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HomeMy WebLinkAboutMiscellaneous - 50 CAMPBELL ROAD 4/30/2018 �d 50 CAMPBELL ROAD 1 210/106.8-0065-0000.0 \\ J I to: r jet r o t i L Location 'b C KM 1-,L-C. No. 3 r tl b 9 Date • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ /- Building/Frame Permit Fee $ / Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# A Vt Building Inspector Commonwealth of Massachusetts Sheet Metal Permit Date: Permit# Estimated Job Cost: i 1 L) Permit Fee: $ ( J q Plans Submitted: YES NO Plans Reviewed: YES �NO 731 Business License# (a4 Applicant License# � Business Information: Property Owner/Job Location Information: Name: PA Ff It's 1440ot Name: Of s Street: S S i,�1 p�,w r hSt. Street: --" City/Town: kc '�� t City/Town: A) o r L A J ty, "' Telephone:(17S)10 Y 110 3 Telephone: Photo I.D. required/Copy of Photo I.D. attached: YESy NO Building Type: Residential: 1-2 family Multi-fancily Condo/Townhouses Commercial: Of ice Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. t-" over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC ✓ Metal Roofing Kitchen-Exhaust System Chimney/Vents Provide brief description of work to be done: INSURANCE COVERAGE: I have a current Iia_ bilifv insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes WNo❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy [ge" Othertype of indemnity ❑ Bond ❑ 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[D4, 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 r - Type of License: By ❑Master Title ❑ Master-Restricted lity/Town - EP-ou—meyperson Signature of Licensee 'ermit# =ee$ El Jo urn eyperson-Restricted License Number: 3 3 j Check at www.mass.gov/dpl nspector Signature of Permit Approval Sheet Metal Commercial Guidelines I Life Safety J Critical Systems 7mspection Checklist Yes No N/A, f Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided ✓ All workers performing sheet metal work onsite has valid Massachusetts sheet metal license °�- All sheetmetal workbeingperforined with proper journeyperson--to-apprentice ratios Fire dampers with access doorproperly installed and checked for operation Smoke and combination fire/smoke dampets with access doors properly installed- actuator checked for proper operation(May also be verified by fire department during fire alarm.testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke/atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed(where required)and operation verified(May also be verified by fire department during fire alarm testing) Grease/kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper 616janees,fire rated enclosures and pressure testing req*cd.- --ainfb instal e iequxred oir egtirpment and - 4 F ._. '1= _ C- _ _ ✓ Duct penetrations in fir.o'MtQ-,�,vali:3 and floors sealed Metal roofing systems installed watertight bsing proper materials and fasteners Flexible duct reins installed 6'-0"maximum length Ductwork installed using proper hanger spacing,hanger stock,threaded rod and angle iron Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean-properly sized filters installed(final inspection) Testing and Balancing report complete(final sign-oft) Sheet Metal Residential Guidelines I luspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to- apprentice ratios Equipment sized per heating/cooling load calculations Duct work sized per manual "D"calculations Bath/shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" FIexible duct runs installed 14'-0"maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean-properly sized filter installed(final inspection) Testing and Balancing report complete(final sign-off) wrightsoft� Load Short Form Job: V Date: Jan 12,2017 Entire House By: Franks Heating Service 555 Woburn St,Tewksbury,MA 01876 Phone:978-851-4403 Fax:978-851-0398 For: i1 - • s • Htg clg Infiltration I Outside db(°F) 1 88 Method Simplified Inside db(°F) 70 75 Construction quality Average Design TD (°F) 69 13 Fireplaces 1 (Average) Daily range - M Inside humidity(%) 30 50 Moisture difference(gr/Ib) 28 28 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Trade Trade Model Cond AHRI ref Coil AHRI ref Efficiency 80AFUE Efficiency 0 SEER - Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 823 cfm Actual air flow 823 cfm Air flow factor 0.021 cfm/Btuh Air flow factor 0.044 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.71 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) mas 371 16682 7471 353 330 m bath 38 2570 1637 54 72 bed3 179 8605 4289 182 189 bath2 55 2642 1405 56 62 bed2 179 7791 3600 165 159 hall 140 594 238 13 11 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. I'1 htSOft" 2017-Jan-1216:08:27 W �r+ 9 Right-Suite®Universal 2017 17.0.17 RSU10062 Page 1 ftCCI1 ...tsoftHVAC\Project\50 campbell rd andover ma.rup Calc=MJ8 Front Door faces: N u Entire House d 963 38884 18640 823 823 Other equip loads 0 0 Equip. @ 1.00 RSM 18640 Latent cooling 7650 TOTALS 963 38884 26290 823 823 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. .� wrightSoft Right-Suite®Universal 2017 17.0.17 RSU10062 2017-Jan-12 16:08:27Page 2 .�CP1 ...tsoftHVAC\Project\50 cam pbell rd andover me.rup Calc=MJ8 Front Door faces: N ti The COPI2mon Vearth of Massachusetts _ Depax'tmeSt of Indus&ia Accidefats F Comgress,S`treet,,S`u&t 100 $ostox�,MA 021X4-2017 ..= F �< www.m aSS.g'ov1Xa O - lectriciansl'luabers. WalkersCompe�atro Xnsuxnce Affidavit:Bulders/CoutractorsE BE F]LEx3 WXTSTI�PF�:MITTING A-O'IS012TJ;"S'. ..Please Px�nt D 1 A ••licautTtxfor:m.ation Namo(Businessloiga=�ion/Individual): Address: � �. �r N, �f�s76 Phonc#: 11`�1 -t551-1103 City/StatelZip: .. ... .. , . Type ' Axe you an employer?Check the appre of project(reg opriate box. ' and/or t time). 7.. F]NWd6nstCdd_UOn ar 1.❑I am a employer with employees(fuIl P 8. 0 Remodeling 2.❑IamasolDproprietororl)aTtaorshipandhayenoemployeesWorlang ozmem 9 ❑Demo]Itloxl any capacity.ji�I'ovaorkers'comp.insurance required-] e oworkers'comp.hAUancerequired_]t 10❑Building addition 3.Q I am ahomeowner doing allworkmys 7£[N zO e Iwill 4.� Jam a homeowner and wM be taring contractors to conduct aIl work o0 or p p y- 11.❑Electrical repaizs or additions tors ailherhave workers'compensation insurance or are sole , ensuretbat all couixac bixi re airs or additions �-tP ees. 12.''_��]'` Plum:_ g l� proprietors witi,no em Ioy 5.❑I am a general contiacto�and I hay e�andhave worke actors�P listed oaths attached sheet. 13•.L]Rbofrepairs These sub-contractors haveennpioY 14.M Other of ere tion ez MGL G. ' a c oration and its,offo6m have exercisedlheir right mp pe 6.�Weare orP urance re ] 152,§1(4),and v e hava no empldy,es.[No workers comp.rns q *Any applicamthat cheolss box#1 must also fill out the sectionbelou*showing their orkers'compensationpoficpmfomsation th are doing all work and$renhire outside contractors must submit a new affidavit indicating such i Homeowners who submrt•thvg afdaavf indicating the name of the sub-contractors and state whether or not1hose,ewes have tContractors that check ihis box must attached an addition sshe v de their workers_'comp.policy number. employees. If the sub-coniractorshave employees,they Pr' em to ees Below istliepoZicyaridjobsite X am an eyn-ployer that is providing rvo 7�ers'compensation insurance for my p y information. _ . 7n surauce Company Nama: L- C2 VC.#:. \'jC T.U v 1�-5 u Policy#or Self-ins. 3 Exp7ratianDate• Job Site Address: 5- 0 C C"' 1..c.[ City/Sfate/Zip: Attach a copy of tote•workers' compensation policy declaration page(showingthe policy amby a foie up to$500-00 Failure to secure coverage as required under MGL o-152' §25A is a criminal viol punishable { and/or one-year imprisonment as well as civil penalties in the form of a STOP WORg ORDER- s o a fine of f to $250.00 a day against the violator.A COPY Of this statement may be forwarded to the Of$ce ofTnvestigations of the DTA foxinsuxance coverage verification. I do herehy eertcfy under t7z its andpenalties ofpeYjury that the inforlrcolzon provided wave true and cot�ec Date: Si atur . phone#: official use only. Do not-tvrite in this creea,to he completed by city or town official FermitiUcense# City or Town- Issuing Authoxity(circle one}: rieal>nspector 5.Plumbingfkspeetor 1..Board of 1Sealth 2.Building Department 3.City/Town Clerk 4.Elect 6.Other Phone#= Contact Person: U Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their eanployees. 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 trust&of an individual,partnership,association or other legal entity,employing emplbyees:.However the owner of a dwelling house having not more than three apartments and who resides therein,or the o ccupant 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 bean 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 applica&wlid 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 filll out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply=b=contractors)name(s),address(es)and phonenumber(s)alongwiththeir cerUcate(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. B e advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is b eing requested,not the Department of Iudustrial•Accidenis. Should you have any questions regarding the law or if you are required to obtain a ivorkers' 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 aidxdavit 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 p ermit/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 b een officially stamp ed or marked by the city or toVVM 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 ahome owner or citizen is obtaining a license or permit natrelated to any business or commercial venture (i.a.