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Miscellaneous - 56 CIDERPRESS WAY 4/30/2018
F NORrH Q tL-ED ,6 6 f O a_ ....••" • A APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION �9SSACHUSE��y BUILDING PERMIT # -- ADDRESS/LOCATION OF PROPERTY: Ile, r S Map It) qC Parcel 3 Lot Number 6 ; r SUBDIVISION: e, S DATE REQUESTED FILED/READY FOR INSPECTION: O 12 I f I CLOSING DATE ON PROPERTY: _/�//:��/, FIVE 5 DAYS NOTICE PRIOR TO CLOSIA DATE IS RE UIRED ALL WORK AND SIGN-OFFS MUST BE Cr ETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLL 20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET AL APP ICABLE CO APPLICANT SIGNATURE Permit Issued to: )_LC Address:—IIS �, )f,,!aPJ,, ,jA-aAw, AkA- 4lSzT ROUTING TOWN ENGINEER, SITE PLAN-DRIVE-WAY REVIEW` * 41,91 ra CONSERVATION © Q u i-suA iD2 x(2 . 111 4 PLANNING t-'/, ❑ (N 14o B DPW-WATERMETER 41 t/j Z SEWER CONNECTION C�3' DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW J/ru� a_s_--, - _. �Iqll ,- SIGNATURE' File:Application for OC form revised Jan 2007/2011 1 / 11) THE BOUNDARY INFORMATION SHOWN HEREON WAS TAKEN FROM A / MAP 104C LOT 29 PLAN ENTITLED "PLAN OF LAND; MEETINGHOUSE COMMONS AT N/F ESSEX COUNTY SMOLAK FARMS, SOUTH BRADFORD STREET, NORTH ANDOVER, GREENBELT ASSOC., INC. MASSACHUSETTS"; SCALE: i" d 80'; DATE: JULY 20, 2001 BY THIS OFFICE. RECORDED AS PLAN #14828 IN THE ESSEX COUNTY NORTH DISTRICT REGISTRY OF DEEDS. / 2) THE INTENT OF THIS PLAN IS TO SHOW THE AS—BUILT LOCATION ���� OF THE FOUNDATION ONLY. lV" 104C 3) THE FOUNDATION SHOWN HEREON IS NOT WITHIN THE 100 YEAR LOT 28 1229' FLOOD ZONE AS TAKEN FROM THE FLOOD INSURANCE RATE MAP FOR THE TOWN OF NORTH ANDOVER MASSACHUSETTS COMMUNITY / PANEL NUMBER 250098 0007 C, MAP REVISED: 8/2/83, `'1'? 4) THE CONCRETE FOUNDATION SHOWN HEREON HAVE BEEN INSTALLED Vp SUBSTANTIALLY IN ACCORDANCE WITH THE 408 SITE PLAN AS rrrr/� ^....,,. ^`` `� Jsx�'s-�p+T G 1.08 R3 APPROVED BY THE TOWN OF NORTH ANDOVER PLANNING BOARD. ; J� `•.� i �,T � ;? Y/y 0,34 LIP �`s �� �,� �s \ I HEREBY CERTIFY THAT THE LOCATION OF THE TOWNHOUSE UNIT .� r � NUMBERS 20-23 FOUNDATION SHOWN HEREON IS THE RESULT OF A f� � Qr� �'`' •/ <� �,�^�.`(+ i \ FIELD SURVEY BY THIS OFFICE MADE ON DECEMBER 30, 2011. ol �'` � �� � � w% ^,� �. �.. FRANCHER Na 361:8 AL \` LICENSED LAND SURVEYOR DATE AL CERTIFIED FOUNDATION PLAN / MEETINGHOUSE COMMONS TOWNHOUSE UNITS 20-23 rr &\\ AL GRAPHIC SCALE CIDERPRESS LANE AIL o u eo :rb NORTH ANDOVER, MASSACHUSETTS AL PREPARED FOR MEETINGHOUSE COMMONS, LLC ' / 1oo (IN FELT) 121 CARTER FIELD ROAD inob - 60 !i. NORTH ANDOVER, MASSACHUSETTS oll / / / r I\ . 44 elan Road,SNb One o / \\ // / R Sal.m.(003)$0olioow7o \ ` F W911 lOanb,Ina. ENOINECRS-RMN[R!•SURVEYOR! SCALE: 1' 50' DATE: JANUARY 3, 2012 DRAWING s 9Vc , pCQ�Vpl I \ / N0. DESCRIPTION 8Y DATE DRAWN BY: CHECKED BY I PROJECT N0. NAME �DpOF 1 REVISIONS CMF 1 250508 25050FP.DWO VkORT#1 '9 O tt,,tD 1.616�O ~ APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION o M . K 9,e coma BUILDING PERMIT #S SSACHUs�t ADDRESS/LOCATION OF PROPERTY: CI S Map Parcel-3 I Lot NumberAlt SUBDIVISION: (gz0*0'S DATE REQUESTED FILED/READY FOR INSPECTION: �/(o 12f4ZI 1 I Z CLOSING DATE ON PROPERTY: FIVE 5 DAYS NOTICE PRIOR TO CLOSIA DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE CO ETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLL ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET AL APP ICABLE CO S. APPLICANT SIGNATURE Permit Issued to: LIZ Address: 5 l ROUTING TOWN ENGINEER, SITE PLAN–DRIVE-WAY REVIEW' fit, 4151"*- CONSERVATION 0 p u nu is M - 11 l V PLANNING N'j A ❑ C N 40$ DPW-WATER METER 9`_ 4I q/j Z SEWER CONNECTION C' DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW I`�1�� ``L-. jq C' SIGNATURE File:Application for OC form revised Jan 2007/2011 NORTH TON"M Of _ Andover t No. ��► x C, __ = o �` dover, Mass., ///Ah O LAKE 'Q COCMICKEWICK y�• loci RATE BOARD OF HEALTH Food/Kitchen Septic System PERMIT T. BUILDING INSPECTOR THIS CERTIFIES THAT...........�/��G�!'.! "r6J:E..... 1�1.%1 �.: ... Foundation �� ....�................ ............................... ............................. Rough ................ buildings on 4.d.... �i �� �C-. ,S.... . ..a.. . has permission to erect....................... l /9 ••• •• ••••• ••����•to be occupied as...............�... �%h�: ...0 fah. .. . . f1I�......................................................... Chimney provided that the person accepting this permit shall in every resp t conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws rola nng to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO ARTS Rough � � .............................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIREDEPARTMENT Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. { 1) THE BOUNDARY INFORMATION SHOWN HEREON WAS TAKEN FROM A MAP 104C LOT 29 PLAN ENTITLED "PLAN OF LAND, MEETINGHOUSE COMMONS AT N/F ESSEX COUNTY SMOLAK FARMS, SOUTH BRADFORD STREET, NORTH ANDOVER, GREENBELT ASSOC., INC. MASSACHUSETTS"; SCALE: 1" a 80'; DATE: JULY 20, 2001 BY THIS OFFICE. RECORDED AS PLAN #14828 IN THE ESSEX COUNTY / NORTH DISTRICT REGISTRY OF DEEDS. 2) THE INTENT OF THIS PLAN IS TO SHOW THE AS—BUILT LOCATION OF THE FOUNDATION ONLY. MAP 104C 3) THE FOUNDATION SHOWN HEREON IS NOT WITHIN THE 100 YEAR 12.29' FLOOD ZONE AS TAKEN FROM THE FLOOD INSURANCE RATE MAP LOT 28 FOR THE TOWN OF NORTH ANDOVER MASSACHUSETTS COMMUNITY PANEL NUMBER 250098 0007 C, MAP REVISED: 6/2/83. UN? 4) THE CONCRETE FOUNDATION SHOWN HEREON HAVE BEEN INSTALLED � � ?� 1'oo APPROVED BYYTHE TOWN IN DOFCNORT'H ANDOVER PLANNIE WITH THE 408 SITE NG BOARD, 0.34 i�/,� �`��` `�>'�`^�`. `����� c1� �' J �S�• I HEREBY CERTIFY THAT THE LOCATION OF THE TOWNHOUSE UNIT NUMBERS 20-23 FOUNDATION SHOWN HEREON IS THE RESULT OF A �4 �/ `�� ,�`�.' e1�°�0�`' / "�r� / '\ FIELD SURVEY BY THIS OFFICE MADE ON DECEMBER 30, 2011. CHRISTOPHER SsS G i / `•—� FRMCNER AL / ' LICENSED LAND SURVEYOR DATE AL AIL AL AL �•-- CERTIFIED FOUNDATION PLAN MEETINGHOUSE COMMONS TOWNHOUSE UNITS 20-23 +� +111 GRAPHIC SCALE / / \ CIDERPRESS LANE ` a 1 NORTH ANDOVER. MASSACHUSETTS $ AhD FOR AL MEETINGHOUSE COMMONS, LLC g, NORTH 1 CARTER FIELD ROAD 1 inch p 2AN OVER, MASSACHUSETTS / -?� / // \ // ` ■ 44 Was Read,Su1N One saNm.Now�6033) 0720 030"/ At. / \ MHF Waign CenaultanU,Ina. ENO1NURS-PLANNLRS'SURVLYORS SCALE: 1' - 70.1 DATE JANUARY 3, 2012 1 DRAVANO �4 elU(0 I \ NO. DESCRIPTION 8YDATE RAWN BY: CH CKED BY: PROJECTN0. NAME �` / F "` REVISIONS CMF 1 250508 1 2505CFP.DWO i Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer A Tanning(Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packa_ging/Sa1es ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS 2-l;,> t{O$ �nd c4 V, CONSERVATION Reviewed on Si nature COMMENTS_ A ae 2�Z - �)l�f i,n aGcesccCa trace W�OD C d,,,,( J�Ic�t t C /S HEALTH Reviewed on Signature COMMENTS ,r Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Z��^�J 1 Comments 'hater&Sewer ConnectioniSi nature&D e , s Drivewav Permit PW Town Engineer: Signature: - I Located 384 Osgood Street FIRE DEPARTMENT -Temp D er onsite yes _ no Located at 124 Main Street Fire Department signature/date COV50NTS V4ORTH Town of Andover . . A. 7a - /ax - _ dover, Mass., AC OCHICHEwICK 0 RA TED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �` BUILDING INSPECTOR THIS CERTIFIES THAT.............! W .. .... .....f�... cs ;a!e ..........................................................I......... Foundation has permission to erect........................................ buildingson.. �,.. -?., .✓ `,.. ?r ..... ......7....... Rough U GY['c�•s+ �/� Chimney to be occupied as................ ........................................ .......... .................................................................................................. provided that the person accepting this permit shall in e ry respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS � n T T ELECTRICAL INSPECTOR V 1 V C LESS ONST R V CTION ARTS Rough :-'9!•• ............................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises -- Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. REScheck Software Version 4.4.0 Compliance Certificate Project Title: Meeting House Commons Energy Code: 20091ECC Location: North Andover, Massachusetts Construction Type: Multifamily Building Orientati n: Bldg.orientation unspecified Glazing Area Percentage: 12% Heating Degree Days: 6322 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: Building 6 Tara Leigh Development,LLC O'Sullivan Architects,Inc. North Andover,MA 115 Carter Field Road 580 Main Street North Andover,MA Suite 204 978-6876-2635 Reading,MA 01867 781-439-6166 Compliance:1.1%Better Than Code Maximum UA:875 Your UA:865 The%Better or Worse Than Code index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code tome. Floor 1:All-Wood Joistfrruss:Over Unconditioned Space 4396 30.0 0.0 145 Ceiling 1:Flat Ceiling or Scissor Truss 4396 30.0 0.0 154 Front Walls:Wood Frame,16"o.c. 1613 19.0 0.0 80 Orientation:Unspecified Window 3:Vinyl Frame:Double Pane with Low-E 155 0.330 51 SHGC:0.30 Orientation:Unspecified Window 4:Vinyl Frame:Double Pane with Low-E 42 0.280 12 SHGC:0.27 Orientation:Unspecified Door 1:Solid 80 0.160 13 Orientation:Unspecified Sides:Wood Frame,16"o.c. 2660 19.0 0.0 151 Orientation:Unspecified Window 5:Vinyl Frame:Double Pane with Low-E 140 0.330 46 SHGC:0.30 Orientation:Unspecified Rear Walls:Wood Frame,16"o.c. 1784 19.0 0.0 80 Orientation:Unspecified Window 1:Vinyl Frame:Double Pane with Low-E 345 0.330 114 SHGC:0.30 Orientation:Unspecified Window 2:Vinyl Frame:Double Pane with Low-E 21 0.280 6 SHGC:0.27 Orientation:Unspecified Door 3:Solid 80 0.160 13 Orientation:Unspecified Compliance Statement: The proposed building design described here is wns1 tent with the building plan ,specifications,and other calculations submitted with the permit application.The proposed building as be n designed to meet th 009 IECC requirements in REScheck Version 4.4.0 and to comply with the mandatory requirements listed i the RESc ck Ins tion Checklist. ..__06����!DRi✓ A .��L���:-_ ... ___.________,w__.�..._.._.�____.�..�_.... _.._..�. .:... ._ Project Title: Meeting House Commons Report date: 12/07/11 Data filename:K:\Zahoruiko\Meetinghouse Commons-No Andover\Meeting House Townhouses\CD's\Building 6\Building_6.rck Page 1 of 6 REScheck Software Version 4.4.0 Inspection Checklist Ceilings: ❑ Ceiling 1:Flat Ceiling or Scissor Truss,R-30.0 cavity insulation Comments: Above-Grade Walls: ❑ Front Walls:Wood Frame,16"o.c.,R-19.0 cavity insulation Comments: ❑ Sides:Wood Frame,16"o.c.,R-19.0 cavity insulation Comments: ❑ Rear Walls:Wood Frame, 16"o.c.,R-19.0 cavity insulation Comments: Windows: ❑ Window 3:Vinyl Frame:Double Pane with Low-E,U-factor:0.330 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: ❑ Window 4:Vinyl Frame:Double Pane with Low-E,U-factor:0.280 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: ❑ Window 5:Vinyl Frame:Double Pane with Low-E,U-factor:0.330 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: ❑ Window 1:Vinyl Frame:Double Pane with Low-E,U-factor:0.330 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: ❑ Window 2:Vinyl Frame:Double Pane with Low-E,U-tactor.0.280 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: Doors: ❑ Door 1:Solid,U-factor.0.160 Comments: ❑ Door 3:Solid,U-factor.0.160 Comments: Floors: ❑ Floor 1:All-Wood Joistlfruss:Over Unconditioned Space,R-30.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: Project Title: Meeting House Commons Report date: 12/07/11 Data filename:K:\Zahoruiko\Meetinghouse Commons-No Andover\Meeting House Townhouses\CD's\Building 6\Building_6.rck Page 3 of 6 0 Joints(including rim joist junctions),attic access openings,penetrations,and all other such openings in the building envelope that are sources of air leakage are sealed with caulk,gasketed,weatherstripped or otherwise sealed with an air barrier material,suitable film or solid material. p Air barrier and sealing exists on common walls between dwelling units,on exterior walls behind tubs/showers,and in openings between window/door jambs and framing. Recessed lights in the building thermal envelope are 1)type IC rated and ASTM E283 labeled and 2)sealed with a gasket or caulk between the housing and the interior wall or ceiling covering. Ll Access doors separating conditioned from unconditioned space are weather-stripped and insulated(without insulation compression or damage)to at least the level of insulation on the surrounding surfaces.Where loose fill insulation exists,a baffle or retainer is installed to maintain insulation application. Wood-burning fireplaces have gasketed doors and outdoor combustion air. Air Sealing and Insulation: I Building envelope air tightness and insulation installation`complies by either 1)a post rough-in blower door test result of less than 7 ACH at 33.5 psf OR 2)the following items have been satisfied: (a)Air barriers and thermal barrier:Installed on outside of air-permeable insulation and breaks or joints in the air barrier are filled or repaired. (b)Ceiling/attic:Air barrier in any dropped ceiling/soffit is('substantially aligned with insulation and any gaps are sealed. (c)Above-grade walls:Insulation is installed in substantial contact and continuous alignment with the building envelope air barrier. (d)Floors:Air barrier is installed at any exposed edge of insulation. (e)Plumbing and wiring:Insulation is placed between outside and pipes.Batt insulation is cut to fit around wiring and plumbing,or sprayed/blown insulation extends behind piping and wiring. (t) Corners,headers,narrow framing cavities,and rim joists are insulated. (9)Shower/tub on exterior wall:Insulation exists between showers/tubs and exterior wall. Sunrooms: I] Sunrooms that are thermally isolated from the building envelope have a maximum fenestration LI-factor of 0.50 and the maximum skylight LI-factor of 0.75.New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Materials Identification and Installation: Materials and equipment are installed in accordance with the manufacturer's installation instructions. Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R-value. 0 Materials and equipment are identified so that compliance can be determined. O Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. Insulation R-values and glazing U-factors are clearly marked on the building plans or specifications. Duct Insulation: f-1 Supply ducts in attics are insulated to a minimum of R-8.Ali other ducts in unconditioned spaces or outside the building envelope are insulated to at least R-6. Duct Construction and Testing: Building framing cavities are not used as supply ducts. I] All joints and seams of air ducts,air handlers,filter boxes,and building cavities used as return ducts are substantially airtight by means of tapes,mastics,liquid sealants,gasketing or other approved closure systems.Tapes,mastics,and fasteners are rated UL 181A or UL 181 B and are labeled according to the duct construction.Metal duct connections with equipment and/or fittings are mechanically fastened.Crimp joints for round metal ducts have a contact lap of at least 1 1/2 inches and are fastened with a minimum of three equally spaced sheet-metal screws. Exceptions: Joint and seams covered with spray polyurethane foam. Where a partially inaccessible duct connection exists,mechanical fasteners can be equally spaced on the exposed portion of the joint so as to prevent a hinge effect. Continuously welded and locking-type longitudinal joints and seams on ducts operating at less than 2 in.w.g.(500 Pa). Duct tightness test has been performed and meets one of the following test criteria: (1)Postconstruction leakage to outdoors test:Less than or equal to 351.7 cfm(8 cfm per 100 ft2 of conditioned floor area). (2)Postconstruction total leakage test(including air handler enclosure):Less than or equal to 527.5 cfm(12 cfm per 100 ft2 of conditioned floor area)pressure differential of 0.1 inches w.g. (3)Rough-in total leakage test with air handler installed:Less than or equal to 263.8 cfm(6 cfm per 100 ft2 of conditioned floor area) when tested ataressur � e differential of 0.1 inches w.g. Project Title: Meeting House Commons Report date: 12/07/11 Data filename:K:\Zahoruiko\Meetinghouse Commons-No Andover\Meeting House Townhouses\CD's\Building 6\Building_6.rck Page 4 of 6 5 (4)Rough-in total leakage test without air handler installed:Less than or equal to 175.8 cfm(4 cfm per 100 ft2 of conditioned floor area). Temperature Controls: 0 Thermostats exist for each dwelling unit(non-dwelling areas must have one thermostat for each system or zone).A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each room is provided. Electric Systems: ❑ Separate electric meters exist for each dwelling unit. Heating and Cooling Equipment Sizing: } Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code. ❑ For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2009 IECC Commercial Building Mechanical and/or Service Water Heating(Sections 503 and 504). Circulating Service Hot Water Systems: ❑ Circulating service hot water pipes are insulated to R-2. ❑ Circulating service hot water systems include an automatic or accessible manual switch to tum off the circulating pump when the system is not in use. Heating and Cooling Piping Insulation: ❑ HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-3. Swimming Pools: Heated swimming pools have an on/off heater switch. ❑ Pool heaters operating on natural gas or LPG have an electronic pilot light. Timer switches on pool heaters and pumps are present. Exceptions: Where public health standards require continuous pump operation. Where pumps operate within solar-and/or waste-heat-recovery systems. ❑ Heated swimming pools have a cover on or at the water surface.For pools heated over 90 degrees F(32 degrees C)the cover has a minimum insulation value of R-12. Exceptions: Covers are not required when 60%of the heating energy is from site-recovered energy or solar energy source. Lighting Requirements: ❑ A minimum of 50 percent of the lamps in permanently installed lighting fixtures can be categorized as one of the following: (a)Compact fluorescent (b)T-8 or smaller diameter linear fluorescent (c)40 lumens per watt for lamp wattage—15 (d)50 lumens per watt for lamp wattage>15 and—40 (e)60 lumens per watt for lamp wattage>40 Other Requirements: ❑ Snow-and ice-melting systems with energy supplied from the service to a building shall include automatic controls capable of shutting off the system when a)the pavement temperature is above 50 degrees F,b)no precipitation is falling,and c)the outdoor temperature is above 40 degrees F(a manual shutoff control is also permitted to satisfy requirement's'). Certificate: A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R-values:window ❑ P 9 U-factors;type and efficiency of space-conditioning and water heating equipment.The certificate does not cover or obstruct the visibility of the circuit directory label,service disconnect label or other required labels. NOTES TO FIELD:(Building Department Use Only) Project Title: Meeting House Commons ~-~ _ .. e.__. .__ ------•• -- Report date: 12/07/11 Data filename:K:\Zahoruiko\Meetinghouse Commons-No Andover\Meeting House Townhouses\CD's\Building 6\Building_6.rck Page 5 of 6 IL-nh,-fi,mac ency g etI.Jficaie EM,- Ceiling I Roof 30.00 Wall 19.00 Floor I Foundation 30.00 Ductwork(unconditioned spaces): ----- M, 75 A Window 0.33 0.30 Door 0.16 NA Heating System: Cooling System: Water Heater: Name: Date: Comments: tiiaxsachvsct#s-Department of Puhlic Safety- ' Board of Building ' ..Rc„lutations and Standards Constructton SuPervisor License License: cs ss417 Restrictedao 00 Tt-1ONWS:D ZAHORUIKO k 115 CARVOIELD RD N ANDOVEI ,1VfA.p1845 -- ]Expiration: 415M2 t'nm[[[isimrr Trn: 21090 The Commonwealth ofMassach.. Department of fit&g� rir Accidents Office ofz,,zvesdiaajions =600 Washinon . BOS'O t, M4 02111 'Workers'Compensation ins xsbov/dia '�Dnlicant Tnformafion °r��Affidavit~BuilderslCo�atractors/Blectricians/PIumbers PIease print blv Name{B,tsiness/Organization/ln�v; _ C Aadreis: City/sbftTipear, v 1 Phone ll- Are you an employer?Check the appro riate b p o= 1.❑ I am a employer wiihT 4- I aim a YPe of Project r employees(full and/or ��contractor and i ���' - ?-® I am a sole Part-time).* have him.-d the so�� 6. XNear c '�orpartn_ listed am the attached I 7. ship and have no employees These sheet ❑Remodeling Working mr me in a-► b- actors have 8. ❑Demolition oris eq Workers'camp. 5. ❑ We are a c COMP. n 9- ❑Building ding addition officers have eaeatised their I0.[]E(whica,repain cn.additions �.❑ I am a homeow=doing an wor; - mysel£ o rW of��on PcrMGL I L [N [� a� �. �b� or ms�e ,tP 152,§I(4)�and We have no r--pairs additions smPloyers_ [No*others' . 12.[:]Roof comp.ms[uance ] I3.❑other `r�Y ► that c1t_: b ? wneawnen;vvhp subm¢ n...�res°71 out the --doing ali wo*and -- 'Conhac0ors that nc��this hox const atmcned an addi(i�al s .�av �_tame of -.ram s employrwt - - o8 n � anmdatheir sub-maditmaune•wwa�fadPdrAYn d& mtss g� arkers,inf�madnicefor ---- _ _. 'n3'employees Below is Name: the Fo and ce Com' ' J�site P0licY#or Se = I€•a s.Lac. - E*rafion Date: Job Site Address; Attack a copy of the workers'co Fauhme to secote mPe�fion Policy declaration page(show the poli numr as Cy ber and irafi under Section 25A ofi GL c. 132 on date �e uP t4$1,500.00 and/or one-year can lead#0 Bae imposition of Of up to 5250.00 a as well as civil PmtaWes in tie£oam of a STOP WORK enaltiks of a day against the violabt Be drat a copy o fg foxed to BR and a fine Iavestigaans of the DIA fiat insurance on may Office of - I do her QIP-unaier Pis and- . ofPe►7�L►iat Sionan.,r- "yotl LT true and COrrect Phone#. -79-46 S7� Ofjrcrcl use only. Do not wr*in Luis area to be comPleted by city m.to►vn ofilnid City or Town: " P Authority(a rde one,- . cease# L Board of Heaitb L Bur1ffing,Department 3-ci 6.Other o� IT Clerk 4.Ekctrical huspector 5.Plumb' Q �e Inspector COA�L<'Per'StpI: Phone�: Date...3.-I.-Z.171...... NORTl� °f<<``°:•'"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............t. .......... ........ has permission to perform ....... v .....6'0- 1,..b.6.............................. wiring in the building of Kig!7 :n.�..!7WC.t...........&.L.� ............. ......... at.... U1 � ................. orth Andover,Mass. S s-o Fee.,��.4 '. Lic.No..r".IZZ 46...............:,.� f .. .... EL CTRICAL��tSPE�Ir Check At `� 0690 commonwealth of Massachusetts official Use Only - Department of Fire Services PernntNo. l � _ BOARD OF FIRE PREVENTION REGULATIONSOccupancy 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 C),527 CMR 12.00 (PLEASE PRINT.ININKORTYPE ALL XFORMATION) Date: 3 111 CL_ City or Town of. NORTH.ANDOVER To the Inspector of Wires: By this application the undersigned gives notice ofliis or her intention to perform the electrical work described below. Location(Street&Number) $`� —SS Owner or Tenant Telephone No. . I ——4 9— Owner's Address v%-/ - .7-i V v Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building J. 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 Ampaclty Location and Nature of Proposed Electrical Work: U,t— r Com letion o the ollowin table, be waived b the Insector of Wires. No.of Recessed Luminaires ( No.of Ce%-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets V, No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency >tg g rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No,of Zones No.of Switches No.of Gas Burners No.ofDetection and Initiatin Devices No.of Ranges l No.of Air Cond. Total - No,of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ......__...__ . .... .........._........... Detection/AlertinLy Devices No.of Dishwashers ( Space/Area Heating KW Local❑Municipal Connection El Otter No.of Dryers ( Heating Appliances Security Systems:x No.of WaterNo.of Devices or Equivalent Si Heaters KW No, as Data Wiring: Signs Ballasts No.of Devices orE uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No,of Devices oar E uivalent d j, .Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value fJ&-- INSURANCE ctrical Work: �r ry�y. (When required by municipal policy.) Work to Start: 3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. C E: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such c�ove eism force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE I.T BOND ❑ OTHER ❑ (Specify:) X cerfify,under thains and penalties ofpedulry,that the information on this application is true and cor:p de FIRM NAME: ,�.•-ty}G� [�G C�'L 6C-- LIC.NO.: /<— Licensee: ✓►-i -'I Signature LIC.NO. (Ifapplicab e,a er"exempt"in the license numberline, Address: PC," Bus.19A!0) Bus.Tel.No.; , (9! *Per M.G.L c. 147,s.57-61, ecurity work requires Department ofPubli Safety"S"License: Alt. Lic.No. - S--rad 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 Signature Telephone No. PERMIT FEE:$ r' J 4 A..[0.V Uf Y r�JG•�eC.r.:s.OJ.Y"e i. .. �'�ssecl-� _ �'ailefl-•j I fie-inspection x'equurecT($50.OQ)�j ] mn 3nspectoxs'co�une�afs: (flip eefors'ftuatuxe-)10�fnittals) plate L INSP)gCtION; rVfmectors' - T'C+'aflecl--j �' � �te�nspection.xeQufxecT($�0.00)--[ � . comm enfs: (ffls�ectoxs81 tare-n itials) Slate 3,r7 7D"RC dOTTND 3N PECZIO T: , �.'assed-j ] 3�`azTecl--j ) ate-xnspecfion,xet�uiretl($50.00)�j ] r Inspectors'conments: (lnspectoxs' ignatuxe- no?niffaTs) Date . �.'.�T�PECTJCOIV"--�E�,'►�CE: � . Passed—[ I+'aiied- j � !`fie-inspection required($50AD) -j � �tspectbxs'eoJmmep��s: (Cuspeetoxs',�zgnatuxe�1aoJnitials) Date 'assed•--j � I+,`aiTer�--[ �. 'ate-inspection recluix'ed($50.OD)�[ ) - �S�]eCtOxs'CD711n7,�T1tS: ' Lispectors' ignatwre no initials) ))ate 1)GOR ['-A,GN.ASE TO BE T+MLYD dli7T ASD MFT ON SITE N TM.APXA TO DE INSPECTED 19 NOT ACCESSEBEE.AND.A"MNSPECTION OF 550,0 0 is TO BY,C"C-€ARGED• - t The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations qu 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �ALA1-.r-e= �cc� , Address: L-4_� Piot �t , City/State/Zip: t�� �,p►.�� � 63k� Phone#: 2? Are n employer?Check the appropriate box: Type of pro' ct(required): 1. I am a employer with ') 4. ❑ I am a general contractor and I 6. ew 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. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ElWe are a corporation and its 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 . m selfo workers' comp. c. 152,§1(4),and we have no y [N p 12.❑Roof repairs insurance required.]f employees.[No workers' ' comp.insurance required.] 13.❑Other P *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 ire 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. {-- A V V n� Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a file 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 ofup to$250.00 a da against the violator. Be advised that a co of this statement may be forwarded p Y g copy y rw to the Office of Investigations of the DIA for insurance coverage verification. I do hereby jcerunder the pains and penalties ofperjury that the information provided above is true and correct. Si ature: Date: 31 ,Phone#: Z_-- 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#' �i Information and Instructions V 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 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 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 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 Mossa.,chusetts Department of Industrial.Accidents Office of Investigations 600 Washington Streot Boston,MA,02111 Tel,#617-727-4900 ext 406 or 1-877,7MASSAFE Revised 5-26-05 Fax#617-727,7749 www.mass,80V1dxa 0 Date. .'