth of Vaejac4wetb Official iUse Only Acc c7 Permit No. partment o/_tire Service Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1107] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: // - a O T 1!T_ City or Town of: &irTH At4 IJoy 1, 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) 316 R Ri,F1 1'f rA14e-4 l L A Al C Owner or Tenant go aty C 24 t/l Telephone No. `�7? 7-& 6 79� Owner's Address Is this permit in conjunction with a building permit? Yes rX No ❑ (Check Appropriate Box) Purpose of Building 1,2 C°'1 I n® Utility Authorization No. Existing Service Amps J / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Wor �er � l r `✓ its eP 4<0 AX 1 & rNo. t &/T' fdf Com letion o the of win table m be waived b the Ins ector o Wires. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grud. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and Initiating Devices ol No.of Ranges No.of Air Cond. 3Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Togs KW No.of Self-Contained Totals: (' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications 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: Q da,C`" (When required by municipal policy.) Work to Start: /`7 /,I'- 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 .® BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: " ),ler4c. LIC.NO.: -,A Licensee: ��r�s��,o�er �a IZos, Signature LIC.NO.: JC90 -,rj (Ifapplicable,enter "exe pt"in the license number line.) Bus.Tel.No.: >fI-710-S907 Address: S , �'a .54. $ r ,;, O 3 Alt.Tel.No.: *Per M.G.L.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 owner ❑owner's a ent. Owner/Agent PERMIT FEE $� �-- Signature Telephone No. v / �,�z�,� � �� �� � �� . � E �� �� � i i I a CONINIONWEAI.TH OF MASSACHUSETTSB ARD ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REG JOURNEYMAN ELECTRICI �II CHRISTOPHER P DEROSA � I 5 FAIRFAX ST BURLINGTON MA 01803-2830 10904 B 07/31/16 39035coma { Go,hii;ohiV4th.ofMas usetts ' Divisionof.Registrati , :a 4 Board of ftgctn t s GHRIST y 5 FAIRF 1= -'BURLING 4 Master Bec ' 'a te/ 21712-A 07131/2016 408791 Serial No Ex iration•Date. °t License No. P , The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 -- Boston,MA.02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE TILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibiv Name(Business/Organization/Individual): DCR054 /,c4-ri c Address: City/State/Zip: BcN-1- J-a, MA, 017o3 Phone#: 78/- 7/0-S Fo 7 Are you an employer?Check the appropriate box- Type of project(required)' 1.0 I am.a.employer with 3. : employees(full and/or part-time).* 7. Q New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3..Q I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10[)Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.®Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.F1 Other 152,§1(4),and we have no.employees.[No workers'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 Us affidavit indicating they are doing all work and then hire outside contractors must sgbmit a new affidavit indicating such tContractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,ley must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'.Below is the policy and jolt site information. Insurance Company Name: Policy#or Self-ins,Lic.#: Expiration DateA:, fob Site Address- 3/6 R a.I e i q h -&,V e r!) L n. City/State/Zip:/V An Jove�/I A 0/8`/S Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 7doliereby ce un the ins and penalties ofperjury that the information provided above is true and correct. I aO-/Sre: Date: Phone#: 781- 7/o- 5407 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/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6,Other Contact Person: Phone#: 4 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 liire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out the workers'compensation affidavit completely,by checking the'boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents foi•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 yo'u'are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter-their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 389 Date lol A.�•1-••...... pE i N NOFTN TOWN OF NORTH ANDOVER h0 02 ,. s1p� PERMIT FOR MECHANICAL INSTALLATION f D 49 SACHUSEt This certifies that -.i?Q� � v . .1,�w1 !' `.�. • • . has permission for mechanical installation x in the buildings of . . .r'^ C`7. .4l."`: . . . . . . . . . . . . . . . . . . at . � . . . .i.> .a��'!� ,-Northdover, Mass. Fee. .. t>f..f' Lic. No.. . . . . . . . . . . . . ; . GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date : Z T, i s Permit# �� Estimated Job Cost: Aq too Permit Fee: $ Plans Submitted: YES NO ✓ Plans Reviewed: YES NO Business License# Applicant License# Business Information: Property Owner/Job Location Information: Name: od Name: Zb .} ' `3 es 1�-/� —�-�--- Street: 31 Street: S( City/Town: An� U�Fs[�l City/Town: 1Q )61^-v0 v C Telephone: 44 H b 3 C) Telephone: 79 I -3015 Photo I.D. required/Copy of Photo I.D. attached: YES NO Building Type: Residential: 1-2 family v Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: r-, Renovation: HVAC Metal Roofing Kitchen-Exhaust System Chimney/Vents Provide brief description of work to be done: o J r nJ ALe S uJ I I INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes❑ No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bbnd FT— OWNER'S T "OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box(],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ Check at www.mass.gov/dpl Inspector Signature of Permit Approval Date It .. ..... . 389 . H°RTM TOWNNORTH ANDOVER 1 f =°y`.�.•� �°� o°� IT FOR MECHA�NICAL INSTALLATION ON PERM 3 � ° F f • + � a c• ,SSACHUSE This certifies that `C �- hasP ermission for mechanical installation . in the buildings of . . -- �l Nort • , h d-over., Mass. at . . . . .�`�. . . . . . . . . . : . Fee. , Llc. No.• ' ' GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer 400MMONW6U OF M • mo Lejaggel • SHEEN NOTAL W01K;ERS„ )SSUES THE fOLLOW)1VG`LIC£NSE S `AMASTERNl2l STR1 5!r j �1 CHARVES A BROWN. 396 SALEM 5TREET: f � 16 � i kY 1 M I NGTQN , A 01887-12 \ 66 04Y 8 1£r 232743 f i Th7 e Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation p ton Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please PrintApplicant Information Please Print Legibly Name(Business/Organization/Individual):COOLING UNLIMITED INC Address:565 A MAIN ST City/State/Zip:READING MA 01876 Phone#:781-944-1030 Are you an employer?Check the appropriate box: Type of project(required): LE]I am a employer with 15 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doingall work myself 9. ❑Demolition y [No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.R]Plumbing repairs or additions 5.C3 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.$ 13.❑Roof repairs 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ASSOCIATED INDUSTRIES OF MA Policy#or Self-ins.Lie.#:WMZ8008005492013A Expiration Date:6/22/16 Job Site Address:316 RALEIGH TAVERN RD City/State/Zip: N ANDOVER MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer der th d pen 1 ' of perj that the information provided abov is true d�correct Si nature: Date: Cfl�7 � Phone#:781- 4 -103 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/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: aco CERTIFICATE O °"TE'M►��°""") F LIABILITY INSURANCE 6/9/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COMTNAMEACT Select Dept. ext 66807 Eastern Insurance Group LLC PHONE (508)651-7700 FAXIC,NO- 1781}586-62�f 233 West Central Street -MR AESS:selectwork@easterninsurance.com.selectwork®easterninsurance.com INSURER(S)AFFORDING COVERAGE NAIC 9 Natick MA 01760 INSURERA:The Netherlands 24171 INSURED INSURERB.EXCelBiOr Insurance Company 11045 Cooling Unlimited Inc. INSURERC:Peerleas Ina CO 24198 565 Main Street INSURER D.Assoc Industries Mass Mutual INSURER E: Reading MA 01867-3135 -INSURER F COVERAGES CERTIFICATE NUMBER:Master 15-16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE A POLICY NUMBER MOLICY EFF MMNDTYYYY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 X COMMERCVLL GENERAL LIABILITY DAMAGE T RENTED PREMISES Eaoccun n $ 100,000 A CLAIMS-MADE OCCUR EP1056836 /10/2015 /10/2016 MED EXP(Any one person) $ 5,000 PERSONALS ADV INJURY $ 1,(700,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PROLOC _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaccident) 11000,000 B ANY AUTO BODILY INJURY(Per person) S ALL OWNEDX SCHEDULED 1056837 /10/2015 /10/2016 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X AUO OSS NED TPROPERTY DAMAGE $ Pr $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 11000,000 C EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTIONS 10,OOC L8916944 /10/2015 /10/2016 D WORKERS COMPENSATION WC STATU- OTH- $ AND EMPLOYERS LIABILITY YIN XFR ANY PROPRIETOPJPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1 OFFICERIMEMBER EXCLUDED? NIA ,000,000 (Mandatory in NH) 80080054922015A /22/2015 /22/2016 E.LOISEASE•FAEMPLOYE S 1 000 000 If yes,desaibe under - DESCRIPTI�J OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N mwe space Is required) Heating/Cooling Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Evidence of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE John Roegel/PRG I ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. I1%10025 oninnsm Tho aropri n�mn�nri 1n„n ern rnnic*o ri m2r4e of Gr npn Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 First Floor Breakdown Item Name U-Value /SHGC Net Area Htg. HTM. Clg. HTM Sens. Htg. Sens. Clg. Lat. Clg. Total Clg. Construction Type First Floor 0 , 1707 . 0 1707 Dining Room 0. 460w 400 860 North Wall 0.24 56 18 7:55 :1008 423 0 423 Frame Wall/PartitionINAINAlWoodINoneiNoneiNAISiding or StuccojNA Window-8x5 0.66/0 40 '49.5 25.55 1966 1022 0 1022 OperablelBay WindowjClearj2 PanelWood;Wood with Metal Clad, or Vinyl Entry0 .0 0 0 South Wall 0.24 75' 18 7.56 1350 567 0 567 Frame Wall/PartitionINAINAlWoodINonelNoneINAISiding or StuccoINA % D6or-3x7 0.29 21 2115 9 457 189 0 189 MetallPolyurethane CorejNo.Storm Family Rodm 0 460 400 860 _T South Wall 0.24 . 80 18 7.56 1440 605 0 605 Frame Wall/PartitionINAINAlWoodINonelNoneINAISiding or StuccoINA Window-6x4 0.57/0.56 24 4215 34.42 1026 826 0 826 OperablejNormal WindowjClearj2 PanelWood, Wood with Metal Clad, or Vinyl East Wall 0.24 144 18 8.88 2592 1279 0 1279 Frame Wall/PartitionINAINAlWoodINonelNoneINAISiding or StuccoINA North Wall 0.24 62 18 7.56 1116 469 0 469 Frame Wall/PartitionINAINAlWoodINonelNoneINAISiding or StuccoINA Window-6x7 0.57/0.56 42 42.75 22.21 1795 933 0 933 Adtek Accul-oad Report Version 7.0.1 Page 17 Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 OperablelNormal WindowjClearj2 PanelWood, Wood with Metal Clad, or Vinyl Kitchen 0 3860 400 4260 South Wall 0.24 56 18 7.55 1008 423 0 423 Frame Wall/PartitionINAINAlWoodINonelNoneINAISiding or StuccojNA Window-8x5 0:57/0.56 40 49:162 39:58 1966 1583 0 1583 OperablelBay WindowjClearj2 PanejWood;Wood with Metal Clad, or Vinyl North Wall 0.24 88 18 7.56 1584 665 0 665 Frame Wall/Partition INAI NAIWoodINone INoneINAISiding or StuccoINA Window-2x4 0.57/0.56 8: 42.75 22.25 342 178 0 178 OperablejNormal WindowjClearj2 PanejWood, Wood with Metal Clad, or Vinyl _ Living Room _ 0 1621 400 2021 Floor 0.295 968 22.125' 1997 530 0 530 Floor Over Enclosed Unconditioned Crawl Space or BasementlNo Insulation on Exposed Walls, or Vented Space IPassivelNAI No.InsulationICarpet or HardwoodINAINA North Wall 0.24 56 18 7.55 1008 423 0 423 Frame Wall/PartitionINAINAlWoodINoneINoneINAISiding or StuccoINA Window-8x5 0.57/0.56 40 42.75 222 1710 888 0 888 T OperablelNormal WindowjClearj2 PanelWood, Wood with Metal Clad, or Vinyl West Wall 0.24 160 18 7.56 2880 1210 0 1210 Frame Wall/PartitionINAINAlWoodINoneiNoneINA[Siding or StuccojNA South Wall 0.24 56 18 7.55 1008 423 0 423 Frame Wall/PartitionINAINAlWoodINonelNoneINAISiding or StuccoINA Window-8x5 0.57/0 40 42.75 34.43 1710 1377 0 1377 OperablejNormal WindowjClearj2 PanejWood, Wood with Metal Clad, or Vinyl Adtek Accul-oad Report Version 7.0.1 Page 18 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Second Floor Breakdown Item Name LI-Value /SHGC Net Area Htg. HTM. Clg:HTM Sens. Htg. Sens. Clg. Lat. Clg. Total Clg. Construction Type Second Floor 0 1707 0 1707 Bath 1 0 - 0 -0 . . 0 South Wall 0.091 60 6.825 2.42 410 145 0 145 Frame Wall/PartitionINAINAlWoodIR-13INoneiNAISiding or StuccoINA Window-2x2 0.57/0 4 42.75 34.5 - 171 138 .0 138 Operable I Normal WindowjClearj2 PanejW6od, Wood with Metal Clad, or Vinyl East Wall 0.091 48 6.825 . 2.42 328 116 0 116 Frame Wall/PartitionINAINAlWoodIR-131NoneINAISiding or StuccoINA Bath 2 — 0 0 0 0 _.._. South Wall 0.091 44 6.825 2.41 300 106 0 106 Frame Wall/PartitionINAINAlWoodIR-131None INAISiding or StuccoINA Window-2x2 0:57/0 4. 42.75 34.5 171 138 0 138 OperablejNormal Window1dear12 PanelWood, Wood with Metal Clad, or Vinyl Bed 0 i 460 400 860 East Wall 0.091 100 6.825 2.41 682 241 0 241 Frame Wall/PartitionINAINAlWoodIR-131NoneINAISiding or StuccoINA Window-2x5 0.57/0 10 42.75 64.2 427 642 0 642 OperablelNormal WindowjClearj2 PanelWood, Wood with Metal Clad, or Vinyl Window-2x5 0.57/0 10 42.75 64.2 427 642 0 642 OperablejNormal WindowjClearj2 PanelWood, Wood with Metal Clad, or Vinyl North Wall 0.091 96 6.825 2.42 �W655 232 0 232 Adtek Accul-oad Report Version 7.0.1 Page 19 ` Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Frame Wall/PartitionlNAINAIWoodIR-131 None INAISiding or StuccolNA Bed 2 0 230 200 430 North Wall 0.091 86 6.825' : 2.41 587 207 0 207 Frame.Wall/PartitionlNAINAIWoodIR-131NoneINAISiding or StuccolNA Window-2x5 0.57/0 10 42:75 ' 22.2, 427 - 222 0 222 OperablelNormal WindowlClearl2 PanelWood;Wood with Metal Clad, or Vinyl West Wall 0.091 86 6.825 2.41 587 207 0 207 Frame Wall/PartitionlNAINAlWoodlR-131 None INAISiding or StuccolNA Window-2x5 0.57/0 : 10 42.75 64.2 427 642 0 642 OperablelNormal WindowjClearj2 P n )Wood, Wood with Metal Clad, or Vinyl Bed.3 _ - 0 230 200 430 West Wall 0.091 70 6.825 2.41 478 169 0 169 Frame Wall/PartitionlNAINAIWoodIR-13INoneINAISiding or StuccolNA Window-2x5 0.57/0 10 42.75 . 64.2 427 642 0 642 OperablelNormal WindowlClearl2 PanelWood,Wood with Metal Clad, or Vinyl South Wall 0.091 86 6.825 2.41 587 207 0 207 Frame Wall/Partition NA NA Wood R-1 31NoneINAISiding or Stucco NA Window-2x5 0.57/0 10 42:75 34.4 427 344 0 344 OperablelNormal WindowlClearl2 PanelWood, Wood with Metal Clad, or Vinyl Closet 0 0 0 _ 0 South Wall 0.091 24 6.825 2.42 164 58 0 58 Frame Wall/PartitionlNAINAIWoodIR-131NoneINAISiding or StuccolNA Office 0 1607 239 1846 Ceiling 0.049 807.68 3.675 2.7 2968 2181 0 - 2181 Adtek Accul-oad Report Version 7.0.1 Page 20 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Ceiling under FHA Vented Attic or Attic Knee Wall, No Radiant BarrierjAsphalt ShinglesjDark or F _ Bold ColorJR-19 insulation North Wall 0.091 76 6.825 2.41 519 183 0 183 Frame Wall/PartitionINAINAlWoodIR-13INoneINAISiding or StuccoINA Window-2x5 0.57/0 10 42.75' : 22.2 427 222 0 222 OperablelNormal WindowjClearj2 Pane.lWood, Wood with Metal Clad, or Vinyl Window-2x5 0.57/0 1042:75 22.2 427 222 0 222 OperablelNormal WindowjClearj2 PanelWood,Wood with Metal Clad, or Vinyl Adtek Accul-oad Report Version 7.0..1 Page 21 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 First Floor CFM Duct sizes and velocities based on settings selected in the setup screen. *Duct sizes calculated using this CFM. Winter Summer Winter Summer Return Supply Calculated Calculated System System Item Name Velocity 'RA Duct Size Velocity. SA Duct Size CFM CFM CFM CFM First Floor 0 .0 638 1072 0 *0 Dining Room . .0. "0. 67 100 0 *0 Entry 0 U 45 42 0 'O Family Room 0 0 176 240 0 *0 Kitchen 0 0 114 348 0 *0 Living Room 0 0 236 342 0 '0 Adtek Accul-oad Report Version 7.0.1 Page 22 Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Second Floor CFM Duct sizes and velocities based on settings selected in the setup screen. *Duct sizes calculated using this CFM. Winter Summer Winter Summer Return Supply Calculated Calculated System System Item Name Velocity RA Duct Size Velocity. SA Duct.Size CFM CFM CFM CFM Second Floor0 0 348 698 0 *0 Bath 1 0 0 31 30 0 *0 Bath 2 0 0 15 18 0 *0 Bed 1 0 0 70 150 0 *0 Bed 2 .0 . . 0 64 104 0 *0 Bed 3 0 01 60 108 0 *0 Closet 0 0. 6 5 0 *0 Office 0 0 103 283 0 *0 Adtek Accul-oad Report Version 7.0.1 Page 23 Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 First Floor (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75 Heated Area 918 Sq.Ft. Winter: 05 70 Cooled Area 918 Sq,Ft. Heat/Los.s Summary (July Heat Load Calculations) Gross Sensible Latent Area Loss Gain Gain Walls 1088 14994 i6487 0 Windows 234 . 10515 6807 0 Doors 21. 457 , 189. 0 Ceilings 0 0 0 0 Skylights 0 0 0 0 Floors 968 1997 .530 0 Room Internal Loads 0 640.1 1600 Blower Load 1707 . 0 Hot Water Piping.Load .0 0 0 Winter Humidification Load 0 0 0 infiltration 4544 619 498 Approved ACCA Ventilation. . . 0 0 0 MJ8 Calculations Duct Loss/Gain EHLF=0.08 ESGF=0.04 2601 841 416 AED Excursion n/a 409 n/a Subtotal 35108 23990 2514 Total Heating 35108 Btuh 11 kw of electric heat Total Cooling 26504 Btu_h 67 Linear ft.of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values, window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. This application has glass areas that produce relatively large cooling loads for part of the day. Variable air volume devices may be required to overcome spikes in solar load for one or more rooms.A zoned system may be required, or some rooms may require zone control(provided by individual,motorized, thermostatically controlled dampers). Adtek AccuLoad Report Version 7.0.1 Page 1 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Second Floor (Average Load Procedure) Design.Conditions Location: Boston AP, Massachusetts Elevation: . 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 42*..N Design Grains: 26 Summer: 95 75. Heated Area 648 Sq.Ft. Winter: 1-5 7.0 Cooled Area 648 Sq.Ft. Heat/Loss Summary (July Heat Load Calculations) Gross Sensible Latent Area Loss Gain Gain Walls 864 5297 1871. 0 Windows 88 3758 3854 0 Doors 0.. 0 0 0 Ceilings, 792: 2968. 2181 0 Skylights 0 . .. 0 0. .1 0 Floors 0 0 0 0 Room Internal Loads 0 2527. 1039. Blower Load 1707 0 Hot Water.Piping Load 0.. 0 .. 0. Winter Humidification Load 0. 0 0 Infiltration 4348 608 489 Approved ACCA Ventilation. . . 0 0 0 MJ8 Calculations Duct Loss/Gain EHLF=0:17 ESGF=0.235 . 2783 2597. . 436 AED Excursion. n/a 0 n/a Subtotal 19154 15345 1964 Total Heating 19154 Btuh 6 kw of electric heat Total Cooling 17309 Btuh 37 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values,window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 2 f Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd • (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Dining Room (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75 Heated Area 120 Sq.Ft. Winter: 1-5 70 Cooled Area 120 Sq.Ft. Heat/Loss Summary (July Heat Load Calculations) Gross Sensible Latent Area Loss Gain Gain j Walls 96. 1008 .. 423: . 0 Windows .40 : 1966 1022 0 Doors 0' 0' 0 0 Ceilings 0 0 .0 0 . ..Skylights 0 0 0 0 Floors 0 0 0 0 Room Internal Loads 0.. 460. 400 Blower Load 0 160 0 Aim Hot Water.Piping Load 0 0 Winter Humidification Load 0 0 Infiltration 462 63 51 Approved ACCA Ventilation 0 .0 0 MJ8 Calculations Duct Loss/Gain 275 79 39 A ED Excursion n/a. 0 n/a Subtotal 3711 2206 490 Total Heating 3711 Btuh 2 kw of electric heat Total Cooling 2696 Btuh 7 Linear ft.of Hydronic Baseboard Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values;window types,duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 3 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Entry (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75 Heated Area 120 Sq.Ft. Winter: -5 70 Cooled Area 120 Sq.Ft. Heat/Loss Summary (July Heat Load Calculations) Gross Sensible Latent Area Loss Gain Gain Walls 96 1350 567 0 Windows 0 0 0 0 Doors 2.1 . ..457 189 0 Ceilings 0 0 0 0 —Skylights 0 0 0 0 Floors 0 0 0 0 Room Internal Loads. 0, 0 0 Blower Load .0 66 0 Hot Water Piping,Load. 0 0 Winter Humidification Load 0 0 Infiltration 462 63 51 Approved ACCA Ventilation, 0 0 0 MJ8 Calculations Duct Loss/Gain . 182 33 16 AEP Excursion fila. 0 n/a Subtotal 2451 918 67 Total Heating 2451 Btuh 1 kw of electric heat Total Cooling 985 Btuh 5 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACOA.All computed calculations are estimates.based on building use,weather data, and inputted values such as R-Values,window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 4 I Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Family Room . (Average Load Procedure) Design Conditions . Location: Boston AP, Massachusetts Elevation:. 20 ft Daily Range: Medium Input Data: Outdoor DryBulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75. Heated Area 2.3.4 Sq.Ft. Winter, •5 70 Cooled Area 234 Sq.Ft. Heat/Loss Summary (July Heat Load Calculations) Gross Sensible Latent Area Loss Gain Gain Walls. .352 5148 2353 .0 Windows 66 :. 2821 1759 0 Doors 0 0 0 : .0 . Ceilings 0 0 0 0. Skylights 0 0.. 0 0 Floors 0 0 0 0 . Room Internal Loads, 0 460 400 Blower Load 0 382 0 Am Hot Water Piping.Load. 0 0 Winier Humidification Load 0 0 infiltration 1001 136 110 Approved ACCA Ventilation 0 0 0 MJ8 Calculations Duct Loss/Gain 718 188 . 93 AED Excursion n/a 52 n/a Subtotal 9688 5331 603 Total Heating 9688 Btuh 3 kw of electric heat Total.Cooling 5934 Btuh 19 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values,window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 5 i Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Kitchen (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation:. 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75. Heated Area 204 Sq.Ft. Winter: -5 70 Cooled Area 204 Sq.Ft. Heat/Loss Summary (July Heat Load:Calculations) Gross Sensible Latent Area Loss Gain Gain Walls 192 2592 1088 0 Windows .48 _. 2308 1761 0 Doors 0. 0 .0 0 Ceilings 0 0 0 0 Skylights 0 0.. 0. .. 0 Floors 0 0 0 0 Room Internal Loads 0 3860 400 Blower Load 0 555 0 Hot Water.Piping,Load. 0 0 Winter Humidification Load • 0 0 Infiltration 924 126 161 Approved ACCA Ventilation .0 0 0 MJ8 Calculations Duct Loss/Gain 466 273 136 AED Excursion n/a, 318 n/a Subtotal 6290 7981 636 Total Heating 6290 Btuh 2 kw of electric heat Total Cooling, 8617 Btuh 12 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACOA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values, window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 6 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: i Job#: Date: 10/29/2015 Living Room (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation:. 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: .420 N Design Grains: 26 Summer: 95 75. Heated Area 240 Sq.Ft. Winter: -5 70 Cooled Area .240 Sq.Ft. Heat/LPs.s Summary (July Heat Load Calculations) Gross' Sensible Latent Area Loss Gain Gain Walls 352. 4896 2056. 0 Windows 80 3420 2265 0 Doors 0_ 0 .0 . .0 Ceilings . 0 0 0. 0 Skylights. 0 0 0., . 0 Floors 9.68 1997 530 _ 0 Room Internal Loads 0.. 1621 400 Blower Load 0. 544 0 . Hot Water Piping.Load. 0. .. 0 Winter Humidification Load 0 0 Infiltration 1694 231 186 Approved RCCA MJ8 Ventilation 0 0 0 Calculations Duct Loss/Gain .061 268 133 AED Excursion. n/a 177 . n/a Subtotal 12968 7692 718 Total Heating 12968 Btuh 4 kw of electric heat Total Cooling 8410 Btuh 25 Linear ft.of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values,window types, duct loss,etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 7 Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Bath 1 (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75. Heated Area 48 Sq.Ft. Winter: -5 70 Cooled Area 48 Sq.Ft. Heat/Loss Summary (July Heat Load Calculations) Gross Sensible Latent Area Loss Gain Gain Walls. 112 73'8 261 0 Windows 4 171 138 0 Doors 0.. 0 0 0 Ceilings, 0 0. 0 0 Skylights 0 0 0. .. 0 Floors 0 0 0 .0. Room Internal Loads 0 . " 0. .. 0 Blower Load 0 74 0 Aim Hot Water Piping Load 0. 0 Winter Humidification Load 0 0 Infiltration 564 79 63 Approved ACCA Ventilation 0 0 0 MJ8 Calculations Duct Loss/Gain250 112 19 AED Excursion. . fila 30 nla Subtotal 1723 694 82 Total Heating '1723 Btuh. 1 kw of electric heat Total.Cooling. 776. Btuh 4 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition :and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values,window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 8 Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Bath 2 (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75 Heated'Area 30 Sq.Ft. Winter: -5 70 Cooled Area 30 Sq.Ft. Heat/Loss Summary (July'Heat Load Calculations) Gross Sensible Latent Area . Loss Gain Gain Walls 48.. 300 106 0 Windows -4 171 138 0 Doors 0 0 0 0 Ceilings 0 0 0 0 Skylights . 0 0 0 0 Floors 0 0 0 0 Room Internal Loads 0.. 0. 0 Blower Load 0 43 0 Hot Water Piping Load 0 0 . Winter Humidification Load 0 0 Infiltration 242 34 27 Approved ACCA Ventilation, .0 .0 0 08 Calculations Duct Loss/Gain 121 65 11 AED Excursion n/a .30 n/a Subtotal 834 416 38 Total Heating 834 Btuh 1 kw of electric heat Total Cooling 454 Btuh 2 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values, window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1Page 9 Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Bed 1 (Average Load Procedure) Design.Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75. Heated Area 180 Sq.Ft. Winter: -5 7.0 Cooled Area 180 Sq.Ft. H eat/Loss Summary (July Heat Load,Calculations) Gross Sensible Latent Area. Loss Gain Gain Walls .216. 1337 473. 0 . .Windows .20 854 1284 0 Doors 0. 0 0 0 Ceilings 0 0 0 0 Skylights. 0 0 0 0 Floors 0 0 0 0 Room Internal Loads 0.. 460 400 Blower Load .0. . 36.6 0 Hot Water.Piping Load 0 0 Winter Humidification Load 0 0 infiltration 1087 152 122 Approved ACCA Ventilation . 0 0 0 MJ8 Calculations Duct Loss/Gain 557 . 557 . 94 AED Excursion. . n/a 179 n/a Subtotal 3835 3471 616 Total Heating 3835 Btuh 2 kw of electric heat Total.Cooling 4087 Btu.h 8 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual.J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values,window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 10 Cooling Unlimited Inc. Ronn Colton 565A Main St-Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Bed 2 (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer.: 95 75 Heated Area 144 Sq.Ft. Winter: -5 70 Cooled Area 144 Sq.Ft. Heat/Loss Summary (July Heat Load Calculations) Gross Sensible Latent Area Loss Gain Gain Walls 192 1174 .414 0 Windows 20 - 854 . 864 0 Doors . 0 0 .0 0 . Ceilings 0 0 0 0 Skylights 0 0 .0 0 Floors 0 0 0 0 Room Internal Loads 0 230 . 200 Blower Load 0 ..254 0 Hot Water.Piping Load 0 0. Winter Humidification Load 0 0 infiltration 966 135 109 Approved ACCA Ventilation .0 0 0 MJ8 Calculations Duct Loss/Gain 509 386 65 AED Excursion nla 258 n/a Subtotal 3503 2542 374 Total Heating 3503 Btuh 2 kw of electric heat Total Cooling 2916 Btuh 7 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values,window types, duct loss,etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 11 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Bed 3 (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: :42* N Design Grains: 26 Summer: 95 76 Heated Area 120 Sq.Ft. Winter: 4 70 Cooled Area 120 Sq.Ft. Heat/Loss Summary (July Heat Load Calculations) Gross Sensible Latent ...Area .Loss Gain Gain Walls 176. 1065 . 376. 0 Windows 20 854 986. 0 Doors 0 0: .0 0 Ceilings 0 .0 0 0 Skylights ' 0 0 . 0 0 floors 0 0 0. 0 Room Internal Loads. 0, 230 200 Blower.Load 0 265 0 Hot Water.Piping.Load. 0. 0 Winter.Humidification Load 0 0 Infiltration 886 124 100 Approved ACCA. Ventilation_ 0 0 0 MJ8 Calculations Duct Loss/Gain 477 404 68 AED Excursion nla 167 n/a Subtotal 3281 2552 367 Total Heating '3281 Btuh 1 kw of electric heat Total Cooling . 2919 Btu.h 7 Linear ft. of Hydronic Baseboard *Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA. All computed calculations are estimates based on building use,weather data,and inputted values such as R-Values,window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 12 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Closet (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation:. 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 420 N Design Grains: 26 Summer: 95 75 Heated Area 18 Sq.Ft. Winter, -5 70 Cooled Area 18 Sq.Ft. Heat/Loss Summary (July Heat Load Calculations) Gross Sensible Latent Area Loss Gain Gain Walls 24 . 164 58 0 Windows 0 0 0 0 Doors 0.. 0 .0 0 Ceilings . 0 0 . 0 0 Skylights p . .. 0 .0 0 Floors 0 0 0 0 Room Internal Loads 0 .'0. 0 Blower.Load 0 12 0 Hot Water.Piping.Load. 0 0 Winter Humidification Load 0 0 Infiltration 121 17 14 Approved ACCA Ventilation, , . 0 0 0 MJ8 Calculations Duct Loss/Gain 48 18 3 AED Excursion n/a 0 n/a Subtotal 333 104 17 Total Heating 333 Btuh 1 kw of electric heat Total.Cooling. . 121 Btuh 1 Linear ft. of Hydronic Baseboard "Calculations are based on the ACCA Manual.J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values,window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 13 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Office (Average Load Procedure) Design Conditions Location: Boston AP, Massachusetts Elevation: 20 ft Daily Range: Medium Input Data: Outdoor Dry Bulb Indoor Dry Bulb Latitude: 42°. N Design Grains: 26 Summer: 95 75 Heated.Area 108 Sq.Ft. Winter, -5 70 Cooled Area 108 Sq.Ft. Heat/Loss Summary (JulyHeat Load Calculations) Gross Sensible Latent Area Loss Gain Gain Walls 96.. 519 183 0 Windows 20 854 444 0 Doors 0 . 0 0 0 Ceilings 792. 2968 2181 .0. Skylights 0 0 0. .. 0 Floors 0 0 0 0 Room Internal Loads, 0 1607 239 Blower Load 0 693 0 Hot Water.Piping Load 0 0 Winter Humidification Load 0 0 Infiltration 483 68 54 Approved.ACCA Ventilation . . 0 0 0 MJ8 Calculations Duct Loss/Gain _ 820 1054 177 AED Excursion . n/a 0 n/a Subtotal 5644 6230 470 Total Heating 5644 Btuh 2 kw of electric heat Total Cooling 6700 Btu_h 11 Linear ft. of Hydronic Baseboard *Calculations are based on the.ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are estimates based on building use,weather data, and inputted values such as R-Values, window types, duct loss, etc. Equipment selection should meet both the latent and sensible gain as well as building heat loss. Adtek AccuLoad Report Version 7.0.1 Page 14 Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030 -jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 First Floor . AED Curve - DAL — 1.3 — 1.5 14000 12000 10000 `- 8000 s _ 00 6000 i 4000 2000 8 9 .10 1.1 12 13 14 15 16 17 18 19 20 Hour AED Excursion: 409 btuh AED Status: System does NOT have Adequate Exposure Diversity. AED Flag: This application has glass areas that produce relatively large cooling loads for part of the day. Variable air volume devices may be required to overcome spikes in solar load for one or more rooms.A zoned system may be required, or some rooms may require zone control (provided by individual, motorized, thermostatically controlled dampers). Hours are listed in 24-hour format: 8 is 8am, 20 is 8pm. Adtek Accul-oad Report Version 7.0.1 Page 15 i Cooling Unlimited Inc. Ronn Colton 565A Main St- Reading, MA 01867 316 Raleigh Tavern Rd (781)944-1030-jgrier@coolingunlimited.com N Andover, MA 01845 Sales Consultant: Job#: Date: 10/29/2015 Second Floor AED Curve DAL 1.3 1.5 6000 - 5000 - 4000 00050004000 3000 rn 2000 - 1000 0 8 9 10 11 12 13 14 15 16 17 18 19 20 Hour AED Excursion: 0 btuh AED Status: System has Adequate Exposure Diversity. AED Flag: No AED Flag. Hours are listed in 24-hour format: 8 is 8am, 20 is 8pm. Adtek Accul-oad Report Version 7.0.1 Page 16 p 9 S " 1 _. . 2 �u��� go AL 500 � 8 T7I Q 1.50 PM i Date..."..1....�..�.�. . . .................... r►ORTh TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING �ssAcmus�c This certifies that .... �.'..... ..�...... .^j.. ....... ....................................... has permission to perform .... �...h. h�� p ..... . .......................................... wiring in the building of....l,.0....`t� . ........................................................................................ # at .... . 1p..,l�C��,�{�..... ......2.!J..Jr� North Andover,Mass. ........................... .......... ;.� 36 3� �. `ter '--�.J '��. � ' Fee.....:........................Lic.No. ......5.. ....... ELECTRICAL INSPECTOR / Checkit 2� Ij// M a. Official Use Qnly - i Commonwealth of Massachusetts Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(Iv1EC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her' tentiion top erform the electrical work described below. Location(Street&Numb Ow or Tenant 1 Telephone No. Owner's Address � �v`'C � Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters " Number of Feeders and Ampacity Location and Natu a of Proposed Electrical Work s Completion of th. following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.o Emergency ig ting No.of Luminaires Swimming Pool rnd. El In- E] Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Gas Burners 1°10.of Detection and No.of Switches Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons No.of Waste Disposers HeatFumTotalNumber .Tons KW No.of Self-Contained "'" " Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ Connection El Heating Appliances KW Security Systeme— nt No.of Dryers No,of Devices or E uivale No.of Water KW No.of No.of Data Wiring: ' Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electric 1 Work: or C-,' (When required by municipal policy.) Work to Start: '31 / 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 ® BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on 171 is application is true and complete. FIRM NAME: _ LIC.NO.: Licensee: c P� D✓'� Signature LTC.NO.:-36=1517 00 (If applicable,enter exgmptll in the lice a an er it e.) �� us.Tel.No.: Address: Alt.Tel.No.:_,5 ee- *Per M.G.L c. 147,s.57-61,security work requires Department of P lic Safety"S"Licens : 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)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ �j 0 OT Signature Telephone No. Y ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the f permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed' f 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 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. ❑ 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—Per mit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: ry Inspectors Signature: Date: y ROUGH INSPECTION: Pass M Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Inspection Required($.) ❑ Inspectors Comments: �h, -- 3 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Ploase Print Le ibl Name (Business/Organization/Individual): G C-_ Address: ,7 L ��_. / VQ City/State/Zip: O l Phone#: C `3 C-3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.