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Depaitment 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 HILLCOR-02 DKULICK ACORD" DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1/5/2017 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(les)must have ADDITIONAL INSURED provisions or 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 License#1780862 5%JACT HUB International New England PHFAX, -0038299 Ballardvale Street IDONE, A/CNo):(978)988aWilmington,MA 01887 R SS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:LIbe Mutual Insurance Company 23043 INSURED - INSURER S:American Fire and Casualty Company 24066 Hillis Corp INSURER C:Independence Casualty Insurance Company 11984 DBA Frank's Heating Service 555 Woburn St INSURER D: Tewksbury,MA 01876 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXPJJIL LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OX OCCUR BKS55555637 01/0112017 01/0112018 DAMAGE_MISES RENTED E TErtence $ 300,000 MED EXP(Any oneperson) $ 15,000 PERSONAL SADV INJURY $ 1,000,000 GEHL AGGREGATE LIMIT APPLIES PER 2,000,000 R�� GENERAL AGGREGATE $ POLICY�X JECT �LOC PRODUCTS-COMP/OP AGG 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident)X ANYAUTo BA1656678207 01/01/2017 01/01/2018 BODILY INJURY Per person) OWNED SCHEDULED AUTOS ONLY AUTOS BODILY BODILY INJURY Per accident $ AUTOS ONLY LAUTOS ONLY arr acEdRQ AMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 3,000,000 EXCESS LIAB I I CLAIMS-MADE BKS55555637 01/0112017 01/01/2018 AGGREGATE 31000,000 DED I I RETENTION$ C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITYER ANY PROPREIIETOR/PARTNERIEXECUTIVE YIN N C100113103 06/30/2016 06/30/2017 E L.EACH ACCIDENT 500,000 We Mry In gER EXCLUDED? a NIA 1 NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF COVERAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ONLY ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �.�N►MpNIN �.. ..._. • MOF sHE aQA Mq SCHUSS issues E 'NIE' RX -- At' ° �Q R 'PER,H `Fptko wh y�NG tE T�MOTHy R P SON U..NREST CENSE *10 y�� AQWEI? RI to HAV AVE EHHI�� �1823 fa v , 3731' , 1g3pd9 i .N� �J Level 1 177 cfm 5 6 c m 165 fm bath2 ��,��' bed2 33 cfm C, mas hall �o 9 cfm 42 cfm bed3 1 cfm �V 177 cfm 72 cfm IN cfm Job M Scale: 1/4"= 1'0" Performed for: Franks Heating Service Page 1 555 Woburn St Right-Suite®Universal 2017 Tewksbury, MA 01876 17.0.17 RSU10062 Phone: 978-851-4403 Fax: 978-851-0398 2017-Jan-1216:08:00 Project8.rup t`- Date....... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING C H This certifies that ...........A.... ..4 ............................ has permission to perform ........C�4111104".. ............................ wiring in the building of.......A/P K—.5. ..................................... at .............................. North Andover,Mass. Fee... Lic.No.fl.lit)l........ .......... ELECTRICAL iKPI CIbR Check # 8541 • Commonwealth of Massachusetts official Use only �,. Department of Fire Services Permit N°._ � y E BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (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 W INK OR TYPE ALL INFORMATION) Date: / ,�_ o City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) e4 /y£L L/ Q fx, (�Owner r Tenant Telephone No. Owner's Address f a Is this permit in conjunction with a building permit? Yes ®� No ❑ (Check Appropriate Box) Purpose of Building 3tS Utility Authorization No. Existing Service a41� Amps /2 L /?EV Volts Overhead R Und rd g ❑ No.of Meters New Service it Amps t/ / /i Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: a e�� CJ/�Tl� 7 Q co---lefion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets s' No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o. o mergency lg g d rnd. Batte Units - No.of Receptacle Outlets /0 No.of Oil B i Burners ALARMS FIP,E No.of Zones No.of Switches S-" No.of Gas Burners No.-of Detection and No,of Ranges No.of Air Cond. Total Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat p 1P Tons KW o.of Self-Contained Totals: . ......... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: No.of water N No.of Devices or Equivalent No.of r Heaters KW Si s Ballasts Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total Hp No. Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: %lfQ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived b the owner,caner no permit� � p 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:) P ify:) I certify, under the pains and nalties of perjury, that the info ' o this appli FIRM NAME: cation is true and complete- Licensee: omplete Licensee: ; ;�_� LIC.NO.: �,y� �1YA111 p�(a� Signature � (If applicable, enter"exempt"in the license number line.) LIC.NO.: cf Address: �Q ��Q (�� ` r Bus.Tel No.: d *Per M.G.L c. 147,s.5 61,se' curity work'requues Deparent�of Public Safety" Alt.Tel.No.: 4 ety 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 agent. Owner/Agent Signature Telephone No. PERMITFEE: $ A � 1 i F The Commonwealth of Massachusetts Department of Industria!Accidents j Office of Investigations }' t; 600 fffashington Street R% Boston, MA 02111 www.n2ass.gov/dia . Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information -Please Print Legibly Name(Business/Organization/individual): Address: \ 0 -)� C A ee.rI Ci /State/Zi �' p Wb v ti ry }V\A? Phase #: . Are you an employer?Cheek.the appropriate box: I am a employer with S4. ❑ 1 am a general contractor and I Type project(required): employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2,❑ I am asole proprietor or partner_ listed on the attached sheet.I 7. ❑Remodeling ship and have no employees These suit-contractors have S. ❑Demolition working for .in g an act worker y capacity, s comp.insurance. 9, ❑ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required-] office 10.❑Electrical a officers have exercised their repairs or additions ns 3. ❑ 1 am a homeowner doing all work Tight o f exemption per MGL 11.❑ Plumbing repairs or additions myself, [No•workers'comp, c. 1.52, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs q ] .employees. [No workers' 1 g ❑Other comp. insurance required..] *Any applicant that checks bo)'#I must also fill out the section below showier their workers'com satin t g pen n oil info Homeown policy information, ets who submit this affidavit indicating they are daring all w 4 g eY B work and then hire outside contractors m Contractors that check this box mustattaehed an must submit a new affidavit indicating such. additional sheat showing the name Of the sub-contractors and r th �.� m , their work--- -_...,,.po.:c,irsrmation. I ant an employer that is providing:workersI compensation insurancefor my employees: Below is the olicy and job site informn. patio Insurance Company Name:alz\-4---AIDP �t'Oli 12 Policy#or Self-ins.Lic.4: ',,,10— I .f(= Expiration Date: t `� Job Site Addres Lbs M 1�,` �� City/State/Z r,1 Attach a copy of the worke ' compensation policy declaration page(showing the policy n amber 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 co of this statement may be PY forwarded Inv Y to the Office of estigations of the DIA for insurance coverage verification. I do h c er a at,, and en aloes n er'u that r P ,rp 1 at the in formation Provided l7' ,f P cded above is true and correct Si titre: Date: 1 Phone#: `p\ ) O ficial 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 ortrustee 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,notthe 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 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 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Y - X& AER-11111 NO. ? o � APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 I MAP NO. t I LOT NO. 12 RECORD OF OWNERSHIP iDATE BOOK PAGE — ZONE SUB DIV. LOT NO. I LOCATION _ D- PURPOSE OF BUILDING 2 � OWNER'S NAME "JV L/Y�T�tA/v� NO. OF STORIES J_ SIZElt o' Tn OWNER'S ADDRESS 15-6 A+ ENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN 3 �1 DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS - POSTS ��� --- DISTANCE FROM STREET Q3 DISTANCE FROM LOT LINES—SIDES r��- I REAR `�U GIRDERS /B AREA OF LOT JD FRONTAGE/l HEIGHT OF FOUNDATION /�, �l !1 _4 '/_TF{/CKNESS IS BUILDING NEW SIZE OF FOOTING 1CD �tX`"�"` IS BUILDING ADDITION ,/per_ MATERIAL OF CHIMNEY � h IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND f�� A WILL BUILDING CONFORM TO REQUIREMENTS OF CODE ` n, IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE 3 PROPERTY INFORMATION INSTRUCTIONS LAND COST i SEE BOTH SIDES EST. BLDG. COST .r ,,,_,_„y PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PERS . FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED Q _S BOARD OF HEALTH SIGNATU E OF OWNER OR AUTHORIZED AGENT FEE PLANNING BOARD PERMIT GRANTED /s 1-19 BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY S-0IESTHIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY _ OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- . APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ a- 1 2 13 CONCRETE BL'K. PINE _ BRICK OR STONE HARDW'D PIERS PLASTER _ _! DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T' AREA _ 1/ 1/2 FIN. ATTIC AREA _ NO B'M'T FIRE PLACES - _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW'D _ ASBESTOS SIDING -COMMON VERT. SIDING ASPH.TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME _ CONC. OR CINDER BLK. - STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 M. ( = GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING' _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING II 11 HEATING - WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GASOIL B'M'T2nd ELECTRIC 1st 13rd I NO HEATING ' „3 i, r y. 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