. I .. .. HpRT� TOWN OF NORTH ANDOVER 0 '< •< op PERMIT FOR MECHANICAL INSTALLATION ,SSACMUSES This certifies that . :�1 . . . . . : `! ..}: . . . . . . . has permission for mechanical installation in the buildings of . . . . . . . at l.^.. . . . /-. ,I- .�'�- . . . . ., North Andover, Mass. Lic. No. . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: Permit# Estimated Job Cost: $ Permit Fee: $ , Plans Submitted: YES NO Plans Reviewed: YES NO Business License# 196 Applicant License# Jc 6 Business Information: Property Owner/Job Location Information: Name: J&J Heating & Air Conditioning Name:Tara Leigh D-velopment LLC Street: 17 Arlington St.:, Street: 56 Ciderpress Way City/Town: Dracut, HA 01826 City/Town: North Andover, MA 01845 Telephone: .978-454-8197 Telephone: 978-687-2635 Photo I.D. required/Copy of Photo I.D. attached: YES NO Staff Initial J-1 /M-1-unrestricted license J-2 /M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential:T--2-family �11�Iulti-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other ; Square Footage: under 10,000 sq. ft. ✓' over 10,000 sq. ft. Number of Stories: •' Sheet metal work to be completed: New Work: ✓ Renovation: HVAC ✓ Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: �`� �j�7a / d u�7�w o�'Gr -F B►^ h'U.¢c s r T e� INSURANCE COVERAGE: I have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L.Ch..112 Ye4'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 ❑ 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❑,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. Duct inspection required prior to insulation installation:YES NO 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 i t ©MMNIIVEAL7H OF:MASSACH.UETTS .. l'S A BUSINESS - "1SSUE$THE ABOUE L��ENSE Td fDWAi�� t A:Y6TTE: - J > J HEATING A;IR -:GONDIIONIN 1 T ALINC70N STREET # l _ _ I�RACUT } MA 19� 401/196CENSE NO. /14 9527 EXPIRATION • Tire Commonwealth; of Massachusetts .._- fA Department of Industrial Accidents. ' Office of Investigations 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 Leizibly Name.(Business/Organization/Individual): J&J Heating.&Air Conditioning,Inc. Address:17 Arlington St City/State/Zip:Dracut, MA 01826 Phone#:978-454-8197 Are you an employer?Check.the appropriate box: ✓ 4. I am a general contractor and I Type of project(required): 1.❑ I am a employer,with ❑ employees(full and/or part-time).* have hired the sub-contractors 6• ❑✓ 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 El Building addition [No workers' comp,insurance p.insurance. required.] 5. ❑_We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their ]1.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption-per MGL 12.E 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#1 must also fill out the section below showing their workers'compensation policy information. t liomeowners 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 slate whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that Ls providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Great-American Policy#or Self-ins.Lic.#:WC 6418907 04 Expiration Date:06/02/2012 Job Site Address:All locations In City/State/Zip: . Attach a•copy of the workers':compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a. fine up to$1,500.00 and/or one-year-imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250:00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the/.DIA for insurance coverage verification. I do Itereby c d r townpA na tle u that the information provided above IT fruh and correct. Si na e Phone.#:978-454-8197 Official use only. Do.not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector G.Other Contact Person: Phone#' DYYYY DATE r �ACORnM CERTIFICATE OF LIABILITY INSURANCE 06/06/2011 PRODUCER 97F.$,$$7.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward 91 Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR k South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 0. Box 457 sfie1d, MA 01983INSURERS AFFORDING COVERAGE NAIC 4 ED ]&] Heating & Air Con Ttion ng, Inc. INSURERA: Great American 17 Arlington Street INSURER B: Dracut, MA 01$26 INSURER C: INSURER Q INSURER E: COVERAGES LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING THE POLICIES OF INSURANCE ANY REQUIREMENT,TERM CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR PER AGGREGATE LIMITS INSURANCE SHWN MAY HAVE BEEN REDUCED DESCRIBED HEREIN IS PAID CLAIMS. SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH PO LSR NSR POLICYEFFECTIVE POLICY EXPIRATION LIMITS I TYPE OF INSURANCE POLICY NUMBER TE MMIDD GENERAL LIABILITY PAC6418906-04 06/01/2011 06/01/2012 EACH OCCURRENCE $ 1,000,00C COMMERCIAL GENERAL LIABILITY PREMISES Ea occurtence $ 300,00 CLAIMS MADE a OCCUR MED EXP(Arty one person) $ 10,00 PERSONAL&ADV INJURY $ 1 000,00 A X GENERAL AGGREGATE $ 2.000.00 PRODUCTS-COMP/OPAGG $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JEST LOC AUTOMOBILE LIABILITY CAP6418957-02 06/01/2011 06/01/2012 OPROPERTYDAMAGE DSINGLELIMIT $ nt) 1 000,00 ANY AUTO ALL OWNED AUTOS NJURY $ on) A X SCHEDULED AUTOS X HIRED AUTOS NJURY $ accident) X NON-OWNED AUTOS TY DAMAGE S dent) AUTO ONLY-EA ACCIDENT $ GARAGELIABILITY ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EACH 6CCURRENCE $ EXCESS I UMBRELLA LIABILITY OCCUR D CLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE EEE�l a RETENTION $ WORKERS COMPENSATION WC6418907-04 06/02/2011 06/02/2012 X TORY LIMITS ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 1 000 OO ANY PROPRIETORIPARTNER/EXECUTIVE� A OFFICER/MEMBEREXCLUDED? uu E.L.OISEASE-EA EMPLOYE $ 1,000,00 (Mandatory In NH) It es,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,00( 00 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Evidence of,Insurance AUTHORIZED REPRESENTATIVE Peter Sennott LA `�`" •-»•^�' ACORD 26(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD v, r r r nom. u�► ro V/ V4 10U3/L4/.0 "U/0 h : 0503031 GREAT AMERICAN •ALLIANCE INS CO Administradve Offices WC 00 00 01A ( Ed . 01 /97) 301 E 41h Street Cincinnatl OH 45202.4201 ll•• 1 RICAN. 513 369 5000 ph Policy N o . 6 I C I 1 --L6 141 1 1819 10 171 10 t 4I INSURANCE GROUP l-- Prior Policy No . .61C, I 1161411181910171 I J WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE nsurance is afforded by the Company named below, a Capital Stock Corporation : GREAT AMERICAN ALLIANCE INSURANCE COMPANY NCCI Company No . 14028 ............. ..... ...... ... ..... ...:v• •,v.... .. r.. :r .... :: •?:r f:;r r..v":r }r.•}Y.:•};..r•,•,•'F.•:•:;:}:v'4:4}}}i}�'i':::F'}'v':I:S'i.'•�?$::::v :•':::::::•%::iiil:$'•,} . .... ..:...::::.... ..v::r::::.v;..,.. :...: !. .;}.....; .• v,.SA : 4: Y .;;4r ,/r9J rr r'lJf,:ryfJ',..}..:n,.'fI:.JEi/¢J+J�}.:?.,/!E:5•r?:J:r.•s.•:3.•}:}•!•>:<..!5:•>:�:•::•'}>:: h 5. •y. .... .��.y.{�}�::;:!:•::::.. ., ...:..::.., •.:5i .S,S}i. !'.i;3£'. u!1 fi.'�'!•.^;•• ,.��:rf., '�J/r ,.;�>,':';?;��•l.•. fil.rr?::r •;}J.5!';i:;...F,./,•p::'�::w:::::: 1 'he Insured : J&J HEATING & AIR CONDITIONING Legal Entity : j INC. Corporation . lailing Address : 17 ARLINGTON STREET FEIN No . : 042488433 DRACUT, MA 01826 ether Identification Number : See Extension of Information Page . !I Ither workplaces not shown above : See Extension of Information Page . . ..... ...... .. .................. . .. . .. . ...;.. ..,...:: »::.:.r.:::. ..:::..:r::.r...::.::::::..:.::.}:::.�:•::.5:.:;:<.>••}>:.}}:?.w:.::•.:::!?.}'!.5555>r::;r.55:.�+<:;>}::}}::.>:<: .. .............:..::.:.:r:::;.� .....:.,..:....:::.: •: .: :. . .:..!5:.:r.rfr,..:.•rf,. ..?.r.:5.v ,,.t:. . f.. f J..:..;.:r:.!;:..?::..; r}... .x... r5.. .2y : rJ' i.y, J.1.ir r: S.?:.rr.:rf:2+;�;rr;?ir..f...:::5}Y::rr.:,.}w}•r:5:',•f:!.: <,•:?:::`:?•:�i.'•'::'•:'.'•:'tw}:?:: i�. .�.: ••.455x:::..r•:5::.,f: r:J3,. .}. . r:Jlrr.6:?�>~'�s�k?f/.•.:.?�i,:...«..r.r...:..,.....::�.rv.:.,..:.:•;.:::r:s?.:::.::...:.:... ...J • •5•?•.. ..:.:<>.?r::;•:: :....:.: ,• •.!. >:�;::.5.:,?Nr.}!:::.r,.,•:.•::}:'•�xfr.;,.,fr:..', } s�x�:.?r�.:�:..r.....:......... . 'he policy period is from 06 /02 /2011 to 06/02/2012 12 :01 A.M. Standard Time at i he Insured ' s mailing address . ............. .. ...... .. .... .....v•:•.•v:rrr•..; ., ...•.., ... t:•. .• •::}.. ..r:• r •: :••55:f•5'S'�5�"+5:4�:!r•:+:'!ti�vl.•5'rn+•5'•5rri}:•}5i:+ ti:ir�iY:Srti•5i i,ti}:iy:(}•ii'f:• i.•,•?+}r:: yy.:•.4!r+ f l /5: �� .Fi• {S/?vr:r•r?�f%k !.r rr:r r/�::+?r:„Jr.:?{}i}:^.?4'!..:45'!::4 w::4:/?5i:?iv'rJ.4:•:/.;ti?•5Sr .I�. t:.:::: .. J.5,;x5.�..•• :.. .?J>!:!,:::>��5:4a,':�:>,.{.�:' .:: .: ': J,'9,r'�•;::r. . ;•ry . .;ry,�.�!,:?::.,s�;::!c.::fir,,:??,.;;�5!.}.!c :?.:•...:.!:::.;•:..;•.::.;•::::..!;..;..;;.:::••::::::::: 1. Workers Compensation Insurance.: Part One of the policy applies to the Workers Compensation Law of the states listed here : MA, NH 1 . Employers Liability Insurance : 1. Part Two of the policy applies to work in each state listed in Item 3 .A. The Limits of our Liability under Part Two are : Bodily Injury by Accident $ 1 •,000 ,000. each accident Bodily Injury by Disease $ 1 ,000 ,000 policy limit l Bodily Injury by Disease $ 1 ,000 ,000 each employee ;:' Other States ' Insurance : Part Three of the policy applies to the states , if any , listed here : All I states except ND, OH, WA, WY states desi.gnated in Item 3 .A. I. This policy includes these endorsements and schedules : See FORMS AND t ENDORSEMENTS Schedule , 06 22A 01 WC 99 (01 /97) . ............ ........ .... ....... ...... ........;.. .:. •: .• •;:: .., ...,. •+r :r..x;•:r...:::•.}rF.!v'k'i.:::rr•5:•5'•Y.!•i::r.r?:{:.:;:•}5:?;}5Y.!i:i}55::5ri45?:},55';!:iii 5::}:;i:!:riS:S[:Sii'r,: .............. RAM . .. .:.:.:.... ........:..........:.;.�;:5::::.;.•::•: ::.v/.ttvr nvv,�, .. :.8??. .r+f r ..a'r .r3. .{•.:.: .:nrf.•':.J.;•i•5:•5::.:4:v •}. :::r:•:},..:::r:r...'.... :.5 :.ri .y ,rL°;...: :r• //. +. •^r:•r!?+,:.fr,.:i.:3,rr::;:?•}:f:. /,+r::::Jr:rr`r:::.'t+`•5:}}i•.'. •i:•f:•`.:5}:!i5:;<•,.:w,....n....r ..:.. .,.::::.,.;.. +.. .!M;!:r:?Yy:.•.., .,u .6,JJf:.?r,',i :rr,.v.', ;%'.,>r:.�iSJ:w}/..;;.. !r..:::::r.+,..::r..,.J:.:G:).r/..•::...;;....: -:i }:�!2's�::;::.::0.'•;R:;:<.i}:i<ii;:l��: ::?;::;::,;r,::ki'3i�ri;>::':d::;.. •.J •rr...:�:: :�.... S r•:•� �� �F he premium for this policy will be determined by our Manuals of Rules , :Iassifications , Rates and Rating Plans . All information required below is ' ubject to verification and change by audit . See Extension of Information Page ...... ... ..........................,. :r... •• ........ :. vi}•:x:::.•?+4•••r,•}Y!.iri{:!:{::i:!i•''SiiS;t;•f5•. ................. .............. •.:.v. .. ...........v•:!v:::.. .{.. .r .. ., v:.r JJ : 4 {r..:r k:.4.:.y •Yi/r rJv:,fr,.n:JrF.'J.r J r.,.;n.:..:•n!.r+:•::•:5:rr.:5::•:..Ji v;;}�:%%:i::r•,.}i:;:v:nryii::i. :rf,••}:;+•: ::rr:>r:r•!4.., •+.,�u.:r�. ,C fr •.l�t,J•:'�.'/..4..•3'r':�'' •r •/S.},::rr,!.>;�r.n:.!•.rJ •. ....5;:!q....::.:•:!:.......::.::::••::::.: t (?.'i:}''11i:i}i:ii}:' .:'; :: .}}:. .:: •.v,.;•.{:v r;/vi:5lf'i:?:.i}:..r y.:.:.:;; i'}:.< .:\4:6 ..:./rJ��:��•J.'•iYF +r.,�{,,r. /n'•: '.�57::. .�:v::.1�... i�.I�.:E3jVJ.;4 .. v'� •rr/•,'{.r ::. ::•i5}}}}}'!555:{!{.ii:::... 'OTAL ESTIMATED ANNUAL COST: $ 46 ,014 Minimum Premium: $ 750 Ieposit Premium: $ 46 ,014 Date of Issue : 06/22 /2011 J::f:.555.::::}55'::5rr:.<:i:<•<•?:i!<;ii:r.k%::i:;:i•5�;:«:;<:>�;: ...... ... .....:. :..::....:...:::••:::... ..:,:..: .::::r;:::rr + iii;+;. :r:f..:r:..: ::., JSr. :.r:•:.... .r r•!:.::::r., y...�fri::•hi�i;?...., :... rr??:.;.:�:.:.: ...{.;.�.v::fr:.::?,.r.. ..:u•;•: i.{.J .�:7�!!nr.+4?•:! rr.??;. ,:.fii•.r. rr::..f.::J%%i:' :i.:I:$•:?t:r:;es;�•r;'.•.i••,:.yi!. 54::r.+fi::'. .!•:::}•v. ix f...1....:r.4>f..rr..:::..�f...: .:•.. •.� .... .. •.:. n : }+. .r.....::::!:r.,}:\?4.:•J.%:•��r:r�.•.. .v. ::•::+.r,� 6�Si,:H.:.::,f,.rr 4 :+i•!.!'?{ .�`:�f0:i:�:::Z:�1�:i:?:�:' s:5:#�: •.. : :.5;.�:�.:�!. : .;.:..<:.>:.,.,.::<r..r::...:..r .,?Y>.•.:...w,... ...n . r.rJ::s.......:...:'JrrS�`rir.:::::::.N.S'i':.5i•;. ................ fame of Producer : EDWARD F . SENNOTT INSURANCE A Servicing Office : PO BOX 457 SPECIALIZED MARKETS TOPSFIELD 01983 657 :o u n t e r s i g n e d by : Copyright 198.7 National Council on Compensation Insurance ;F2R39011i00 01A IEd . 01 /97 ) PRO (Page 1 of 4 1 w Load Short Form Job: 56 Ciderpress press Date: Apr 26,2012 �•�r Entire House s u•r.,,fir.. y' JW Heating and Air Conditioning 17 Arlington st,Dracut,ma 1826 - +ar For: Tara Leigh Development 115 Carterfield rd, North Andover, MA D - e o 0 Htg Clg Infiltration Outside db(°F) 12 88 Method Simplified Inside db(°F) 68 75 Construction quality Average Design TD (°F) 56 13 Fireplaces 0 Daily range - L Inside humidity(%) 50 50 Moisture difference(gr/Ib) 43 28 HEATING EQUIPMENT COOLING EQUIPMENT Make Goodman Mfg. Make Goodman Mfg. Trade GOODMAN Trade GOODMAN, JANITROL,AMANA DISTI... Model GMH950453BX Cond GSX130301 D* AHRI ref no2002182 Coil CA*F3030*6D* AHRI ref no.4700038 Efficiency 95 AFUE Efficiency 11.3 EER, 13 SEER Heating input 46000 Btuh Sensible cooling 19880 Btuh Heating output 44000 Btuh Latent cooling 8520 Btuh Temperature rise 42 OF Total cooling 28400 Btuh Actual air flow 947 cfm Actual air flow 947 cfm Air flow factor 0.038 cfm/Btuh Air flow factor 0.050 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.91 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) kitchen 180 2239 2172 85 108 hall 60 407 72 15 4 living room 195 3092 2135 117 107 dinning room 225 1556 1180 59 59 stairs 105 603 107 23 5 entry 180 3092 1879 117 94 m bath 108 1691 1053 64 53 laun 72 503 187 19 9 elev 60 420 156 16 8 Loft 264 3379 978 128 49 Bedroom 2 180 2628 3765 99 188 2nd stairs 105 629 253 24 13 1/2 bath 90 539 217 20 11 master bed 330 4223 4815 160 240 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. CCwri9 htsoftH Right-SuRe®Universal 8.0.24 RSU05790 2012-Apr-26 08:04:34 I is and SettingskOwner\Desktop\Tara Leigh 52 Ciderpress way.rup Calc=MJ8 Front Door faces: Page 1 Entire House d 2154 25001 18970 947 947 Other equip loads 8696 2389 Equip. @ 0.93 RSM 19779 Latent cooling 2170 TOTALS 2154 33697 21949 947 947 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. .� wrightsoft`° Right-Suite®Universal 8.0.24 RSU057so 2012-Apr-26 08:04:34 Page 2 ...ts and Settingsl0wner\Desktop\Tara Leigh 52 Ciderpress way.rup Calc=MJ8 Front Door faces: 1 tt Building Analysis Job: 66 Ciderpress press Date: Apr 26,2012 Entire House By: JW Heating and Air Conditioning 17 Arlington st,Dracut,me 1826 For: Tara Leigh Development 115 Carterfield rd,North Andover, MA 0 _ Location: Indoor: Heating Cooling Boston Logan Int'I AP, MA, US Indoor temperature(°F) 68 75 Elevation: 30 ft Design TD (°F) 56 13 Latitude: 420N Relative humidity(%) 50 50 Outdoor: Heating Cooling Moisture difference(gr/lb) 42.7 27.8 Dry bulb(°F) 12 88 Infiltration: Daily bu bg(e(°F) 72 (L) Method Simplified _ F� Construction quality Average Wind speed(mph) 15.0 7.5 Fireplaces 0 . e Component Btuh/ft' Btuh %of load Walls 3.6 7145 21.2 walls Humidification Glazing 16.7 3102 9.2 f Doors 21.7 911 2.7 r Ceilings 1.4 1748 5.2 ventilation Floors 1.4 1310 3.9 Glazing_i Infiltration 2.6 5701 16.9 Ducts 5084 15.1 . Piping 0 0 Doors Ducts Humidification 5312 15.8 Ceilings Ventilation 3385 10.0 Floors Adjustments 0 Infiltration Total 33697 100.0 Component Btuh/ft' Btuh %of load Walls 1.0 1966 9.2 walls Blower Glazing 43.6 8101 37.9 Doors 10.3 434 2.0 Internal Gains Ceilings 1.3 1572 7.4 Floors 0.3 297 1.4 Infiltration 0.3 646 3.0 Ducts 3694 17.3 Ventilation 0 0 Glazing Internal gains 2260 10.6 Duds Blower 2389 11.2 Adjustments 0 Infihration rw Total 21359 100.0 Doors CeilingsOther Latent Cooling Load=2170 Btuh Overall U-value= 0.060 Btuh/ft2-°F Data entries checked. wri9 htsoftW Right-Suite®Universal 8.0.24 RSU05790 2012-Apr-26 08:04:34 �� ...ts and Settings\Owner\Desktop\Tara Leigh 52 Ciderpress way.rup Calc=MJ8 Front Door faces: Page 1 Component Constructions Job: 56 Ciderpress press Date: Apr 26,2012 Entire House By: JW Heating and Air Conditioning 17 Arlington at,Dracut,me 1826 0 - 0111"JOIJIT90 For: Tara Leigh Development 115 Carterfield rd, North Andover, MA D - 0 0 0 0 Location: Indoor: Heating Cooling Boston Logan Intl AP, MA, US Indoor temperature(°F) 68 75 Elevation: 30 ft Design TD(°F) 56 13 Latitude: 420N Relative humidity(%) 50 50 Outdoor: Heating Cooling Moisture difference(gr/Ib) 42.7 27.8 Dry bulb(°F) 12 88 Infiltration: Daily range(°F) - 15 ( L ) Method Simplified Wet bulb( F) - 72 Construction quality Average Wind speed (mph) 15.0 7.5 Fireplaces 0 Construction descriptions Or Area U-value Insul R Htg HTM Loss Clg HTM Gain ft' Btuhtff--°F W-T/Btuh BMW Btuh Btuhtftl Btuh Walls 12F-Osw:Frm wall,wd ext,1/2"wood shth,r-21 cav ins,1/2" ne 342 0.065 21.0 3.61 1236 0.99 340 gypsum board int fnsh,2"x6"wood frm se 737 0.065 21.0 3.61 2664 0.99 733 sw 252 0.065 21.0 3.61 911 0.99 251 nw 646 0.065 21.0 3.61 2335 0.99 642 all 1977 0.065 21.0 3.61 7145 0.99 1966 Partitions (none) Windows 2 glazing,clr outr,air gas,wd frm mat,clr innr,1/4"gap,1/8"thk:2 ne 90 0.300 0 16.7 1501 38.0 3423 glazing,clr outr,air gas,wd frm mat,clr innr,1/4"gap, 1/8"thk se 42 0.300 0 16.7 701 48.7 2047 sw 54 0.300 0 16.7 901 48.7 2632 all 186 0.300 0 16.7 3102 43.6 8101 Doors 11 DO:Door,wd sc type sw 42 0.390 0 21.7 911 10.3 434 Ceilings 16B-38ad:Attic ceiling,asphalt shingles roof mat,r-38 ceil ins,1/2" 1209 0.026 38.0 1.45 1748 1.30 1572 gypsum board int fnsh Floors 19A-38bswp:Flr floor,frm flr, 10"thkns,hrd wd flr fnsh,r-38 cav ins, 945 0.029 38.0 1.39 1310 0.31 297 tight bsmt ovr wri htsoft° 2012-Apr-26 08:04:34 9 Right-Suite®Universal 8.0.24 RSU05790 Page 1 ...ts and Settings\Dwner\Desktop\Tara Leigh 52 Ciderpress way.rup Calc=MJ8 Front Door faces: $ ._ Project Summary Date: 66 C26e ore2 press Entire House By: J&J Heating and Air Conditioning 17 Arlington st,Dracut,me 1826 • • • For: Tara Leigh Development 115 Carterfield rd, North Andover, MA Notes: Weather: Boston Logan Int'I AP, MA, US Winter Design Conditions Summer Design Conditions Outside db 12 OF Outside db 88 OF Inside db 68 OF Inside db 75 OF Design TD 56 OF Design TD 13 OF Daily range L Relative humidity 50 % Moisture difference 28 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 19916 Btuh Structure 15276 Btuh Ducts 5084 Btuh Ducts 3694 Btuh Central vent(55 cfm) 3385 Btuh Central vent(0 cfm) 0 Btuh Humidification 5312 Btuh Blower 2389 Btuh Pi in p g 0 Btuh Equipment load 33697 Btuh Use manufacturer's data n Rate/swing multiplier 0.93 Infiltration Equipment sensible load 19779 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 0 Structure 1280 Btuh Ducts 891 Btuh Heating Cooling Central vent(0 cfm) 0 Btuh Area(ft2) 2154 2154 Equipment latent load 2170 Btuh Volume(ft3) 17496 17496 Air changes/hour 0.32 0.16 Equipment total load 21949 Btuh Equiv.AVF(cfm) 93 47 Req.total capacity at 0.70 SHR 2.4 ton Heating Equipment Summary Cooling Equipment Summary Make Goodman Mfg. Make Goodman Mfg. Trade GOODMAN Trade GOODMAN, JANITROL,AMANA DISTI... Model GMH950453BX Cond GSX130301 D* AHRI ref no2002182 Coil CA*F3030*6D* AHRI ref noA700038 Efficiency 95 AFUE Efficiency 11.3 EER, 13 SEER Heating input 46000 Btuh Sensible cooling 19880 Btuh Heating output 44000 Btuh Latent cooling 8520 Btuh Temperature rise 42 OF Total cooling 28400 Btuh Actual air flow 947 cfm Actual air flow 947 cfm Air flow factor 0.038 cfm/Btuh Air flow factor 0.050 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.91 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. wri htsoft® 2012-Apr-2608:04:34 9 Right-Suite®Universal 6.0.24 RSU05790 �+c.P ...ts and Settings\OwneADesidop7ara Leigh 52 Ciderpress way.rup Calc=MJ8 Front Door faces: Page 1 Date. . `3b../. . . .. ./Z- . .. . . NpRTM of TOWN OF NORTH ANDOVER - PERMIT FOR GAS INSTALLATION s • SAC HUSEI This certifies that . . . _".. . . . . . . . . . . . . . . . . . . has permission for gas installation . .� � .4,#,f in the buildings of . . . . . . . . . . . . eh�/ S�ALL at . . , m .e !�?i' SS. . . . . . . . . . . . North Andover, Mass. Fee./N,� Lic. No../.S"/.$:'.7 / . . . . . . . . . GAS WOECTOR Check# /733 8101 ' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Cityfrown: /V. /ynclo7 / , MA. Date: Z9 /Z Permit# Building Location: �� �j�er/j �' Owners Name: Type of Occupancy: Commercial Educational❑ Industrial E] Institutional❑ Residential❑ New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No FIXTURES - - - - - - - - - -W W W W Q co C) Z W O m Z 0 (WU W V (n !— O = W W Z I-- �- z cn O W fY O Z Z O Lu W W O Q M LU WW m O W LU Q p 0 Z V W Z '-� 1— 1— O z J 0 u. co = Z W c W Lu O (n --t Q Q . m W O Z O (j H > Z 1-- _ V o ILL Cal = z O IL H > > > O SUB BSMT. BASEMENT 1-'FLOOR 2 No FLOOR 3 FLOOR 4 TH FLOOR —0 FLOOR 6 FLOOR ' 7 IHFLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: "o / �'llP/ y �h ❑Corporation Address: ZG 2 Cit (Town: 4 State: // ❑Partnership Business Tel:4043Fax: El Firm/Company Name of Licensed Plumber/Gas Fitter: i%T-. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL.Ch.142 Yes❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy �� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner El Agent By checking this box❑;1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ',21 Type of License: By ❑Plumber Title�Ll/z— ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter ❑Master City/Town [-]journeyman License Number: f,�/$-2 APPROVED OFFICE USE ONLY ❑ LP Installer W �. 1 � l - The Commonwealth of Massachusetts Department of fndustrial.Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: 13uilders/Contractors/Electricians/Piumbers _Applicant Information Please Prlurt Lel=><biy • • Name(Business/Organizafion/Individual): I - - - - . Address: ._-- - -- --- -- --- -- - - - - - -- — City/State/Zip: Phone#: Are you an employer?Check the appropriate boa: 1.❑ Tama em employer with 4, Type of project(required):' P Y ❑ I am a general contractor and I employees(full and/orpart-time).' have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or parfner- listed on the attached sheet Remodeling ship and have no employees These subcontractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers'comp,insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.E]Electrical repairs or additions 3.F1.1 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 insurance required.] t 12.❑Roof repairs 4 ] employees. [No workers' • comp.insurance required.] 13.0 Other "Any applicant that checks boxial must also fill gut the section b?ov..•sho:via g a r wa�::3 cWpw•saiion go&c,info-ces�aoa. T Homeowner;who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new Conhactors that check this box must attached an additional sheet affidavit indicating such. eet showing the name of the sub-contractors and their workers'comp,policy information. information.am an employer that is providing workers'compensation insurance far my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: • Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form and a fine of a STOP WORK ORDER a of up to$250.00 a day against the violator. Be advised that a copy of this statement may of Investigations of the DIA.for insurance coverage verification. be forwarded to the Office a Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date.: Phone#: Official use only. Do not ws:ite in this area, to be completed by city or town official City or Town: 1 ermitlLicense# Issuing Authority(circle one): L Board of Health 2.Building Department 3.city/Town Clerk 4.Electrical Inspector 5.PIumbing 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 6r 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-houseor on the grounds br 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 Iocal 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 coimpliance 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 anLLC or LLP does have employees,a policy is required. Be-advised that this affidavit maybe submitted.to the Department of Industrial Accidents fo{rr confirmation of insurance coverage. Also be sure to sign and date-the affidavit. The affidavit should /Je dyk reed 6L L:=e c C o' tS2�.L tdA�✓RV F1,V=' •vn fob Lv F fy .Y. F� P9 1 {oiS- P e f'y :�v� �p :� .tr: pa.�i•o.l; e_s is b�.,ng regaes„�c; not tnY 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 m 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 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance f6r 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-M.. ASSAFE Revised 5-26-05 Fax#6.17-727-7749 ' vvwvmass..gov/dia 9351 Date.�1�?/A : NORTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING _ ,SSACNUSE� // This certifies that //£r / . . . . . . . . . . CT� has permission to perform . ale', 114 4o,. _ ry. . . . . . . . . . . . . . plumbing in the buildings of . ./T�'? �� v. . <<. . . . . . . . , , , at. . . .y-e55. . . . . . . . . . , North Andover, Mass. Fee�G,#r 'Lic. N /S/S� . .44uMBING�ISPECTOR N. . . . . . . . . . . . . . Check # �33 r� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMI'P TO PERFORM PLUMBING WORK CITY 1 wUe,--- MA DATE 1 Z/L`�/w �PERMIT f# JOBSiTEADDRESS ,,p,es,r OWNER`S NAME] 4WNERADDRESS TEL] IFAXI a T-PIE OCCUPANCY TY E COMMERCIAL J �(�! EDUCATIONAL � � RESIDENTIAL 1.] PRINT CLEARLY NEW. RENOVATION: ( REPLACEMENT:( ( PLANS SUBMITTED: YES I 1 NO.1 I FIXTURES-1 FL00R–► BSM 1 2 3 4 5 6 7 a 9 10 11 12 13 14 BATHTUB - / 1 OROSS CONNECTION DEVICE DEDICATED SPECIALWASTE-SYSTEtv1 DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM } DEDICATED WATER RECYCLE SYSTEM DISHWASHER I / DRINKING FOUNTAIN FOOD DISPOSER i . I .. .I FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _ —• ....i . . ! _. LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK " TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES. / WATER PIPING .OTHER INSURANCE COVERAGE: I have a ctirrl:nt iiabilit iiisitratice policy.br its substantial equivalent which meets the requirements of MGL Ch.142. YES 'ND IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COUI:RAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L-/ OTHER TYPE OF INDEMNITY 1 + BOND(, i OWNER'S INSURANCE:WAIVER-(ant aware that the licensee.tioes not have ihe'Insurance coverage required by Chapter"142 of the Massachusetts General Laws,and thatatty sigiiature on this pentiit application vaaives this regtlire(nent. OMK-ONE09LY: OWNER AGENT - SIGNATURE OF OWNER R AGENT I hereby certify that all of the details and irifonnaHon I have submitted or entered regarding his application are true and accurate to the best of my knovrledge and that all plumbing work and Installations performed under the permit issued for this application W11 be in compliance with all Pertinenf the Massachusetts Mate Plumbing Code and Chapter 142 of Hie General Laws. I PLUMBERS NAME: I LICENSE 11]/�/S 7 j SIGNATURE MPI ( JP I 1 CORPORATION f .fit#i JPARTNERSRIP I 1##1 1 LLC 1/011 COMPANY NAME (k V) ��t t'� J ADDRESS I &.0 /d In 11 d V- CITY i PR ]STATE I �) I J ZIP]. Q�67 CO I TEL 160:3 FAX] CELL f/��- 7d 3 I EMAIL r 5a(� G i 1lc�1[T�7E)G PL RTG7[NS7P76ar7CTONNOTE,9 S ELCM MR.- MiCL 1!'7576:ONLY FrNAL TNS7PE,CTIONNOTrS No i o> /� THIS APPLICATION=SMYt-S AS THE PERMTT Y� PEE::$. 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