® I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' 131-1 Other comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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. am an employer that isproviding workers'compensation insurance for my employees. Below is thepo 'cy an job site zformation. r isurance Company Name• C_/ olicy#or Self-ins.Lic.#: Expiration Date: )b Sitc Address:_ /�^ t f� � z� City/State/Zip: /JUr Cy1LrCJ Itach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Pup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify zcn r the pa' s and penalties of perj ry that the information provided bove 's trate and correct `111Z 3 i nature: Date: F j7 lone#: l Official ztse 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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their 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 c workers' compensation insurance. If an LLC or LLP does have P q carry P 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 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 of 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 to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 evised 5-26-OS WWW mace onv/din Date .��/, '/�� . TOWN OF NORTH ANDOVER PERMIT FOR WIRING C 4)2NPirs ��P -��9 r This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform wiring in the building of . .` .d l "j. . . . . . . . . . . . . . . . . . . . . . . . . . Nort A.dove ,Mass. Fee . -�5 �:. . Lic. No. . . . . . . . . . . . . . . ✓�% f?,1. .1 ELECTRICAL INSPECTOR f Check# 11333 Commanwea&o1 Ma6dacLetto �- :e Only � c 1� 20partment o f_?i,e&rvim pancy and Fee Checked BOARD OF FIRE PREVENTION REGULAI ',;v. V071 leave blank APPLICATION FOR PERMIT TO PERFORM.ELECTRICAL WORK All work to be:performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION). Date:: a City. or Tow_ n of: � v 10 Pl bZublpf-L To the.lnspector of Wires: By this application-the undersigned gives notice of his or her:intentionto perform the electrical work described below. Q, Location(Street&Number) Owner or Tenant. :.Telephone No. 0%9 9s Owner's Address Is this permit in.conjunction with a:building permit? Yes -Ell. Z No- (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead'[] Undgrd.❑ No.of Meters' Number of Feeders and Ampacity. .= Location and Nature of Proposed'Electrical World Com letion o.the ollowin table may,be waived by the Inspector of Wires. No.of Recessed Luminaires. No of Ceil.-Sus Fans No..of Total P .�addle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs ., Generators KVA Above In o.OTE mergency Lighting No.of Luminaires Swimming.Pool: rnd. ❑ rnd. Battery Units No.'of Receptacle Outlets No.of Oil Burners FIRE ALARMS No,of Zones No.of Switches No.of Gas Burners No:of etectton and Initiating Devices Total No.of Ranges No..of Air Cond. Tons No._of.Alerting Devices Heat Pump umber Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices Municipal No.of Dishwashers S ace/Area Heatin KW . Local ❑ Other P g �`:Connection No,of Dryers Heating Appliances Key" Security Systems:* Y No.of Devices or Equivalent No.of Water KW No,of No.:of: Data Wiring Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirm No.of Devices or E uivalent OTHER: � Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: l '` (When required by:municipal policy.) ' Inspections to be requested in accordance with MEC Rule 10,and upon completion. Work to Start: �SJ1�b 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: INSURANCFj� BOND ❑ OTHER ❑ (Specify:) I certify, under the pairs and penalties of per ury,that the informattiio•n.on this application is'true and complete. FIRM NAME: �Ol �2Ss�o"Y� ec ''��CSS JVC ��' LIC.NO.: Licensee: Signature LIC.NO.: (If applicable, ter "exe pt."in the lice se nurnke line.) Bus.Tel.No.: V:: 5 Address: X 1( � Sw40,1` Alt.Tel.No.: Q 2S L -S11°S, *Per M.G.L. 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 havethe liability insurance coverage normally required by taw. By my signature below,I hereby waive this:requirement. I am the(check one),❑owner ❑owner's a ent. Owner/Agent PERMIT FEE: $ Signature Telephone No. Ap_ C,N e�14 s c�, 31 L 09728 Date TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING oll4 This certifies that . �l �A�- . . . . . . . . . . . . . . . . . . . . has permission to perform . .{,G.�►��c� �c.,. . . . . . . . . . . . . . . plumbing in the buildings of. � �P j . . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee . .3oo.o. . Lic. No. . . . . . . . . . V PLUMBING INSPkTOR Check#_ MASSACHUSETTS UNIFORM APPLICATION FOR PERMITTO DO PLUMBING X11/1 ' ��' 49!�� .MA. Date: Permit# Building Location: 06/-,9'i�Ze�-�/-P/XOwners Name: D/yi� (��.✓(,P✓ Type of Occupancy: Commercial❑ Educational❑ Industrial❑ institutional❑ Residential lJ JNew:.0 Alteration: Renovadon:0 Replacement: Plans Submitted: Yes 0 No FWURES DEDICATED o: SYSTEMS p N t7 � Z � a Z Z Z � Yl � a Q S ~ Q 3 N d: 3 W O aW to Q Z 0: Oji o W 3 x o F- 3 Z < 0 3 d " z W �1 > o = s a oe A us SUB BSMT. BASEMENT 1sr FLOOR 2 FLOOR 3 FLOOR 4m FLOOR e FLOOR I FLOOR 7 FLOOR 8 FLOOR / Check One Only Certificate# installing Company Name-,&,t4 . � L5�s f1.�1�/�'r�G�•.�Ziit% _ / � ! ration /Town: /1'f,� State:. Mpg ❑Partnership BtIsiness Tel: /�//�Os Q� Fax: �'� ����J ❑F'inNCompany me of Licensed Plumber: A&021i5 INSURANCE COVERAGE: I have a currentia�bilityirmurance policy or its substantial equivalent which meste the requirements of MGL Ch.142 Yes ff'N o❑ If you have checkedfes,plqase indi to 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 Owner ❑ Agent ❑ S• nature of Owner or Owners Aaent 1 hereby certify that all of the details and Info... n 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 pan*issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter t42 of Wonend taws. By Type of License: Titleumber Signature of Lic d Plu bar citynownMaster 1 �3 APPROVED OFFICE USE ONLY) rpJoumeyman Ucense Number. Lk V-&\ cs- VV klp ` F, a .. _ n .- _ _i. «7 ,_ � �✓/� �� °�� G-e�r�� E i The Conintonivealth of Massaclucsetts Department of hidustrial Accidents Office of Investigations !' 600 Washington Street Boston,MA 02111 unwi,.ntass gov/dia 'Workers'Compensatioli Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information '' Please Print Legibly Name(Business/Organization/individual): D!/�/ � ��,� =, ' Address: City/State/Zip 'Phone Are ou an employer?Check the appropriate box: '' ' ' ' ' ' ` ' 11 Type of project(required): 1.( I am a employer with i .; ❑'In a general contractor and I employees(full and/or,part-time). � bade hired the sub-contractors b ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached'sheet. 7. ❑RemodeIing shipand have no employees These sub-contractors have . . , _ 8. ❑Demolition working for me in any capacity.-W employees and have workers' g ❑Building addition [No workers' comp. insurance comp. insurance-t required.] 5. ❑ We are a corporation and its l0.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.ffllPlumbing repairs or additions myself. [No workers'.comp. right of exemption per MGL 1 ❑Roof repairs insurance required]t, ;c. 152,.§1(4),and we have no employees.[No workers' 13.❑Other . ..... comp.insurance required.] Any applicant that checks box#F 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 a new affidavit indicating such- Contractors that check this box'must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees.'If the sub-contmctois have employees,they must provide their workers'comp.policy number. I ant an employer that is providiiig workers'contpetisatiottitistirancL for rigt employees. Below is thepolicy and job site information. _ Insurance Company Name:--: 07-ldp(/f Aj�j� Policy.#or Self-ins.Lie.#: D 1,3o?lp Expiration Date: Job Site Address: 3/lO , �,F,Gd/ ,� City/state/Zip:,/20 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ut r the pains and penalties f perjnty that the information provided above is true and correct. Sienature: Date: v� / Phone# Official use only. Do not write in this area,to be completed by city or totvtl 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 b.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 emplopee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." tion or other legal- ,or any two or more lmi .association corporation 1; h' An employer is defined as an individual,partners p, ►p er or the al representatives of a deceased employer,of the Foregoing engaged in a joint enterprise,and including the leg p _ receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the- dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.' MGL chapter 152,§25C(6)also states that"every state or local-licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states••Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,Supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of ss r), pp y LLC or Limited Liability Partnerships(LLP)with no employees other than the tY insurance. Limited Liability Companies( ) . members or partners,are not required to cant'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(lie 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 time city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.# 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 _ www.mass.gov/dia i COMMONWEAL OF MASSAMHUSET. TS o.44fTa"o3iof�Y >i �rLT :•.F-` PLUMBERS AND GASFITTERS REG1STE RED AS APLUMBING MB ING CORP =- - ISSUES THE ABOVE uiENSE To.. .GEORQE. R LAROSE g ANDOVER PLUMBING & HEATING. Cis =20 'AEGEAN 'DR _METHUEN MA. 01844:-1580 _- 2122 05/01/14 172545 ��= -COMMONWEALTH OF MASSACHU$ = COMtVIONWEALTH OF MASSACI$USE'i'HS== .d.1Ylo7` ==:o•-o o = o 0 0 •.o r't toh21'9 f e 'bY(=, o, "n o PLUMBERS AND GASFITTERS `�`` �= = LICENSED AS A MASTER PLUMBER". ': PLUMBERS AND JOURNEYMAN : .ICENSED AS A JOURNEYMAN PLUMBER ISSUES THE ABOVE LICENSE TO: = ISSUES.TFIE ABOVE LICENSE TO: 'GEORGE R LAROSE -��4E01?6E- R :L=AROSE . - 44 ODILE ST ` .!4 :-OD.ILE .ST Y iMETHUEN MA 01844.-423.3`=; `M HUEN" MA 01844-4233 9983 05/01/14 18725 05/01/14 172562 �rJ�IAI.°---..-._...� Q=I :t11(Cj�l}u jj ' 40-4 w"4 0-0 9047 Date. .'? : HORTp °'< '° '•�"o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHUS� y This certifies that . .' . (IAC.km. . .PL (a. . . . . . . . . . has permission to perform . . . . . . . . . . . plumbing in the buildings of . +1.y r-\. . .6, 0. . . . . . . . . . . at . 3.16 . R."I x.',.k. . . . . . . .. North Andover, Mass. Fee.6c1:�47. .Lic. No.. . . . . . . . .A - . PLUMBING INSPECTOR Check It �� i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING • City/Town:U �oC / Ove t MA. Date��I�F Permit# Building Location:'3 ( (1 �./>-�•e.t � � , Owners Name:1<0,14 X 0 GU�.��ti PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential�- New:[] Alteration:❑ Renovation: Replacement:❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED w z SYSTEMS F- Z z w zU h on Con < N 0 Z H J, UU {N U, LU 0 4Q' Q m y W In aLn z C' ��., Cn ~ W z En y C X1- N fa W o LL F a N a z s o m Z n to u ° x w f. w D o w w z x ° O t- U z a LL a a = w w 021 O w Q Q cn O O g S O O z v, r- w v, a m m o o u. x O x ° z a a a x -SUB BSMT° o r a } Y — Ln En t`z X BASEMENT 1sT FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR ST"FLOOR e FLOOR ' 7'FLOOR 8T"FLOOR installing Corrpz,ny Name:Nt;e-l Gs� P�v Check One-Only Certificate i Address a� ����� „ n /" �Corporation City/Town: ,os (_y State,/A f j ��( �� �� G a ❑Partnership Business Tel:.Pf— Fax:f�)Ci�yL _3� f ❑Firm/Company Name of Licensed Plumber: P l3 A INSURANCE COVERAGE: I have a current IiabiLkinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.14 If you have checked Yes,please indicate the type of coverage by checkingtheappropriate box bel2 Yes El No E]ow. 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 Si nature of Owner or Owner's A ent Owner ❑ Agent ❑ hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and Accor f Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a.e to the best o.my By Type of License: Title Signature Plumber 9 ture of Licensed Plumber �itylfown ❑Master APPROVED(OFFICE USE ONLY) ❑Journeyman License Number: Z' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: ILK— City/State/Zip: Phone #: — t G —(' 1--2 I employer?Check the appropriate box: _ employer with �- 4. ❑ I am a general contractor and I Type of project(required):yees(full and/or part-time).* have hired the sub-contractors6 ❑New constructionsole proprietor or partner- listed on the attached sh%et. # 7• ❑Remodelingd have no employees These sub-contractors have 8. ❑Demolition g for me in any capacity. workers'comp.insurance.rkers' comp.insurance 5. ❑ We are a corporation and its9 ❑Building addition d.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12•0 Roof repairs insurance required.]t" employees.[No workers' comp.insurance required.] 1311 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 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'pomp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: GZ L f -Q Policy#or Self-ins.Lic.#: E ` � ( , xpiration Date: Job Site Address: City/State/Zip)�y A7 "I Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration da 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. Ido hereby certify under thepains anpenalties of perjury that the information provided above is true and correct. . Signature: Date: — 20 Z G l(` Phone#: 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/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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers',compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their 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 1 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 as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston}MA 02111. Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia I� "s COMNIpNWEAL"FH OF MASSACHUSETTS"+" • o:.. LICENSED S A MAST ER'PLUMBER ISSUES THE ABOVE LICENSE TO: .i ROBERT A STELLAED ! � 89 OLD LOWELL RD �- �� 1 WESTFORD MA -0"1886-3820 9241 05%01/12 , 799915 S 1 0204 Date.? 0.0k. ... .1/......... HORTM TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SSACNUSEt }1 This certifies that ............. t�........................................ has permission to perform .......B `'t -... !'K. ? `"'-....1.......... wiring in the building of 441*24-'V e- �1-'T7 N.."................... ....................... ......:...........:...........'.................. orth Andover,Mass. 14 �rrs :+ Fee..s ............. Lic.No. '�5.. ............ . • E RICAL INSPECTOR Check #�� Commonwealth of Massachusetts Official Use Only Department of Fir Permit No. Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ [Rev. 1/07) (leave blank ' APPLICATION FOR PERM �+ �+ All work to beperformed in accordance PERFORM ELE\.r�R�4� with the Massachusetts Electrical Code(MEC),527 CMR 12.00 WORK®R� (PLEASEPRINTIArINK OR TypE�LO RW TION) Date: City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her intention to perform the ele tri al wk de tor of escribed below. Location(Street&Number) '6 1 � 21 Owner or Tenant 4 Owner's Address t Telephone No. Is this permit in conjunction with a building permit? Purpose of Building �6)1.1– YeS No ❑ (Check Appropriate Box) Utility Authorization No. ExIsting Service la a c> Amps / ayD Volts Overhead Undgrd❑ No.of Meters _ - New-- Service / Amps ____Volts Overhead Number of Feeders and.Am act Undgrd❑ No.of Meters p ty Location and Nature of Proposed Electrical Work: / 6444] Com letion of the followin table may be waived by the Ins ector of Wires. ' No,of Recessed Luminaires � No.of Ceil:Sus No.of p.(Paddle)Fans Total No.of Luminaire Outlets No.of Hot Tubs Transformers ,, . No.of Luminaires Generators ICVA Swimming Pool Above ❑ In- o. o mergency ig No.of Receptacle Outlets grnd' d• Batte Units g No.of OiI Burgers Fl_F-E pLA-13MS No.'of Zones No.of Switches No.of Gas Burners 0.-of Detection and No.of Ranges Total Initiati ' Devices . No.of Air Cond. No.of Alerting Devices No.of Waste Disposers .Heat Pump Number Tons ns Totals: --`..'."-............ - ....I.. No.of Self Contained No.of Dishwashers Deteetion/Alertin Devices Space/Area Heating KW Local❑ Municipal No.of Dryers Heatin A Connection ❑ Other g ppIiances KO4� Security Systems:* No.of Water No.of No.of Devices or E uivalent Heaters 1W No,of Data Wirin Si s Ballasts. No.Hydromassage Bathtubs No.of De No.of Motors Total HP No. or E uivalent Telecommunications Wiring; OTHER: No.of Devices or E uivalent Estimated Value of El ctrical Work:ty-10—A Attach additional detail if desired,or as required by the Inspector of Wires. Work to Start: 0P When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: 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 substantia ess undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuingofficeuivalent. The CHECK ONE: INSURANCEX'.1ti�sorfpeE' OOTHER I certify, under th pains andp ❑ .(Specify:) r� rjury,that the information on this application is true and complete. FIRM NAME: �� (, C • Licensee: LIC.NO.: —�✓,.v, n 1111 Slot cC� Si 4 (Ifapplicable, enter exempt zn the license number line.) gaa�ure LIC.NO.. Address: P��S : /9 boy S h t'^ W e51, MA d 1;F0� : Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires D epartanent of Public Safety"S"License: Alt.Tel. OWNER'S INSURANCE WAIVER; I am aware that the Licensee does not have the liability Lic.No. required bylaw By my signature below,I hereby waive this requirement. I am the(check msur0ance coverage normally one)) owner❑ Signature ❑owner's agent Telephone No. PERMjT'FEE:$ ELECTRICAL PERA T NO. INSPECTION"REPORT[': ELECTRICALINSPECTOR-DOUG SMALL Y.ROUGH INSPECTION: Passed— Failed—[ ] Re-inspection required[($50.00)_f j Inspectors'comm ts: (Inspectors'Signature-no initials) ' Date Z.FINAL INSPE ON; Passed—[ Failed—[ ] Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date 9 ---x 3.UNDER GROUND INSPECTION: 1 Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors' comments: (Inspectors'Signature-no initials) Date 4. SPECTZON—SERVICE: - DA E CALL ED NAATIONAL GRIe f: NAME: Passed—[ ] Failed—[ j Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: Passed—[ ] Failed—[ j Reinspection required($50.00) Inspectors' comments: (Inspectors'Signature-no initials) Date DOOR.TAGS ARE TO BE FILLED OUT AND LEFT ONSITE,IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-1NSPECTI0N OF$50.00 IS TO BE CHARGED. The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Lnpestigations 600 Washington Street Boston, M4 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibi NaMe(Business/Organiza6o vindi-,idual): Address: C C City/State/Zip: b�� R D I � Phone#: Are you an employer?Check the appropriate box: 1• !am a employer with f 4. ❑ I am a general contractor and I Type of project(required): 2.❑ employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction I am a sole proprietor or partner-P listed on the attached sheet 7• ❑Remodeling slop and have no employees These sub= contract ors h working for me m an capacity. ave 8. ❑Demolition Yworkers' comp,insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4 and we •, t )� have s�o 1.]S re i sce.req�.ised.]t employees. [No Niroflkers' 12'01Zoofrcpairs WHIP.insurance required.] 13.❑Other �t that checks box�1 m 3'..rr..C..._ ��.st also$II Out the section bPr,,.�� t Homeowners who submit this affidavit indicatia - noes'-5`heir workers'coWp sation po cy nfo motion #Contractors that check this g they are doing all work and then hire outside box mcontractors must attached an additional sheet showing the name of the sub-contractors must submit a new affidavit indicating such. �) and their workers'comp.policy information. I am an employer that is providing workers'com ensado ` P n rnsur information. ante for my employees Below as the policy and job site Insurance Company Name: i , b/,rl a Policy#or Self-ins.Lic.M W 0 9A 2 '� 0 t Expiration.Date* plJ Job Site Address: e, 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 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 Investigations of the DIA for insurance coverage verificatio may be forwarded to the Office of n. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct: ,Signature: Phone#: Date.: i/7 7 // i Official use only. Do not write in this area,to be completed by city or town offrcial Ci o City r Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical In 5.Plumbing Inspector 6.Other p Contact Person• Phone#: