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Miscellaneous - 80 HOLLY RIDGE ROAD 4/30/2018
10452 Date ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .................. L.A lifts permission to perform .... plumbing in the buildings of ..!.....i.► v. ............................................... at ..:. ::................ ... .. K ............ ..., North Andover, Mass. -71 Fee �ffil.. Lic. No. P.1. ..... PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY i MA DATEJ PERMIT #� JOBSITE ADDRESS _ p m OWNER'S NAME OWNER ADDRESS �4 D- ! TEL FAXI 7 j TYPE OR OCCUPANCYTYPE COMMERCIAL 0 EDUCATIONAL Of RESIDENTIAL PRINT CLEARLY NEW: Q RENOVATION: D REPLACEMENT: PLANS SUBMITTED: YES NODI FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14 BATHTUB 1=1 = pl -1 1 I I--- -[ ! -- -I I -- f f I.I I CROSS CONNECTION DEVICE ! ! ! . I [ __._.I ( _..__r.1 ._ [ __. 1 11=11—i DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM ! _-._.__ I. _._____ _._1 DEDICATED GREASE SYSTEM [ I f ! -_--_-( -_...._.I ! __._.._._I ______1 DEDICATED GRAY WATER SYSTEM ! �.,__-! I ______I ____-1 -__._I I _____._I _____I ___-__ _,_____► 1 ___. _1 I I DEDICATED WATER RECYCLE SYSTEM (-_--___-J ! � _.._._J ..___..._1 I { ! ._._..__i .-.-__J DISHWASHER DRINKING FOUNTAIN —! ..-_..._.1 I _-..-_--_' _.__.._! 1 ! --.----' FOOD DISPOSER FLOOR/AREA DRAIN __.__..._1 .-__-- J I [ ( _...1 _..__._1 .--_.-( 1 .._71 __._._..-.-[ INTERCEPTOR INTERIOR ! .._..-_._f ....____.._i _._.....__ J i --_-__I __.-_-_[-__.-_! _-___I KITCHEN SINK -- J - -E _ .... -I- I LAVATORY LAVATORY ! i J _.--_--_I _._-_-- J !---_._-! J ( ._._._.; I .__.._� ! ---..-1 ROOF DRAIN SHOWER STALL SERVICE I MOP SINK 1_-._--1 ____..__! ___ ___J _____..-_:f __-__-_-{ TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES f WATER PIPING OTHER J -------- I INSURANCE COVERAGE:_ I have liability insurance its MGL Ch. 142. arcurrent policy or substantial equivalent which meets the requirements of YES .V( NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Vi OTHER TYPE OF INDEMNITY _I BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true d 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 compce with all Pertinent rovi ' n e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME` _._ _. _ ..... Q.__._._._..i LICENSE #_% ` SIGNATURE MP d JP _! CORPORATION - �. # I[ -:j', ✓����%p��PARTNERSHIPO#�-�LLC#� !� � COMPANY NAME �/ �rjf� ¢ ,d m DRESS D ,moi'/ UrvJT_ /D _ _` CITY �%J,� U, _ - - - --- STATE ZIP TEL - FAXELL _ ; EMAIL Q _ otei'-__Iclm�b�n_ ct _--� __ mni%_'.. __ _.-_....._- --- ....- o ED N ❑ + WI OI C�ii The Coinmonwealth of massachusetts Departinent of rndustriat Accidents Office of Invesiigations _600 Washington ,street Boston, M4 02111 www nags&g0Y1dia " h Workers' Compensation Insurance Affidavit: Builders/Contractors/I Iectricians/Plumbers Arn licant Information Please Print lJeaa`bIN, Name (Business/OrganizahonlIndividaal): Address: - City/State/Zip: �%�-��/%�' D%�� Phone i'#: Are ou an employer? Check the appropriate bo= Type of project (required):' 1_ ( am a employer with 4. ❑ I am a general contractor and I. 6. ❑New construction employees (full and/or part -time) -12 have hired the sub -contractors 2_ 0-1 am a sole proprietor orpartaer- listed on the attached sheet T 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. E] Demolition working for me in any capacity. [No workerscomp:- workers' comp. insuranCe. 5• We -me -a coFporaiion and its 9. ❑ Building addition required,] 3. ❑ I homeowner doing officers have exercised their right of exemption MGL; 10. Q Electrical repairs or additions 11_ [(Plumbing am a all work per repairs or additions myself [No workers' comp. c. 152, § 1(4), and we have no .12,0 Roof repairs insurance required] t employees_ [No workers' 13.0 Other - _ - comp.insurance.requireinsurance. y trc�t'naiLlY�YCbeP3i mu--:aisoP-Lc:-icese—aften below showin-9 h— wori='co=me s=- � b 6u LD.2c infi...IOnn :L:]!L T homeowners who submit fnis affidavit indicating they are doing aIl work and Oren hire outside contractors must submit a net aim–davit indicating such. $Contractors $tat ohech this box mast attached an additional sheet showing the name ofthe sub -contractors and their workers` comp_ policy information. Iarn an employer that isproviding workers' compensation insurance for my employees Below is thepoticy acid joh sire informal on_ Insurance Company Name: Policy T or Self ins. Lic. M Expiration Date: A o7 Job Site Address: �d �C�✓JC3` City/State/Zip: /yO Attach a copy of iae workers' conripensation 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 tha DIA for insurance mveragoa verification. I do hereby certify undyf the pairs andpenaltiesofperjury that the information provided above is true and correct 0 = YSY -? �j cur[ use oniy. Dro not write an this area, to -he -completed by city or town 0ff -iaL City or Town: 1'ermit/I iceuse # as; Issuin; Authority (circle one): 1. Board of Health 2. Building, (Department 3. City/Town Clerk 4. Electrical inspector 5. PIumbing Inspector 6. Other Contact Person: Phone Finformation and Instructions Massachusetts General Laws chapter 152 requires all -employe rs to provide workers' compensation for their employees. pursuant to thus S&&, an ehnptoyee is def zed as "...every person -in the service of another under any contract of hire, express or implied, oral orYnitxen." An employer is defined as "an individual, Partnership, associwion, corporation orother 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 ox- other legal entity, employing employees. However the owner of a dwelling house having not more than Three aparhnents and who resides therein, or.the occupant of the dwelling house of anotl er who, employs persons to do maictomanee, construction or repair work on such dwelling house or on the grounds or bwlding appurtenanithereto shall not because of such employment be deemed to be an employer." MGL chapter IM; MC(6) also states that "every state or to cal licensing aggency shall withhold the issuance'or renewal of a picemeor permit to operate a business or to menstruct 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(7j states "Neither the commonwealth nor any of its political subdivisions shall en' into any contract icor the pedomaanee of public work ihatil acceptable evidence of complianco wilt the insurance requirements of this chapter -have been presented to the contrasting authority." Applicants Please fill but the workers' compensation affidavit completely, by checking the boxes. that apply to your situation and, if necessaiy, supply sub-contractor(s) name(s), address(es) and Phone number(s) along with their certificates) of insurance. T -ged Lmbtity Companies (LLC) or Limited Lmbft Partnerships (LIQ) with no employees -other tbm tae members or partners, are not required to carry workers' compensation insurance. If an LLC -or LLP does have employees, a policy is mquirrA Be advised $tat this affidavit may be submitted to the Department of Industrial Accidents for conf®ation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be refused to the ofty or town IUL" the applicatim ;3mr taee p sun it. ori license is being reequesL-4 not me Denartinent of Industrial Accidents. Should you have my questions resardimg The taw or ifyou are required to.obtain a worxers' compensation pommy, please call The Department at The member listed below. Self-insured companies should eater their self-insurance license number on The appropriate line. City or Town Of ficials Please be sure that the affidavit is complete, and printed legbly. The Department has provided a- space at The botom. of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be. sure to fill is The pemaitllicense number which win 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 "an locations in (city or town)." A copy of the affidavit that has baa officially stamped or marked by the city or town maybe provided To The applicant as proof that a valid affidavit is on file for fiaiureperaniis or licenses. Anew affidavit must be filed out each year. Where a house owner or citizen is obtaining a license or -oermit not related to any business. or commercial venture (Le. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit - The Of of Investigations would ike is Thank you in advance for your cooperation and.. should you have. any questions, please do not hesitate to give us a ea1L The Department's address, telephone and fax number. The Commonweal ofMassacltusetts Department offndusftial Accid=ts Office of lnvestigafia= tW Washington Streat Basten, MA 02111 Ta #617-727-4944-ext#Q6 or 1-877--MASSAFE Fax # 617-727-7749 Retised 5-26-05 v.rww.tnass_.govfdia i =COMMONiNEALTH OF SEITS N1 NW ND�roi"r'ai►9:I�fB _ PLUMBERS AND GASFITTERS REGISTERED.AS_A PLUMBING CORP -` ISSUES THE ABOVE LICENSE TO: r; ._GEORGE R LAROSE- 'ANDOVER -PLUMBING B NEATLNG.=6E. 2.0.AEGEAN DR - METHA.UEN. M 01544 -35.8m = 2122 05/01/14 .17254S: COMIUIONWEALTH OF MASSACHUS ��17t�!�11Gil�li`1i� L►�' e a = 1 ' o o ' ` -= PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: GEORGE R LAROSE= _44 ODILE ST : ME7'IfUEN MA 01844-42-3..3' %983 05/01/14 a ==COMMONWEALTH OF MA��SySrACRUSE'H'My O ✓O O Ji '«xEW" ' ST C =- 21 O 0~ O - - ` PLUMBERS AND GASFITTERS I.10EN9SED AS A JOURNEYMAN PLUMBS_ ISSUES.TiiE ABOVE LICENSE TO• GEORGE- R LAROSE 044. ODILE- .ST = tETHUEN MA 01$44-4233 05/01/14 s - 172562_ t�9 = i � - _ _•.'r_,�'�jZ�i _ o "�����n�=''' -: - y�lirll'i'C3o - Date.A261-4 ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Zhis certifies that Ln,- ....................... U, . .... ............... has permission for gas i'ijstayIa,ti*o'**n'- in the buildings of ............... o?— 6 ........... . .......... .. .................. . ..... .. . ... at ..... R.b...................... L ..2....,...c..t..;�........... . North Andover, Mass. ....�................ Fee ..4........Lic.100 ............... N ............................................................... GAS INSPECTOR Check 9163 MAVIOM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE PERMIT # 0l�i CITY Ov _ _ _ JOBSITE ADDRESS U D OWNER'S NAME % D G. OWNER ADDRESS O_ LL � TE _ — Q�' FAX[ TYPE OR OCCUPANCY TYPE COMMERCIALPJ EDUCATIONAL ® RESIDENTIAL 6/ PRINT CLEARLY NEW: Q RENOVATION: El REPLACEMENT: ( PLANS SUBMITTED: YES Q NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER�—=j =DL.1 f ! I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER, . _. _ _ . r IE .FIREPLACE FIREPLACE — 1 . I .- _ L- fi= -_ _ FRYOLATOR FURNACE -- GENERATOR GRILLE I- INFRARED HEATER - LABORATORY COCKS MAKEUP AIR UNIT— OVEN POOL HEATER ROOM / SPACE HEATER - ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER _ !� _ ! 1 L,_-- i._,..___ ! -__ _ .__..- .-.._ !-_.._Ns- !._m I_. _ _J i -_—(I WATER HEATER i- --1 OTHER 4. INSURANCE COVERAGE MGL. Ch. 142 YES !3 NO 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of IF.YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E BOND FI�_I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true a 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 compli ce with all Pertinent rovi ion of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _ QLICENSE # 3_ SIGNATURE MP 0� MGF �1 JP EjI JGF Q LPGI © CORPORATION[+�#/ alv � PARTNERSHIP[ #�----___II LLC []#�_ COMPANY NAME•; QgAr, DDRESS CITY �%%�_�. _ -_ _ _ STATEMZIP[-- �,ITEL FAX _- CELLOIEMAIL al9 6(�e/'V�t_Jlta�1� m i • cv o z LU a Me Commonwealth ofMassachusetts Department of hzdustr&[ A ccidentS Office of Lnvesiigadons .600 Washington Street Boston, AM 02111 ir wrvw.M asagov/atia Workers' Compensation Insurance Affidavit: Buffeters/Contractors/Eleclridans/Mumbers ADIicant Information Please Prim Le6ibly- Name (Business/O .-ani hon)Individual): Address: City/State(Zip: Phone #: Areyou an employer? Check the appropriate boa: Type of project (required.): 1. [ Z -I am a employer with S 4. Q I am a general contractor and I. 6. ❑ New constriction employees (full and/or pazt time) * Have hired the sub -contractors - 2 , Q I am a sole proprietor or partner- listed on tlae attached sheet t 7, Q Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. fNo avorlaers' comp: ins�ce workers' comp. insurance, {. Q Vie-RMa .:orporatio$ and iisr 9. (� BniIding addition required.] officers have exercised their 10.0 Electrical repairs or additions 3. Q I am a homeowner doii� all work right of exemption per MGL 11.561umbing repairs or additions myself. [No workers' comp, c. 152, § 1(4), and we have no 12,0 Roof repairs insurance required.] r employees. [No *orkers' 13.Q Other - comp. insurance required.) ? t t * drams< box=l m„�: >�so rZ o. tee se^rio" .- shore b +tw w s-:;oa Laky in orra-40s T Homeowners who submit Uris aiadavit mdicaimg they are door` all work: and area hire outside contactors must submit a neer aiIIdavit indicating such. Contractors $ai check this box must attached an addiiianaI sheet showing the name fthe sr b cout actors and their workers= comp. policy information. lam an employer that is providing workers' compensation insurance for my employees .below is thepolicy and job site informadom Insurance Compiny Name:, Policy # or Self -ins. Lic. #: � D �� �� Expiration Date: A� Job Site Address: /�f�i�,/ City/State/Zig:04' 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 nue up to $1500.00 and/or one-year imprisonment, as well as civil penalties in the foam 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 irar<ce. caverageve*ification. Ido Hereby c un the pains mid er:olties o perju that the information provided above is true and correct . Simature:--- Date: a� % PhnnP� 1,1,5-- lJ✓Y- O_ iciitt use only. Do not write in this area, to-he-cumpleted by city or town oJL-iat City or Town: Permi VUceuse # Issuing Authority (circle one): 1. Board of Health 2. Budding Department 3. City/Town. Clerk 4. Electrical Inspector 5. Plumbing Iatspector 6. Other Contact Person: Phone #: 19 aEE&& jj Massachusetts General Laws chapter 152 requires all . employers to provide workers' compensation for their employees. pursuant to this stature, an employee is defined as "-.every person -in the service of another under any contract of hide, express or implied, oral or.written." An employer is defined. as "an individual, partnership, associattion, corporation or. otherlegal entity, or any two or more of the foregoing engaged in a joint enterprise; and including t1he legal representatives of a deceased employer, or the receiver or trusbm of an individual, partnership, association ox- other legal entity, employing employees. However the owner of a dwelling house having not more than three apartmLenis and who resides iheimn, or -the occupant of the dwelling house of anofl= who employs persons to do mznftmanoe, construction or repair work on such dwelling house or on the grounds or buelding appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,' MC(6) also states that "every state or Ioc mi licensing agency shall withhold the issuance'or renewal, of a license -or permit to operate a business or to cmnsfruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of co3i npirance 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 chaprer•have been presented to the conirM.cting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-coniractar(s) name(s), address(es) and Phone number(s) along with their certificates) of insurance. Limited Liability Companies (Up or Limited Lmbfiity partnerships (LLP) whit no employees -other titan the members or partners, are not required to cavy workers° compg-nsation 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 confirination of insurance coverage. Also be save to sign and date the affidavit The affidavit should b` reruumed io the or t3awn the the applica uon thr :hr p it of license is b.�:ng t% not. the Departrnem. of Industrial Acmdents. Should you have any questions r wdimg the law or if you are required to oomin a wortoers' comVensation Policy, Please call t3ie Depar b neat at the er listed below Self-insured companies should enter their self insurance license number on the appropriate lime. City or Town Of Please be sure $tat the affidavit is complete. andprinted Iegibly. The Department has provided a- space at the bottom of the affidavit for you to fill out in the event the Ofrce of Investigations has to contact you regarding the applicant • please be sure to fill in the permifitlicense number which wll be -used as a reference number. In addition; an applicant that must submit multiple pmmudticense applications m any given year, need only submit one affidavit indicating current policy information (iinecessary) and under "Job Site Address" the applicant should write "all locations in (city or town):- A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to ire applicant as proof that a valid affidavit is on file for $rture permaits or licenses. A new affidavit must be filed out each year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (Le. a dog license or pemdt to bum leaves etc_) said person is NOT required to complete this affidavit - The Office ofIrnesiigations wouldj *:e tc thank you in advance for your cooperation and should you have. any questions, please do nothesitate to give us a call. _ The Deparfinenfs address, t--lephone and fax number•. The CommonweIth ofMassarhuse�ts DEepartm(Mt of lndustri& Accidents Of Bee of Investigatiam- 6W wad agton st=t Bastma, MA 02111 TeL # 617-727-49Q4.eg406 or 1-877 MASSAFE Fax # 617-727-7749 Revised 5-26-05 vtw.mass._govfdia =Z:OMMONWEd�LTH OF ACHUSETTS• =•° REGISTERED PLUMBERS AND GASFITTERS - A PLUMBING CORP =` ISSUES THE ABOVE uCENSE TSD: :GEORGE -R LAROSE :ANDOVER -PLUMBING & HEATING ."C0. f 2.8--AEGEAN-DR .-MTHUEN,MA. 01844:--158077. = 2T22 05/01/14 iim =COMMONWEALTH OF MASSEACHUSE�'`e ° (°J5"'x'it°ti' dY►_ Lyr#%'a= e o • - o o -- PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER'..--... :- ISSUES THE ABOVE LICENSE TO: = GEORGE R LAROSE 44 ODILE ST :.. -�-- NETHUEN MA 01844 -42,33-;? -- 9983 05/01/14 0 MMOAlIlltE�iLTH OF MASSAPHUSETTS: � :: _ - PLUMBERS AND GASFITTERS _LICENSED AS A JOURNEYMAN PLUMB ISSUES.THE ABOVE LICENSE TO: GEORGE- R L=AROSE %4:ODILE .ST .- EtHuEN' NIA 01844-4233=, == 387T3 05/01/14 - 1725b2 'his certifies that .. �.,� , .. � . _ ....... _ . , . has permission for gas installation .. j; ,, , . _ .... , , ... , in the buildings of....H&;-O- .............. . at ..... X30---4-cA, .�'J , , , , North Andover, Mass. Fee, Lic. No.. GASINSPECTOR Check # 7744 Q 8485 Date .�. �.�.I. bwiecrni a.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 'his certifies that .. �.,� , .. � . _ ....... _ . , . has permission for gas installation .. j; ,, , . _ .... , , ... , in the buildings of....H&;-O- .............. . at ..... X30---4-cA, .�'J , , , , North Andover, Mass. Fee, Lic. No.. GASINSPECTOR Check # 7744 Q 8485 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY G^` _ _.._ - W.C� JCt�- - _ MA DATE PERMIT #. GOWNER JbBSITE ADDRESS �'C�.. _ :' „OWNER'S NAME ADDRESS _ { TEL TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL .--{ EDUCATIONAL I RESIDENTIA _ CLEARLY NEW: RRENOVATION: 01 REPLACEMENT: Fj PLANS SUBMITTED: YES 0 NO E. APPLIANCES 7 FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER_I CONVERSION BURNER COOK STOVEJ....._ .. DIRECT VENT HEATER._I.J -.: DRYER_I�_.. FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE _ -. INFRARED HEATER---- LABORATORY COCKS MAKEUP AIR UNIT _ .fI L OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT L—A J TEST_I (--_� I, _ �(IrJ =_ J UNIT HEATER UNVENTED ROOM HEATER WATER HEATER i_. _-1. .—E ..—I OTHER .._.. � . ��, I _ ... ...._.. ........ -- 1 --! I-�.1 I I111 Jll- INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO �( 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENT �I SIGNATURE OF OWNER OR AGENT 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'e4inent prov' ' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME�LICENSE #%31� S URE MPF,MGF [:]I JP [11 JGF LPGI( CORPORATION �# PARTNERSHIP �#L LLC [(# COMPANY NAME:`' -- ......-._ ADDRESS CITY STATE PU 14-i ZIP4 IN FAX --- -� I CELLS _ EMAIL ,- --� -- ---- -:.. - - - -- U Elf) 0 O z o H U W d .S v �.1 z ❑ O °y' ❑ W � O � W O w O IL4t4t z PW.a w 5 Q co a w ® w W N W oz P, a�, a � U �y J a Q Es' co CLi x w F w v� H O z z O H U W P-1 C�7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' ^Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: (,0 j Cicn�c� o�C L . L✓� . City/State/Zip: -,n� ,4— ®_�OJ(phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2 m a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working' -for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: lob Site Address: City/State/Zip: attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 )f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereb:� rtify under the pains and enalties ofperjury that the information provided above 's true and correct. mature�i��/ 6'a Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/I.icense # Issuing Authority {circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised .that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Y Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) •- Division of Professional Licensure Mass.Gov Home State Agencies A -Z Tooic:s Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure SEARCH CRITERIA Profession: Plumber Last Name: beginning with leonard City: amherst Zip Code: 03031 LIC. BOARD LIC. TYPE LIC'NUMBER NAME CITY/STATE STATUS } Plumbers Et i I JOHN A. AMHERST, I Gasfitters Master Plumber 13248 } LEONkRD NH Current — _— __ -t— - Plumbers ft Journeyman 125690 j JOHN k. AMHERST, Current Ga^ sfitters� Plumber I t LEOt8AR4 j NH T� Your search has resulted in 2 licenses Note: If the licensee cannot be found by name and the name typically has apostrophes, spaces, hyphens or periods try doing the search again without these characters. Examples: If the last name is "O'Donnell", try searching for "ODonnell" or "0 Donnell" If the last name is "McDonald", try searching for "Mc Donald" If the last name is "St. Helens", try searching for "StHelenss" or "St Helens" If the last name is "Jones -Doe', try searching for "JonesDoe" or "Jones Doe" The page above has been generated by the Division of Professional Licensure web server on Friday, November 16, 2012 at 7:33:35 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass -Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.uslpubliclpubLicRange.asp?profession=Plumber&lName=leon... 11/16/2012 GENERATOR APPLICATION DATE: LOCATION: Ufa OWNERS NAME: GENERATOR kw c9c) NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: 603 - ss— -. 2// ELECTRICAL RESIDENTIAL GA _ COMMERCIAL TEMPORARY LOCATION OF GENERATOR: /�_ '4t *ZONING DISTRICT: *CONSERVATION APPROVAL __� (&-.L has permission to perform ....� wiring in the building of ........ �� �c w I............ . . at... P ! � �G'-�". �.�� , �� L?North Andover, Mass. Fee . ''""`—.-ric. No.. ...... ....... ELECTRICAL INSPECTOR Check # ` Y X1.258 p� UscOah► ice, �•� ���'� �. � L l Z - . 0= BOARD OF FM PEON -as •'�'' WORK APPUCATM FM PERIM TO PERFORM EL LCI P k N�OR r� . �1-20 -1z or As Q_ Too 60 01 age (A C.UL►'— d ` - Yes ❑ No icy JM Bw) Is � peemitbt s paum o 13 DC7 ASW=.— v� �r . moa Vabeo�aoc�ai wos1�"' � Z25 � (hYP�'Ya tobeaeq irisceoc+dsaoe�� B:,aoda�os ' redbyapowsw6mo meg 0��i�s � aiaaea�oe 'b�oP � own& she �oeesoe pso s' is in progofs�e w �e 6 Eff som ❑ v II tsar-} � ` &r L martglr- t=c L �.+ Lie x:33?4 E - l� Be�oe�.ae Gt feq HILT • A r*Dw Ir►a �S'k ► = . . 4'�'S"' WAiV�: ia�aaaee��L�oasisoe tm��etcbxt aas�ee owls . Yell: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): U Address: NINPhone #: Areyu an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. E] New construction employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. ❑ volition workingfor me in an capacity. any m'• employees and have workers' 9. E] Building addition [No workers' comp. insurance required.] comp. insurance.: 5. ❑ We are a corporation and its 10. F1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13. ❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. 1—/ , 1 / n / Insurance Company Name:. Policy # or Self -ins. Lic. #:U c, (i � WL C � Tk 36 J �5 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). 4 Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under h pains and _ of perjury that the information provideid%abooJve,(isJtrrue and correct Sionahrre- . Date: Of jmial use only. Do not write in this area, to be completed by city or town offickd City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Chyfrown Clerk 4. 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NoX�4.,�.,I�h ............ '14E rIIC,/I; , W�r a Check # 7674 n D/ �//// / �ornmonwealfh o� /i/adaac/iubeffa Official Use Only _f=" c� �Permit No. } ) 2epartmenf of ,}7ire Services ---T— + hl Uv +�1 ., Occupancy and Fee Checked '' ''% BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] y (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK .All work to be performed in accordance with the Massachusetts Electrical Code NEC), 527 CMR 12.00 (,PLE.4S1 PRINT IN INK OR TY L ALL INFORMATION) Date: �' d City or Town of: of+�X A JOue To the Inspector of Yll'ires: By this application the undersigned gives notice -of his or r tate itron to perf rm the electrical work described below. Location (Street & Nuin�cr) n V Hr� l � _ / X, [s A Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose o1' Building Yl I ��M i ) �� L—) 1 r rN yUtility Authorization No. F_xistiag Service imps Volts Overhead/❑ Undgrd New Service Amps / Volts Overhead ❑ _ Undgrd ❑ No. of Meters f No. of Meters No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KV A No. of Luminaire Outlets i No. of Hot Tubs Generators KVA ;No. of Luminaires Swimming Pool Above ❑ In- E]o, rnd. rnd. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of. Zones No. of Switches No. of Gas Burners 11 No, of Detection and Initiatin2 Devices No. of Ranges No. of' Air Cond. Total Tons No. of Alertin Devices g No, of 1Vaste Disposers Heat Pum Totals Number Tons "' " KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KNV Local Municipal Connection El Other No. of -Dryers Heating AppliancesK", Security Systems:* No. of Devices or Equivalent No. of \Vater- llratcrs KNV No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. llydromassage Bitthtubs No. of Motors Total lip Telecommunications Wiring: No, of Devices or Ec uivalent O'fllL.l2: ;lane/ additional debit If desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. iNSURAN'CE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersi+",ned certifies that such cover e is in force, and has exhibited proof of same to the permit issuing office. CiIE.CK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:) li'ertiJj, ander the mins crud penalties ofperjury, that the information on this application is true and complete. 1.1RM )1 E-: ece I: iccnscc: jer�r, �� v f/f c Signator 1C. NO,: �` G ii ir�t�!ir�rhi,, rn1�r �_�rrnp,"hr rhe lice, rep,.r ib e line.) us. To . No.: — Q0 Address: Alt Tel. No.: 1' 61, srct,rity work requires Department of Public Safety "S" License: Lic. No. O\N'NL;R',S INSI!RANCh NV.VV'ER: 1 am aware that the Licensee does not have the liability insurance coverage normally k ,111irk2d L\ I.r\Y. 13y my sign:utire below, 1 hereby waive this requirement. I am the (check one) ❑owner ❑owner's went. tii�in:,turr _ 'Telephone No,PEIZi1MT FIF_: uS' �� 21, 6P�t_o� 1 Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street fL Boston, MA 02111 s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: &:,Aoj G, �(�/ai ( Phone #: �7j ' (j yo o Are you an employer? Check the appropriate box: . ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' cornp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. , iese sub -contractors have workers' comp. insurance. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9.❑ing addition 10. Electrical repairs or additions 1 LEI Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: G UM +c� 1^ ( 11 111-3n S V V—C, " L .e Policy # or Self -ins. Lic. #: UC... 62 Q 3 Expiration Date: 0 -7— Job Site Address:0 City/State/Zip: 0,-A 44R_ A9, 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 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. 1 do hereby certify under the pains a lties of perjury that the information provided above is true and correct. V CJ 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 #: Date .......�.C28 ..... °t"'° TOWN OF NORTH ANDOVER PERMIT FOR WIRING �� This certifies that...........................................�................:S..................... has permission to perform ........../.. (.f. G � fE7.d�.................................... wiring in the building of ............... ' 41 .............................................................. at 2�f>©GLS 1. 1........... � ...........................y ,North Andover, Mass. Fee..................... Lic. No.............. ................... .................................... T ELECTRICAL INSPECTOR Check #� 8074 �-r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Officiall Use Only Permit No. D C� Occupancy and Fee Checked [Rev. 1/07] (le22 ave 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:,. �U City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his o hey{ intention torerform the electrical work described below. Location (Street & Number) X© He l � , ,I-[ Q _V _ Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Buildings_I` N c �) Existing Service Amps Volts Overhead New Service Amps ? / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No ❑ (Check Appropriate Box) Utility Authorization No. ❑ Undgrd Overhead ❑ Undgrd ❑ 0k,V^ P 0 7 V( -i C No. of Meters L— No. of Meters -•• -�.• uuu.aw.ou, ue,au 1 aestrea, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (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 by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liabili inc,„�nce including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such co rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) ��- ��' 0 I certify, under thins and penalties of perjury, that the information on this application is true and complete. FIRM NAME • n C . Licensee: •(C A(( Signature LIC. NO.: 6 (If applicable, enter "exe, �t "int1� a li ns� n tuber 1' Address: {{ Sii el�t't'n(c9 G ✓ dl �r Bus. TeL No.WE U*Per M.G. c. 147, s. 57-61, secunty work requbl� Safe ,� Alt. Tel. No.9 Safety S License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner 11 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ c9A The Commonwealth of Afassachusetts k� ! Department of Industrial Accidents Office of Investigations j ! 600 Washington Street ti _! Boston, MA 02111 { j www massgovldia Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers mllc2nt rn'fnrma"_n Name (Business/brganiration/individual); j" P lvi Address:__ 5 � C city/state/zip-In(� (• Phoneg: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am: a.sole proprietor or have hired the sub -contractors listed partner- on the attached sheet ship and have no employees Pese sub -contractors have working for me .in any capacity, [No workers' comp. insurance orkers' comp. insurance. 5.'M We are a corporation and its required.] 3. ❑ 1 am a homeowner doing officers have exercised their all work right of exemption per MGL myself, [No -workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required_] Type Of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition' 9. ❑ Building addition 10. Electrical repairs or additions I I.0 Plumbing repairs or additions 12. ❑ Roof repairs 13:❑ Other t14- ---- - R I �� L niso me our Inc section below showing their workers' compensation Poi icy information, omeowners who submit this afrWavit indicating they are doing all work and then hire outside c"tmctors must submit a new affidavit indicating such. ;Contractors that check this box mustattached an additions sheershowing tka name of the sub -contractors and their worke s' comp. policy information. Iam an sat`ion. on employer that_isivrovuling:warkers' informcompensatiinsurance for nV employees: Below is Me policy and fob site Insurance Company Name:' l)r (*Y) o Policy # or Self -ins. Lic. #:_ `� C � 0� Expiration D tr r , � �P� ale:Job Site Address: �City/State/ ip: d Attach a copy of the workers, com peasat<on 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 anti 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. ! do hereby cern ett�e. enalties of perjurythat the information pro vided a"Ve fs true and correct�0 . Official use only. Do not write in .this area, to be completed c or town n by d1' fficiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,, partnership, association, corporation or other legal entity, or any, two or more of the'foregoing engaged in a;joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner. of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons. to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence_of compliance with the insurance coverage required." Additionally, MGL chapter I52, §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 cavy 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, not1he 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 numberlisted 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 be= 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 lnvestigations 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 # 617-727-7744 www.mass.gov/dia DENCO ENGINEERING STRUCTURAL ENGINEERS 148 PARK STREET NORTH READING, MA 01864 V: 978.664.6733 F: 978.664.9233 ENGINEER'S FIELD REPORT TO: RICK ANDERSON FROM: DANIEL W. SMITH t40(d SUBJECT: 80 HOLLY RIDGE RD., NO. ANDOVER, MA DENCO JOB NO. 07-010 KENkV� DEN No. CONTRACTOR: RK ANDERSON SIRU DATE: APRIL 07, 2008 WEATHER: t 50' F, CLEAR SKY S CC: PROJECT FILE Work in progress observed: 1. Engineer arrived on job site at approximately 2:30 pm and toured the project site with Contractor 2. Engineer observed that Contractor was in the process of completing or has completed, the following structural items: 0 Contractor is 100% complete with installation of engineered wood LVL beam and PSL support posts for new kitchen addition as designed per Denco Engineering's previously submitted calculations (see copy attached for reference). Structural items above observed by Engineer at time of site visit, except as noted otherwise, were in conformance with the documents prepared by Denco Engineering. Except as noted otherwise above, Engineer takes no exception to work in process or completed at time of site visit. 3. Photo record was taken see photo log attached. 4. Engineer completed tour of work in progress and left job site at approximately 3:00 pm. f•\dws denco projects\2007\07-010 rk anderson\f p 07-010 040708.doc DENCO ENGINEERING STRUCTURAL ENGINEERS 148 PARK STREET NORTH READING, MA 01864 V: 978.664.6733 F: 978.664.9233 PHOTO LOG 80 Holly Ridge Road No. Andover, AAA Date: April 07, 2008 @ 2:30 pm Picture No. 1 — Right end of new LVL beam bearing on double top plate and supported by PSL post below F:\DWS Denco Projects\2007\07-010 RK Anderson\Photo Log 07-010 040708.doc Photo Log 80 Holly Ridge Road, No. Andover, MA Page 2 of 3 Picture No. 2 — Left end of new LVL beam bearing on double top plate and supported by PSL post below Picture No. 3 — PSL support post for left end of beam passes through floor sheathing, behind floor joist, and bears directly on built-up sill Photo Log 80 Holly Ridge Road, No. Andover, MA Page 3 of 3 Picture No. 4 - PSL support post for right end of beam bears directly on existing built-up LVL beam, which then bears directly on built- up sill DENCO ENGINEERING STRUCTURAL ENGINEERS 148 PARK STREET NORTH READING, MA 01864 V: 978.664.6733 F: 978.664.9233 Structural Calculations as per Commonwealth of Massachusetts State Building Code 780 CMR — 6t° Edition For Engineered Wood Beam and Posts R.K. Anderson Company Single -Family Residential Addition North Andover, MA August 28, 2007 Prepared By: /W01 - Daniel W. Smith, E.I.T. Reviewed By: 4t� OF KENNETH DENNISON No. 8889 Kenneth Dennison, P.E. DENCO ENGINEERING Structural Engineers Title : R.K. Anderson Company Job # 07-010 Dsgnr: DWS Date: 6:45AM, 8 APR 08 Description : SFR Addition 148 Park Street Scope: Design New Engineered Wood Beam and Posts North Reading, MA 01864 Rev: 580000 Page 1 User: KW -0605924, Ver 5.8.0, 1 -Dec -2003 General Timber Beam g (c)1983-2003 ENERCALC Engineering Software rk anderson.ecw:Calculations Description New LVL 2nd Floor Beam Over Opening to Addition General Information Dead Load Code Ref 1997 NDS, 2003 IBC, 2003 NFPA 5000. Base allowables are user defined Section Name 5.25x24 h Center Span 24.00ft .....Lu 1.33 ft Beam Width 5.250 in Lett Cantilever ft .....Lu 0.00 ft Beam Depth 24.000 in Right Cantilever ft ...Lu 0.00 It Member Type 1.5 Truss Joist - MacMillan, MicroLam 2.0E E Bm Wt. Added to Loads #/ft Fb Base Allow 2,925.0 psi Load Dur. Factor 1.000 Fv Allow 285.0 psi Beam End Fixity Pin -Pin Fc Allow 750.0 psi Wood Density 35.000pcf E 2,000.0ksi Full Length Uniform Loads Dead Load Total Load Left Cantilever... h Center DL 295.00 #/ft LL 330.00 #Jft -0.625 in Deflection Left Cantilever DL #/ft LL #/ft 1.5 15.9 k Right Cantilever DL #/ft LL #/ft Allowable 1,153.7 Trapezoidal Loads Max. Positive Moment 73.33 k -ft at 12.480 ft h #1 DL @ Left 10.00 #/ft LL @ Left 10.00 Wit Start Loc 0.000 ft DL @ Right 140.00 #/ft LL @ Right 70.00 #/ft End Loc 21.000 ft #2 DL @ Left #1ft LL @ Left 30.00 #/ft Start Loc 0.000 it DL @ Right #/ft LL @ Right 420.00 #/ft End Loc 21.000 ft Summary 122.40Reactions... Beam Design OK Span= 24.00ft, Beam Width = 5.250in x Depth = 24.in„ Ends are Pin -Pin Dead Load Total Load Left Cantilever... Max Stress Ratio 0.599 : 1 Deflection -0.250 in -0.625 in Deflection Maximum Moment 73.3 k -ft Maximum Shear " 1.5 15.9 k Allowable 122.4 k -ft 0.0 Allowable 1,153.7 35.9 k Max. Positive Moment 73.33 k -ft at 12.480 ft Shear. @ Left 11.00 k Max. Negative Moment 0.00 k -ft at 0.000 ft @ Center @ Right 11.88 k Max @ Left Support 0.00 k -ft 0.0 Camber. @ Left 0.000in Max @ Right Support 0.00 k -ft @ Right @ Center 0.374in Max. M allow 122.40Reactions... @ Right 0.000in fb 1,745.88 psi fv 126.44 psi Left DL 4.59 k Max 11.00k Fb 2,914.28 psi Fv 285.00 psi Right DL 4.80 k Max 11.88 k Deflections Center Span... Dead Load Total Load Left Cantilever... Dead Load Total Load Deflection -0.250 in -0.625 in Deflection 0.000 in 0.000 in ...Location 12.096 it 12.096 ft ...Length/Defl OA 0.0 ...Length/Defl 1,153.7 460.80 Right Cantilever.. Camber ( using 1.5 * D.L. Deft ) ... Deflection 0.000 in 0.000 in @ Center 0.374 in ...Length/Defi 0.0 0.0 @ Left 0.000 in @ Right 0.000 in DENCO ENGINEERING Structural Engineers 148 Park Street North Readinq, MA 01864 Title: R. K. Anderson Company Job # 07-010 Dsgnr: DWS Date: 6:45AM, 8 APR 08 Description: SFR Addition Scope: Design New Engineered Wood Beam and Posts User KW -0605924, Ver 5.8.0, 1 -Dec -2003 General Timber Beam (c)1983-2003 ENERCALC Engineering Software Description New LVL 2nd Floor Beam Over Opening to Addition Stress Calcs Bending Analysis Ck 21.207 Le 2.739 ft Sxx 504.000 in3 Area 126.000 in2 Cf 1.000 Rb 5.351 Cl 0.996 Sxx Read Max Moment @ Center 73.33 k -ft @ Left Support 0.00 k -ft @ Right Support 0.00 k -ft Shear Analysis @ Left Support Design Shear 14.38 k Area Required 50.473 in2 Fv: Allowable 285.00 psi Sxx Read Allowable fb 301.93 in3 2,914.28 psi 0.00 in3 2,925.00 psi 0,00 in3 2,925.00 psi @ Right Support Bearing Length Req'd 15.93 k 55.898 in2 285.00 psi Page 2 rk anderson.ecw:Calculations Bearing @ Supports Max. Left Reaction 11.00 k Bearing Length Req'd 2.793 in Max. Right Reaction 11.88 k Bearing Length Req'd 3.017 in Query Values M, V, & D @ Specified Locations Moment Shear Deflection @ Center Span Location = 0.00 ft 0.00 k -ft 11.00 k 0.0000 in @ Right Cant. Location = 0.00 ft 0.00 k -ft 0.00 k 0.0000 in @ Left Cant. Location = 0.00 ft 0-00 k -ft 0.00 k 0.0000 in t=73.3k-ft Dmax =-0.e2. DENCO ENGINEERING Structural Engineers 148 Park Street North Reading, MA 01864 Title: R.K. Anderson Company Job # 07-010 Dsgnr: DWS Date: 6:48AM, 8 APR 08 Description: SFR Addition Scope: Design New Engineered Wood Beam and Posts User KW -0605924, Ver 5.8.0, 1 -Dec -2003 Timber Column Design (c)1983-2003 ENERCALC Engineering Software Description New Support Posts for New 16' LVL General Information Page 1 V Code Ref 2001 NDS, 2003 IBC, 2003 NFPA 5000. Base allowables are user defined. Wood Section Prllm: 3.5x5.25 Total Column Height 8.00 ft Le XX for Axial 8.00 ft Rectangular Column Load Duration Factor 1.00 Le YY for Axial 8.00 It Column Depth 525 in Fc 1,600.00 psi Lu XX for Bending 8.00 ft Width 3.50 in Fb 2,900.00 psi 964.72 psi Manuf 964.72 psi' E - Elastic Modulus 2,000 ksi fbx :Flexural 0.00 psi 0.00 psi Truss Joist - MacMillan, Parallam 2 Loads F'bx: Allowable 2,868.87 psi 2,868.87 psi 2,868.87 psi Dead Load Live Load Short Term Load Axial Load 4,350.00 lbs 7,035.00 lbs 0.00 lbs Eccentricity 0.000in 1,415.35 psi For Bending Stress Calcs... Summary 964.72 psi Max k*Lu / d 50.00 Column OK For Axial Stress Calcs... Cf : Axial 1.000 Axial X -X k Lu / d 18.29 Axial Y -Y k Lu / d 27.43 Using: Prllm: 3.5x5.25, Width= 3.50in, Depth= 5.25in, Total Column Ht= 8.00ft DL+LL DL+LL+ST DL+ST fc : Compression 619.59 psi 619.59 psi 236.73 psi Fc : Allowable 964.72 psi 964.72 psi 964.72 psi' fbx :Flexural 0.00 psi 0.00 psi 0.00 psi F'bx: Allowable 2,868.87 psi 2,868.87 psi 2,868.87 psi Interaction Value 0.6423 0.6423 0.2454 Stress Details Fc: X -X 1,415.35 psi For Bending Stress Calcs... Fc: Y -Y 964.72 psi Max k*Lu / d 50.00 F'c : Allowable 964.72 psi Actual k*Lu/d 23.72 F'c:Allow * Load Dur Factor 964.72 psi Min. Allow k*Lu / d 11.00 F'bx 2,868.87 psi Cf Bending 1.000 F'bx * Load Duration Factor 2,868.87 psi Rb: (Le d / b"2) ".5 8.701 For Axial Stress Calcs... Cf : Axial 1.000 Axial X -X k Lu / d 18.29 Axial Y -Y k Lu / d 27.43 Date. . ",O �T :1�o TOWN OF NORTH NDOVER �,_...._• �L PERMIT FOR,PXUMBING 1S s,cN / G-211his.certifiesthat ...wle,�—i,-,c,x..: . has permission to perform ..t =. §y• �: �• • •. plumbing in the buiIdingsrof .. -,"' ............. at ..._..� .� . /����'�J . ..... ,..-........ ,North 'Andover, Mass. Fee �... Lic. No%l.�. t� ............ .. /' `�-PlUM84 SPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date AF Building Location 11 or ty i �Q� Owners Name M, Ko 1�Rjoj*� t Permit W-2� Ifo Amount Type of Occupancy New �� Renovation ri Replacement Plans Submitted Yes ❑ No FIXTURES (Print or type)P Check one: � \ Installing Company Name CAS h t \ v 4 A' W q F1Corp. Partner UFirm/Co. Name of Licensed Plumber: C k e ffl e C ICI G t del 'Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: yLiability insurance policy Other type of indemnity ❑ Bond 10-1 Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mas achu tts State lum ' g Code and Chapter 142 of the General Laws. By. .�+S�ure or ate-----cL rlulllber Title Type of Plumbing License i 0 'g ,%,% City/Town cense NumDer Master Journeyman APPROVED ❑ (OFFICE USE ONLY `- • DENCO ENGINEERING STRUCTURAL ENGINEERS 148 PARK STREET NORTH READING, MA 01864 V: 978.664.6733 F: 978.664.9233 ENGINEER'S FIELD REPORT TO: RICK ANDERSON FROM: DANIEL W. SMITH rCDENNSON SUBJECT: 0 HOL-LYRIDGE-RDANO: ANDOVER; MADENCO JOB NO.07-010CONTRACTOR: RK ANDERSON DATE: APRIL 07, 2008 WEATHER: t 50` F, CLEAR SKY'S CC: PROJECT FILE Work in progress observed: 1. Engineer arrived on job site at approximately 2:30 prn and toured the project site with Contractor 2. Engineer observed that Contractor was in the process of completing or has completed, the following structural items: 0 Contractor is 100% complete with installation of engineered wood LVL beam and PSL support posts for new kitchen addition as designed per Denco Engineering's previously submitted calculations (see copy attached for reference). Structural items above observed by Engineer at time of site visit, except as noted otherwise, were in conformance with the documents prepared by Denco Engineering. Except as noted otherwise above, Engineer takes no exception to work in process or completed at time of site visit. 3. Photo record was taken see photo log attached. 4. Engineer completed tour of work in progress and left job site at approximately 3:00 pm. f \dws denco projects\200707-010 rk andersonVrp 07-010 040708.doc DENCO ENGINEERING STRUCTURAL ENGINEERS 148 PARK STREET NORTH READING, MA 01864 V: 978.664.6733 F: 978.664.9233 PHOTO LOG 80 Holly Ridge Road No. Andover, MA Date: April 07, 2008 @ 2:30 pm Picture No. 1 — Right end of new LVL beam bearing on double top plate and supported by PSL post below F:\DWS Denco Projects\2007\07-010_RK Andersonftoto Log 07-010 040708.doc Photo Log 80 Holly Ridge Road, No. Andover, MA Page 2 of 3 Picture No. 2 — Left end of new LVL beam bearing on double top plate and supported by PSL post below Picture No. 3 — PSL support post for left end of beam passes through floor sheathing, behind floor joist, and bears directly on built-up sill Photo Log 80 Holly Ridge Road, No. Andover, MA Page 3 of 3 fA i� � •,�„ -j' ,. �� � .,:-,' ""fie_ . Picture No. 4 - PSL support post for right end of beam bears directly on existing built-up LVL beam, which then bears directly on built- up sill DENCO ENGINEERING STRUCTURAL ENGINEERS 148 PARK STREET NORTH READING, MA 01864 V: 978.664.6733 F: 978.664.9233 Structural Calculations as per Commonwealth of Massachusetts State Building Code 760 CMR — 6t' Edition For Engineered Wood Beam and Posts R.K. Anderson Company Single -Family Residential Addition North Andover, MA August 28, 2007 Prepared By: Daniel W. Smith, E.I.T. Reviewed By: KENNETH DENNW: N Nm BBBS STR E� Kenneth Dennison, P.E. DENCO ENGINEERING Structural Engineers 148 Park Street North Reading, MA 01864 ride: R.K. Anderson Company Job # 07-010 Dsgnr: DWS Date: 6:45AM, 8 APR 08 Description: SFR Addition Scope: Design New Engineered Wood Beam and Posts User: M-0605924, Ver 5.8.0, 1 -Dec -2003 General Timber Beam (c)1983-2003 ENERCALC Engineering Software Description New LVL 2nd Floor Beam Over Opening to Addition Page 1 rk anderson.ecw:Calculations General information Ends are Pin -Pin Code Ref: 1997 NDS, 2003 IBC 2003 NFPA 5000. Base allowables are user defined Section Name 5.25x24 0.000 in Center Span 24.00 ft .....Lu 1.33 ft Beam Width 5.250 in Left Cantilever ft .....Lu 0.00 ft Beam Depth 24.000 in Right Cantilever ft .....Lu 0.00 ft Member Type Maximum Shear * Truss Joist - MacMillan, Microl-am 2.0E E Bm Wt. Added to Loads #/ft Fb Base Allow 2,925.0 psi Load Dur. Factor 1.000 Fv Allow 285.0 psi Beam End Fixity Pin -Pin Fc Allow 750.0 psi Wood Density 35.000 pcf E 2,000.0 ksi Full Length Uniform Loads Ends are Pin -Pin -0.625 in Deflection 0.000 in 0.000 in Center DL 295.00 Will LL 330.00 #/ft 0.0 0.0 Left Cantilever DL #/ft LL #/ft Maximum Shear * 1.5 Right Cantilever DL #/ft LL #/ft 0.000 in Allowable Trapezoidal Loads 35:9 k Max. Positive Moment 73.33 k -ft at 12.480 ft #1 DL @ Left 10.00 #/ft LL @ Left 10.00 #/ft Start Loc 0.000 ft DL @ Right 140.00 #/ft LL @ Right 70.00 #fft End Loc 21.000 ft #2 DL @ Left #/ft LL @ Left 30.00 #/ft Start Loc 0.000 It DL @ Right #/ft LL @ Right 420.00 #/ft End Loc 21.000 ft Summary Beam Design OK Span= 24.00ft, Beam Width = 5.250in x Depth = 24.in, Ends are Pin -Pin -0.625 in Deflection 0.000 in 0.000 in Max Stress Ratio 0.599 : 1' 12.096 ft ...Length/Defl 0.0 0.0 ...Length/Defl Maximum Moment 73.3 k -ft Maximum Shear * 1.5 15.9 k Allowable 122.4 k -ft 0.000 in Allowable @ Center 35:9 k Max. Positive Moment 73.33 k -ft at 12.480 ft Shear. @ Left 11.00k Max. Negative Moment 0.00 k -ft at 0.000 ft 0.000 in @ Right 11.88k Max @ Left Support 0.00 k -ft Camber. @ Left 0.000 in Max @ Right Support 0.00 k -ft @ Center 0.374in Max. M allow 122.40Reactions... @ Right 0:000in fb 1,745.88 psi fv 126.44 psi Left DL 4.59 k Max 11.00 k Fb 2,914.28 psi Fv 285.00 psi Right DL 4.80 k Max 11.88 k Deflections Deflection -0.250 in -0.625 in Deflection 0.000 in 0.000 in ...Location 12.096 ft 12.096 ft ...Length/Defl 0.0 0.0 ...Length/Defl 1,153.7 460.80 Right Cantilever... Camber ( using 1.5 * D.L. Deft ) ... Deflection 0.000 in 0.000 in @ Center 0.374 in ...Length/Defl 0.0 0.0 @ Left 0.000 in @ Right 0.000 in DENCO ENGINEERING Structural Engineers 148 Park Street North Reading, MA 01864 Title: R. K. Anderson Company Job # 07-010 Dsgnr: DWS Date: 6:45AM, 8 APR 08 Description : SFR Addition Scope: Design New Engineered Wood Beam and Posts User: KW -0605924, Ver 5.8.0, 1 -Dec -2003 General Timber Beam (c)1983-2003 ENERCALC Engineering software Description New LVL 2nd Floor Beam Over Opening to Addition Stress Calcs Bending Analysis Ck 21.207 Le 2.739 It Sxx 504.000 in3 Area 126.000 in2 Cf 1.000 Rb 5.351 CI 0.996 Sxx Read Max Moment @ Center 73.33 k -ft @ Left Support 0.00 k -ft @ Right Support 0.00 k -ft Shear Analysis @ Left Support Design Shear 14.38 k Area Required 50.473 in2 Fv: Allowable 285.00 psi Sxx Read Allowable fb 301.93 in3 2,914.28 psi 0.00 in3 2,925.00 psi 0.00 in3 2,925.00 psi @ Right Support Bearing Length Req'd 15.93 k 55.898 in2 285.00 psi rk Page 2 Bearing @ Supports Max. Left Reaction 11.00 k Bearing Length Req'd 2.793 in Max. Right Reaction 11.88 k Bearing Length Req'd 3.017 in Query Values M, V, & D a@ Specified Locations Moment Shear Deflection @ Center Span Location = 0.00 ft 0.00k -ft 11.00 k 0.0000 in @ Right Cant. Location = 0.00 ft 0.00 k -ft 0.00 k 0.0000 in @ Left Cant. Location = 0.00 ft 0.00 k -ft 0.00 k 0.0000 in offlu = 73.3k Dnmx =-0.e25in DENCO ENGINEERING Structural Engineers 148 Park Street North Reading. MA 01864 Title: R. K. Anderson Company Job # 07-010 Dsgnr: DWS Date: 6:48AM, 8 APR 08 Description: SFR Addition Scope: Design New Engineered Wood Beam and Posts Timber Column Design Page 1 rk anderson.ecw:Calculation Description New Support Posts for New IF LVL General Information Code Ref 2001 NDS, 2003 IBC, 2003 NFPA 5000. Base allowables are user defined. Wood Section Prllm: 3.5x5.25 Total Column Height 8.00 ft Le XX for Axial 8.00 ft Rectangular Column Load Duration Factor 1.00 Le YY for Axial 8.00 ft Column Depth 5.25 in Fc 1,600.00 psi Lu XX for Bending 8.00 ft Width 3.50 in Fb 2,900.00 psi 964.72 psi Manuf 964.72 psi' E - Elastic Modulus 2,000 ksi fbx : Flexural 0.00 psi 0.00 psi Truss Joist - MacMillan, Parallam 2 Loads F'bx : Allowable 2,868.87 psi 2,868.87 psi 2,868.87 psi Dead Load Live Load Short Term Load Axial Load 4,350.00 lbs 7,035.00 lbs 0.00 lbs Eccentricity 0.000in 1,415.35 psi For Bending Stress Calcs... Summary 964.72 psi Max k`Lu / d 50.00 Column OK For Axial Stress Calcs... Cf : Axial 1.000 Axial X -X k Lu / d 18.29 Axial Y -Y k Lu / d 27.43 Using: Prllm: 3.5x5.25, Width= 3.50in, Depth= 5.25in, Total Column Ht= 8.00ft DL + LL DL + LL + ST DL + ST fc : Compression 619.59 psi 619.59 psi 236.73 psi Fc: Allowable 964.72 psi 964.72 psi 964.72 psi' fbx : Flexural 0.00 psi 0.00 psi 0.00 psi F'bx : Allowable 2,868.87 psi 2,868.87 psi 2,868.87 psi Interaction Value 0.6423 0.6423 0.2454 Stress Details Fc: X X 1,415.35 psi For Bending Stress Calcs... Fc: Y -Y 964.72 psi Max k`Lu / d 50.00 F'c : Allowable 964.72 psi Actual Ic'Lu/d 23.72 F'c:Allow' Load Dur Factor 964.72 psi Min. Allow k'Lu / d 11.00 F'bx 2,868.87 psi Cf Bending 1.000 F'bx' Load Duration Factor 2,868.87 psi Rb: (Le d / b"2) "_5 8.701 For Axial Stress Calcs... Cf : Axial 1.000 Axial X -X k Lu / d 18.29 Axial Y -Y k Lu / d 27.43 Date .... 1 — /. —A.� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... 2 .... .... . .............................. has permission to perform . ............................................... wiring in'the building of .... .................................... I ................................ at .... ........ .. ... North Andover, Mass. Fee .IX5 ....... Lic. No w ....... ELECTRICALINSPe / ;check # � N' 7698 I is• = Commonwealth of Massachusetts Official Use Only Permit No. �o� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]1/99] leave blank .APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with.lhe Massachusetts Electrical Code (MEC), 521 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: � 1 City or Town of: Q, - -� p� Ir To the Inspector of Wires: By this application the undersigned gives notice of his or heintention to per orm the electrical work described below. Location (Street & Number) ;80 • _4611 %-/ Owner or Tenant Owner's Address B this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Vo Number of Feeders and Ampacity Location and Nat -are -of Proposed Electriz-al Work: IN t+l Vol Telephone N(�` (09 l 0cg7 Yes ❑ No .❑ (Check Appropriate Box) Utility Authorization No. a Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters IN6(�r> %D ?C)O . FSONI-I) P11C) C FI. t= S; L T E (;�, QUr`11 /•:.....J..r . ,.r,L. ! /1.... J.._ a_LJ_ - L_ ..._:.._J 1-- •L- '----- -- -11- No. of Recessed Fixtures No. of Ceil: Susp. (addle) Fans No.'of otal Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above n- Wo, _o mergency L igng rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number Tons . KW No. of Self-Containe'd Totals: Detection/Alerting Devices No, of Dishwashers Space/Area Beating KW Local ❑ Municipal f_1 Other Connection No. of Dryers Heating Appliances KW Security ofystemss or Equivalent No: o ater- Kms, Heaters o. o o. o Signs Ballasts Data Wiri n gg No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No, of Devices or E uivalent OTHER: ..u, ar,urr y aesu-ea, or as requirea ny me inspector q/ wirer. INSURANCE COVERAGE: Unless waived by the owner, no permit for the. performance of electrical work may issue unless the licensee provides proof of liability. insurance including "completed operation" coverage or its substantial equivalent. The `.' undersigned certifies that such overage is in force, and. has exhibited proof of same to the permit issuing office. CH, CK ONE: INSURANCE 13OND ❑ OTHER ❑ (Specify:) czD D (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy..) Work to Stan: Inspections to be requested in. accordance with MEC Rule 10, and upon completion. I certify, under the pails acid penalties of perjury, that the information oil this application is true and complete. FIRM NAME: L (__ — 2� L. I r ; LIC. NO.: Licensee: 11 TN0117 U t� f=L. /� Slgnatur LIC. NO.: (Ifapplicabl neer "ex r" i the liceare »umber lure.) BusTel: No. -..y Address: �J , F W 4G l a : (7. i4EI niSj�G 20 M 1'� L -__1 el. No.: yZZ . S�1 1,7" 1/. OWNER'S INSURANCE WAIVER: 1 am awa,<e that the Licensee does not have the liability i ' urance coverage normally required bylaw. By my signature below; 1 hereby;wawe this requirement: 1 am the (check one) ❑ owner ❑ owner's agent. Signature Telephone IVo, PERMIT F. EE.'$ (4.S �� p� l D `z -o7 V`� �� X6..2 �� `� - ��_� 0`� \� ~' �, �; A� Y -� Date ... �:. �M NORTH TOWN OF NORTH ANDOVER -; PERMIT FOR GAS INSTALLATION t w' This certifies that . 4:41 ." ` ....`.�.. . has permission for gas installation `"/,..:%.... . in the buildings of . '� �7:.`L. 'L "` ........................ . at . 7�t�-:.� .... North .Andover, Mass. Fee.7Z..... Lic. No. l�? �1`=# / �� .......... . GAS INS�v70R y V Check 6043 MASSACHUSETTS UNIFORM APPUCATON FOR PERMPT TO DO GAS FITTING (Type or print) Date - CI`% NORTH ANDOVER MASSACHUSETTS //f Building Locations &O A04� rl6;14- Permit # �%% Amount $ 277 Owner's Name �O�//j New Renovation Replacement Plans Submitted Name or type) /1�r10 04/ r Name of Licensed Plumber or Gas Fitterill' 11711 Ch ck one: Certificate Installing Company Corp. E] Partner. 0-Fi rm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes B— NoO If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0 Other type of indemnity ❑ Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner n Agent n hprpku rami A, thot .11 -,F+ke A -+-:1......A :__._ __ _._ _ _ _.._ __._.. ,..........,, ,,.,,,,,,«Mu kU, rincrcui 1n aoove appncatlon are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas C�earChapt 142 of the General Laws. Title City/Town VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber Gas Fitter License Number Master 0 Journeyman U Ea w a ° z z z I- z ¢ wd H F w > C9 O ca > z w O Ew. w F w s o x fz 3 a.4° z o x SUB -BASEMENT CC> B A S E M ENT 1ST. FLOOR 2ND. FLOGR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR Name or type) /1�r10 04/ r Name of Licensed Plumber or Gas Fitterill' 11711 Ch ck one: Certificate Installing Company Corp. E] Partner. 0-Fi rm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes B— NoO If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0 Other type of indemnity ❑ Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner n Agent n hprpku rami A, thot .11 -,F+ke A -+-:1......A :__._ __ _._ _ _ _.._ __._.. ,..........,, ,,.,,,,,,«Mu kU, rincrcui 1n aoove appncatlon are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas C�earChapt 142 of the General Laws. Title City/Town VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber Gas Fitter License Number Master 0 Journeyman ate..................... ,AOR T1y o= �' TOWN OF NORTH ANDOVER 1 D `. ;-.z ; PERMIT FOR GAS INSTALLATION y • th 1 �9SSACMUSEt This certifies that ........... ....... . . has permission for gas installation in the buildings of ............................ . at ....''.f. North Andover, Mass. o Fee .�._ .. . Lic. No../ �� ` 7 ........ GAS INSfPEE Check # 6150 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) DateD 7 NORTH ANDOVER, MASSACHUSETTS Building Locations T 214 HOf�, o�%�j 1 v Owner's Name New D Renovation Replacement ❑ Plans Submitted Permit # lOiCse> Amount $ ` 7n "L J, (Print or type) , / a f I Check one: Certificate Installing Company Name _ ! IC/r� a f [� 09-. %A tGu D Corp. 11 Partner. 1-3 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes NoO If you have checked yes,'please Indic the type coverage by checking the appropriate box. Liability insurance policy ED � Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 1 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S �e C� ode and �( t 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title 0—Plumber 129(`77 City/Town 1:1 Gas Fitter License Number Master APPROVED (OFFICE USE ONLY) 0 Journeyman Ed z rA w vsw z >rA L1, >zw�-CAo z3cd a > A SUB-BASEM ENT a F o BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR O J, (Print or type) , / a f I Check one: Certificate Installing Company Name _ ! IC/r� a f [� 09-. %A tGu D Corp. 11 Partner. 1-3 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes NoO If you have checked yes,'please Indic the type coverage by checking the appropriate box. Liability insurance policy ED � Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 1 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S �e C� ode and �( t 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title 0—Plumber 129(`77 City/Town 1:1 Gas Fitter License Number Master APPROVED (OFFICE USE ONLY) 0 Journeyman TOWN OF NORTH ANDOVER . PERMIT FOR PLUMBING This certifies that ....... has permission to perform ..... ......... plumbing in the buildings of ......... at . . . . ... 41r. North Andover, Mass. Fee Lic. No. ...... PLUIVIOIN9 INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS : Date ` Building Location (7_ off_ 4 QL � C� . Owners Name 121' t1O til?0 WM E Permit #�� -0 ° 1 Amount �31� Type of Occupancy j N q New Renovation 0 Replacement 0 Plans Submitted Yes No FIXTURES (Print or type) Installing Company Name C s t'1 E N �P l V Check one: 0 Corp. 11 Partner U Firm/Co. Certificate Name of Licensed Plumber. C 14A r? I l (P, C 6A -T 6 ',� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: !� Liability insurance policy 0, Other type of indemnity [] Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three, signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa=hSA=PlumbM*gC and ha ter 142 -of the General Laws. P P P� p r By: Signature o kens um er Type of Plumbing License Title 4g2 r' 7 -7 City/Town icense INUMBer Master 0/.�oureyman ❑ APPROVED (OFFICE USE ONLY ■ Date... ....................... Tol TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHUS This certifies that ........................V ... ................................................. has permission to perform . wiring in the building of ..... .............. at ...... ................. )�............ ......... .................... North Andover, Mass. ez Fee9(5 ................. Lic. Nd .. .......... ........ .............. ELEc-micAL INSPE��i�' Check # 7458 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/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 IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To theIn pec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ijo Owner or Tenant OKIvv, /ni9 /U2dvt/ Telephone No. Owner's Address _IkME Is this permit in conjunction with a build' g permit? Yes 2 No ❑ (Check Appropriate Box) Purpose of Building 401, Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters Completion of the following 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 No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In-IET,o. rnd. rnd. of o Emergency Lighting Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. Detection and In itiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers HeatTotals: Number' Tons , KW ... Self-Contained No. of elf-C/Alerting Detect No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of WaterKms, No. o No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _-4-Syo. (When required by municipal policy.) Work to Start: fo z ---r7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera e is in force, and has exhibited proof of same to the permit issuing office. NCE [BO CHECK ONE: INSURAND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: ,9,pz-&e� e5L,&7_s &k4,_ LIC. NO.:,3S/Sp6 Licensee:6,,44 ZZ&La- SignatureV���,� _ LIC. NO.:3SiS9E (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: 1/9 �2u" flit ,'� X 333 �t�N1SF©� AA 9167-y Alt. Tel. No.:928T � 5rY3�3 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. 1 am the (check one) ❑ owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. -� FSA UedA,,, r '� I -e , I & _ - )- ?, (7,7 7 m Lbl-d-ck �A Cq4v cr-z� �l te ,"V% The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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): 1J.� GA_9L->&t:K &2.L-6rfI64-C /'�,rt�•9cT Address: dy �� 14i ii P, 3 City/State/Zip: 614ZAie,-!-3,zo A0 4162-�l Phone #: 33 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I -,employees (full and/or part-time).* U 2. 01_am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.[ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. Other Axa - JAA60W v *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #: 9126 gal - 4`1,33 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 #: