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HomeMy WebLinkAboutCONSTRUCTION OF 15 UNIT RESIDENTIAL APARTMENTS %AORTH BUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 4 Permit NoM ,6`11,-gole, Date Received ATE. US Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION rint PROPERTY OWNER 5ffrber� U,C, ' Print' 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building 11 One family D Addition XTwo or more family [I Industrial [I Alteration No. of units: [I Commercial [I Repair, replacement [I Assessory Bldg 0 Others: [I Demolition 11 Other gmwaw "klafief�lre,#�,�?,-�"?Iq,��I&L,"f f/q�, /N 1011111 111b"M 111/11/11 "1 11/1, DESCRIPTION OF WORK TO BE PERFORMED: 44yr �Tv 6,+ A mA�IV i' V 0& 0 v?,M,e4J3 Identification- #lease Type or Print Clearly OWNER: Name: P5" (Ulf U'C Phone: Address: Aov� 0) b I o q bg Contractor Name: Phone: Email: w0wV OLD VFr1e-(,0 d6' i v, Address: tAwl 6/jizarej I Supervisor's Construction License: C, , 5 (8 2, Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER C, Phone: Address: � �Wdrf LAJ,Vte- ON& Reg. No. I FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.09 PER S.F. Total Project Cost: FEE: $ Check No.:IoZ4 Receipt No.: 12J611 NOTE: Persons contracting ivAth unregistered contractors do not have access to the guaranty fund S iq h atu reof,,coritracto"r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swnnming Pools ❑ Well ❑ Tobacco Sales Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF ® D FORM PLANNING & DEVELOPMENT Reviewed On � Signature_ 1 ? 1 , � 1e, r.' rtra ie � � fig« COMMENTS )IIA115. Per AkAac dmed CONSERVATION Reviewed on /,D(,1' I � Signature COM,TTS O 0 /,, HEALTH Reviewed on ! Signature C6`MM NTS Zoning Board of Appeals.Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer ConneG ion/Si nature& Da 0 (110 Driveway Permit DPW Town Engineer: Signature:_ 111,3115 Located 84 Osgood Street EIRE DEPARTMENT ,;Tempi Du fier onsite ayes„ Located at 124 Main Street Eire ��par� enf sigr��ture/dale COMMENTS t%®RT H Town of ndover 0 �o LAKE ti ver, ass, �f /J COCHICNEWICK �1. f S U J�ArIED P? BOARD OF HEALTH P �ERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ........& ................................................ BUILDING INSPECTOR has permission to erect .................... buildings on .".. .6 ..5rzU,,e-/ (, -z�J Foundation G v / .� ( �.. .... .......... ......... �.................... 111% Rough to be occupied as ���...... XChimney .............. .......................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMITIN 6 MONTHS ELECTRICAL INSPECTOR LES ION STARTS Rough .... ...................... Service ..........., ...... . Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy.Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final NoLathingor Dry WallTo Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Architects • LaGrasse & h Jo'spD LaGrass�AIA Associates, Inc, chltects,Engineers<&�Land'PlannTrs A , Thomas F Galvui,A1A - JuliannaE.Hoch,RA November 2, 2015 North Andover Board of Health North Andover Town Hall 1600 Osgood Street, North Andover, Ma 01845 Re: Bradstreet on Main Attn.Susan Sawyer, Please accept this memo as my Affidavit as an amendment to my Building Permit Architectural Affidavit given to the Building Department for the issuance of a Building Permit. I have never had to submit a special one to the Board of Health and do not have any special forms. The 15 DU building under construction shall comply with the requirements of the Department of Public Health Human Habitation Code MGL 105 CMR 410.000. Exception: When completed,the building will be in compliance with the occupancy requirements, however I cannot certify that the continued operational maintenance of the building under the habitation code will be continued. ��Eo nacHiTF Signed: y� o,lack 01 UIPA A pwER, w o MP a� t� Joseph D LaGra e,AIA FALT H Of- Joseph FJoseph D LaGrasse and Associates, I . 1 Elm Square, Andover, Massachusetts,01810 One Elm Square T 978.470.3675 1420 Celebration Blvd. Andover,MA 01810 F 978.470.3670 Celebration,FL 34747 AA26001333 www.lagrassearchitects.com I"VY 114 %jr I 1"1%1" I-XII""V F�lx OFFICE OF BUILDING DEPARTMENT 400 Osgood Street mm North Andover, Massachusetts 0 1845 D. Robed Nicetta, Telephone(978)688-95454 Building Commissioner Fax (978)688-9542 CONTROL CONSTRUCTION- SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDfNG INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01845 1, ------,HEREBY CERTIFY THAT THE BUILDING CONSTRUCTED AT y IS av DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: AUTHORI SIG L6 No.4153 ANDOVER, DATj%' 10 1 .J /I MA REGIST 16N: NOTE: ENGINEER"WET STAMP" MUST BE AFFIXED TO THIS FORM Control Construction Form revised 11.15.2004 BOARD OF APPEALS 688-9541 CONSERVATI(M 688-9530 Ill'AL111 689-9540 PLANNING 688-9535 Generated by REScheck-Web ComplianceO"$f/ 1 1 Project 39-67 Saunders St., N. Andover Energy Code: 2012 IECC Location: Essex County, Massachusetts Construction Type: Multi-family Project Type: New Construction Conditioned Floor Area: 15,408 ft2 Glazing Area 16% Climate Zone: 5 (6499 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: 39-67 Saunders St Willard Perkins Mark Yanowitz North Andover, Massachusetts Bradstreet Partners,LLC Verdeco Designs LLC 01845 28 Andover St 1 Elm Square Andover, Massachusetts 01845 Andover,Massachusetts 01810 (978)475-5400 978-409-2217 wperkins@hearthstonerealty.com mark@verdecodesigns.com Compliance: 16.6%Better Than Code Maximum UA: 1411 Your UA: 1177 The%Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. r Orel e SSe Ceiling: Flat or Scissor Truss 15,408 0.0 49.0 0.020 308 Wall:Wood Frame,16in.D.C. 7,830 20.0 5.0 0.044 287 Window:Vinyl Frame,2 Pane w/Low-E 1,215 0.300 365 Door:Solid 63 0.200 13 Door: Glass 21 0.300 6 Floor: Unheated Slab-On-Grade 290 10.0 0.684 198 Insulation depth:4.0' Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other calculations submitted with the permit application.The proposed building has been designed to meet the 2012 IECC requirements in REScheck Version 5.5.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklists Name-Title Sig a u Dat Project Title: 39-67 Saunders St., N.Andover Report date: 10/28/15 Data filename: Page 1 of 8 � � � � REScheck Software Version 5.5.0 Inspe��������������y�o�� m�°����������m��~ ction »�^N0����m�.m���m° Energy Code: 20}2 IECC Requirements: IO0.096were addressed directly inthe RESchecksoftware � Text inthe "Comments/Assumptions" column is provided by the user inthe REBcheck Requirements screen. For each requirement, the user certifies that a code requirement will be met and how that is documented, or that an exception is being claimed. Where compliance is itemized in a separate table, a reference to that table is provided. Pre-inspection/Plan Review Val Fie Comp 1 s? 1--'Imments/Assurriptions 103.1, Construction drawings and ElComplies Requirement will be met. 103.2 documentation demonstrate ElDoes Not [PR111 energy code compliance for the []Not Observable building envelope. E]NotApplicable 103.1, Construction drawings and ElComplies Requirement will be met. 103.2, documentation demonstrate E]Does Not 403.7 energy code compliance for E]Not Observable [PR311 lighting and mechanical systems. E]Not Applicable Systems serving multiple dwelling units must demonstrate compliance with the IECC Commercial Provisions, 302.1, Heating and cooling equipment is Heating: Heating: ElComplies Requirement will be met. 403.6 sized per ACCA Manual S based Btu/hr Btu/hr E]Does Not [PR2]2 on loads calculated per ACCA Cooling: Cooling: FINot Observable Manual J or other methods Btu/hr Btu/hr E]Not Applicable approved by the code official. Addit1mna| Cmnmnmmmts/Amsummtimms: Plans Value Complies? Comments/Assumptions pection Verified rIe_1­d'Vfie� Foundation Ins___ 402.1.1 Slab edge insulation R-value. R- R- FIComplies See the Envelope Assemblies [FO1]1 ❑ Unheated n Unheated E]Does Not table for values. Heated n Heated E]Not Observable E]Not Applicable ................... ................... 303.2, Slab edge insulation installed per ElComplies Requirement will be met. 402.2,9 manufacturer's instructions. E]Does Not [F0211 E]Not Observable E]Not Applicable ..........._-.1.1......... ........ ........... 402.1.1 Slab edge insulation ft ft ElComplies See the Envelope Assemblies [F0311 depth/length. E]Does Not table for values. E]Not Observable E]Not Applicable ............. 303.2.1 A protective covering is installed E]Complies Requirement will be met. [FO11]2 to protect exposed exterior E]Does Not insulation and extends a E]Not Observable W minimum of 6 in.below grade. E]Not Applicable ............ ------- .......... 403.8 Snow-and ice-melting system ElComplies Exception: null. [FO12]2 controls installed. E]Does Not E]Not Observable E]Not Applicable J Additional Comments/Assumptions: EHigh Impact(Tier 1) e iUM impact(Tier 2) _­_Fil[:0w Impact(Tier 3) iJ .......... ....... Project Title: 39-67 Saunders St., N.Andover Report date: 10/28/15 Data filename: Page 3 of 8 Sea tion glans Verified Field Verified Framing/Rough-111 Inspection complies' C ornrne nts/Assumption, 3 -tl p Valrre Value � t 402.1.1, Door U-factor. U- U-_ ❑Complies See the Envelope Assemblies 402.3.4 ❑Does Not table for values. [FR1]1 ❑Not Observable ❑Not Applicable w._ __. _.__— __ ...._ _......_— ..._... 402.1.1, Glazing U-factor(area-weighted U-_ U-_ ❑Complies See the Envelope Assemblies 402.3.1, average). ❑Does Not table for values. 402.3.3, ❑Not Observable 402.3.6, ❑Not Applicable 402.5 [FR2]1 t;;t11 303.1.3 U-factors of fenestration products ❑Complies Requirement will be met. [FR4]]L are determined in accordance ❑Does Not fob with the NFRC test procedure or ❑Not Observable taken from the default table. ❑Not Applicable _ .._. .__._...._..— _ _ _..- _..__.._- ...... ...._—_.__.... ..... ... ..,_ .. 402.4.1.1 Air barrier and thermal barrier Complies Requirement will be met. [FR23]1 installed per manufacturer's ❑Does Not instructions. ❑Not Observable ❑Not Applicable 402.4.3 Fenestration that is not site built ❑Complies Requirement will be met. [FR20]1 is listed and labeled as meeting ❑Does Not AAMA/WDMA/CSA 101/I.S.2/A440 ❑Not Observable or has infiltration rates per NFRC ❑Not Applicable 400 that do not exceed code limits. ---- 402.4.4 IC-rated recessed lighting fixtures ❑Complies Requirement will be met. [FR1612 sealed at housing/interior finish ❑Does Not and labeled to indicate s2.0 cfm ❑Not Observable leakage at 75 Pa. ❑Not Applicable ---_......_..__._.__.._____...._____.._.__.._....___._... 403.2.1 Supply ducts in attics are R- R- ❑Complies Exception: null. [FR12]1 insulated to ?R-8.All other ducts R- R ❑Does Not in unconditioned spaces or []Not Observable 2 outside the building envelope are insulated to >_R-6. ❑Not Applicable 403.2.2 All joints and seams of air ducts, ❑Complies Requirement will be met. [FR13]1 air handlers,and filter boxes are ❑Does Not sealed. ❑Not Observable ❑Not Applicable _. __...—._..__.......__.___.__._.___........__---._....__..........._.__..........._._........._ _..__.........___...._..__. _._._..__.._._._.... —._..__......__..._.__.._._..__.__..._...__.._._._---......---....._._..........___._ 403.2.3 Building cavities are not used as ❑Complies Requirement will be met. [FR15]3 ducts or plenums. ❑Does Not kk ❑Not Observable ❑Not Applicable _............. ----..._. _.,_..-_ __.___-_------_...._.___ ___ __.._ _.._.._. ...... 403.3 HVAC piping conveying fluids R- R-_ ❑Complies Requirement will be met. [FR17]2 above 105°F or chilled fluids ❑Does Not fry below 55°F are insulated to�R- ❑Not Observable 3. ❑Not Applicable _ ._.. _._.._ __...... .._..-_-_-__....._._.____...1._........_. 403.3.1 Protection of insulation on HVAC ❑Complies Requirement will be met. [FR24]1 piping. ❑Does Not ❑Not Observable ❑Not Applicable 403.4,2 Hot water pipes are insulated to R- R-_ ElComplies Requirement will be met. [FR18]2 >_R-3. ❑Does Not Q111; ❑Not Observable ❑Not Applicable _ _. —... ...... _ 1 Hi h Im 1.pact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Im act(Tier 3) Project Title: 39-67 Saunders St., N.Andover Report date: 10/28/15 Data filename: Page 4 of 8 sartron Flares�fsrifesel Frsld verified # G rarning /Rough-In Inspection Complies? Cornments/Assn mpteons & Req.113 --- --. C __ .................. - _values — -- -....- -- ...... _— ...._ 403.5 Automatic or gravity dampers are ❑Complies Requirement will be met. [FR19]2 installed on all outdoor air ❑Does Not intakes and exhausts. ❑Nat Observable ❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N. Andover Report date: 10/28/15 Data filename: Page 5 of 8 Sec.tiran I lana Verified Field Verified f insulation lrgspectron Complies Crzrl°irrroents/Assramlations c Rer1.ID value Value III —....-__ — ----- 3011 --303.1 All installed insulation is labeled ElComplies Requirement will be met. [IN13)2 or the installed R-values ❑Does Not ho provided. ❑Not Observable ❑Not Applicable ._._. -_...._.. 402.1.1, Wall insulation R-value. If this is a R- R- ❑Complies See the Envelope Assemblies 402.2.5, mass wall with at least 1/2 of the ❑ Wood ❑ Wood ❑Does Not table for values. 402.2.6 wall insulation on the wall ❑ Mass ❑ Mass ❑Not Observable [IN3)1 exterior,the exterior insulation ❑ Steel ❑ Steel ❑Not Applicable requirement applies(FR10). ................_ ......... 303.2 Wall insulation is installed per ❑Complies Requirement will be met. [IN411 manufacturer's instructions. ❑Does Not ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: I .. _ —.......... _ - 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 39-67 Saunders St., N.Andover Report date: 10/28/15 Data filename: Page 6 of 8 ..... --- _.. _--- ,._ _.- ....... _._... _.. .m. Seetron Plans Vera Ill, rie�ld Verified # Final Inspection Provisions Value __ Value Comp lie s7 Comments/Assumptions Re.q ICS ----— - - _-.. ..._... _ --_......................_.... ..._.._........... _.- ---- 402.1.1, Ceiling insulation R-value. R- R- ❑Complies See the Envelope Assemblies 402.2.1, ❑ Wood ❑ Wood ❑Does Not table for values. 402.2.2, ❑ Steel ❑ Steel ❑Not Observable 6 [Fill' ❑NotApplicable FI1]...._.__........_............_....._.___._..__ __._...__........___. ......-_...__.......__ ._..___ ..__..__...__..._......_._. _....._..__------.___.___.._-.._-._...---_--...__.__...__...._.____ _............-....___._ 303.1.1.1, Ceiling insulation installed per ❑Complies Requirement will be met, 303.2 manufacturer's instructions. ❑Does Not [FI211 Blown insulation marked every 411;111n 300 ft2. ❑Not Observable ❑Not Applicable ..... -------- -- .— ._ _.-_ ------- ----.._. - ----- - — 402.2.3 Vented attics with air permeable ❑Complies Requirement will be met. [F122]2 insulation include baffle adjacent ❑Does Not to soffit and eave vents that extends over insulation. ❑Not Observable ❑Not Applicable 402.2.4 Attic access hatch and door R- R- ❑Com lies Requirement will be met. [F13]1 insulation >_R-value of the ❑Does Not adjacent assembly. ❑Not Observable ❑Not Applicable _.......... __.._._. _..._...................___._...___...___ --....._..._...... __.._ __..... _._..__.____..._..._....._.__.._._...._...-- 402.4.1.2 Blower door test @ 50 Pa. <=5 ACH 50 = ACH 50= ❑Complies Requirement will be met. [FI17]1 ach in Climate Zones 1-2,and ❑Does Not <=3 ach in Climate Zones 3-8. ❑Not Observable ❑Not Applicable _.... ........._._- _..._ 403.2.2 Duct tightness test result of<=4 cfm/100 cfm/100 ❑Complies Requirement will be met. [FI4]1 cfm/100 ft2 across the system or ft2 ft2 ❑Does Not f <=3 cfm/100 ft2 without air handler @ 25 Pa.For rough-in ❑Not Observable tests,verification may need to ❑Not Applicable occur during Framing Inspection. 403.2.2.1 Air handler leakage designated ❑Complies Requirement will be met. [FI2411 by manufacturer at<=2%of ❑Does Not design air flow. ❑Not Observable ❑Not Applicable -........................__._... ..........__...........__ _,_...__....__._....__ ______.._.._ _........_ _......_......._------.-..__ __- 403 1.1 Programmable thermostats ❑Complies Exception: null. [F1912 installed on forced air furnaces. ❑Does Not N []Not Observable ❑Not Applicable 403.1.2 Heat pump thermostat installed ❑Complies Requirement will be met. [Fl 10]z on heat pumps. ❑Does Not l ❑Not Observable ❑Not Applicable -.....__.__.--_-- _._..___.__._._. .___� _......_.._...... _...._,___._ .__--------___..____ _.___._-_................._._ ......................._____.._ 403.4.1 Circulating service hot water ❑Complies Exception:null. [FIll]2 systems have automatic or ❑Does Not A0, accessible manual controls. ❑Not Observable � ❑Not Ap- . -------- _ _.. 403.5.1 All mechanical ventilation system ❑Complies Requirement will be met. [F125]2 fans not part of tested and listed ❑Does Not HVAC equipment meet efficacy and air flow limits. ❑Not Observable ❑Not Applicable _....._.. . . .-....___...._....�__ ._....._. . __.._...- _..... 404.1 75%of lamps in permanent ❑Complies Requirement will be met. [FI611 fixtures or 75%of permanent ❑Does Not ]ern, fixtures have high efficacy lamps. ❑Not Observable Does not apply to low-voltage lighting ❑Not Applicable 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) ^1 3�Low Impact(Tier 3)= Project Title: 39-67 Saunders St., N. Andover Report date: 10/28/15 Data filename: Page 7 of 8 Section Mans verified Field vei ified Final Inspection Provisions Complies? Comments/Assumptions 6t Fieei.11 value value 404.1,1 Fuel gas lighting systems have ❑Complies Exception: null. [F]23]3 no continuous pilot light. ❑Does Not ❑Not Observable ❑Not Applicable _ ........--------...—��-----_.._.___...__ ----_ __._..—.____,. _�___..._,____ ........... 401.3 Compliance certificate posted. ❑Complies Requirement will be met. [F17]2 ❑Does Not , i ❑Not Observable ❑Not Applicable _................ _----------_.�.....___._.._._....___.__._..___...._.__...._.........-.-......__.._.__._...,_._____._.._.._._.._.. _..._—.._....__....._..._.............._._............ ..._....________._..___._.__...___. 303.3 Manufacturer manuals for ❑Complies Requirement will be met. [FI18]3 mechanical and water heating ❑Does Not systems have been provided. ❑Not Observable f ❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) [.. I _._.. - 1 C--- _.._.. _J1 1 ._ Project Title: 39-67 Saunders St., N. Andover Report date: 10/28/15 Data filename: Page 8 of 8 2012 UECC Energy Efficiency Certificate Above-Grade Wall 25.00 Below-Grade Wall 0.00 Floor 10.00 Ceiling/ Roof 49.00 Ductwork (unconditioned spaces): Mw indow OMME 0=30 MM Door 0.20 MM Heating System: Cooling System: Water Heater: Name: Comments The Commonwealth of Massachusetts . Department ofIndlustria_lAccidents 1 Congress Street, Suite 100 .Boston,MA 02114-2017 y� www mass.gov1dna Sy. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name(Business/Organization/Individual): p �l Address: VA v City/State/Zip: vk Phone#: Are you an employer?Check the appropriate box: Type of project(.Tequired): 1.❑1 am a employerwith employees(full and/or part-time).* 7. KNew construction 2.[]I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.No workers'comp.insurance required.] • 9. ❑Demolition 3.FJ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 C]wilding addition ensure that all contractors either have workers'compensation insurance or are sole 11'. Electrical repairs or additions proprietors with no employees. - 12. Plumbing repairs or additions 5:VJ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors Have employees and have workers'comp.insurance.$ 6.F1 W e are a corporation and its of�cers have exercised their right of exemption per MGL c. 14• Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that=box#1 must also fill out the section below showing their workers'compensation policy information. Iiorneowners who submit#tris affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-coniractors have employees,&y must provide their workeis'comp.policy number. ,Tam an employer that is providing workers'compensation insurance for my employees.'.below is thepolicy and job site information. Insurance Company Name: pt Policy#or Self-ins,Lie. VJC,,V 0 0 --(5 Ca Expiration Date:_ ° 1 Job Site Address: 154- " City/State/Zip: P: 0(E5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL o. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify under the pains andpenaldes ofper jwy that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city of'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#: ol(MrV�airr / q�fdr1�1K.. > >CVi'O11fk1MrlIDIpR e r0,11 e c One Elm Square, Andover, MA 01810 978-409-2217 v`•fiww.verdecodesigns November 2, 2015 TO: Gerry Brown, Town of North Andover Building Department RE: Building permit application for 39-67 Saunders Street This memo is to acknowledge that we are proceeding on a design-build basis for certain systems related to work defined in the above permit application and will provide additional design information and affidavits for the following: • Plumbing systems • Mechanical systems • Electrical systems • Fire Sprinkler & Protection systems • Health Department requirements including resident intercom system �4rk Yanowitz Managing Partner Verdeco Designs, LLC DATE(MM/DD/YYYY) ®® CERTIFICATE OF LIABILITY INSURANCE 9/8/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CANT E:CT Lisa London MTM Insurance Associates PHONE (978)681-5700 FNC No,(978)681-5777 1320 Osgood Street A DResS:lisal@mtminsure.com INSURERS AFFORDING COVERAGE NAIL# North Andover MA 01845 INSURERAAtain Specialty Insurance INSURED INSURERB:Safety Insurance Company 39454 Verdeco Designs INSURERC: 1 Elm Square INSURERD: INSURER E: Andover MA 01810 INSURERF: COVERAGES CERTIFICATE NUMBER:15-16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM DDYCY/YYYY MM/POLDD EXP LTR LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 NGEN'L MERCIAL GENERAL LIABILITY PREMISES Eaoccurrence $ rACLAIMS-MADE X❑OCCUR IP159979002 /17/2015 /17/2016 MED EXP(Any one person) $ 5,000 PERSONALBADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY EaaccidentSINGLELIMIT $ 1,000,000 BANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 5057753 /17/2015 /17/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ Jx HIRED AUTOS X AUTOS '.. UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ '.. DED I I RETENTION$ $ WORKERS COMPENSATION WCSTAT'U OTH- AND EMPLOYERS'LIABILITY O S 1 ER ANY PROPRIETOR/PARTNER/EXECUTIVE� N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under '... DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 1600 Osgood St. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE - ��-- M Laorenza/STEPH ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS075 t9ntnnm M The A(nPn m Lr of A(r)PFi a CERTIFICATE OF LIABILITY INSURANCE 7/15/2015 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this c artificate does not confer rights to the certificate holder in lieu of such endorsements(s) CONTACT PRODUCER NAME: MTM Insurance Associates,LLC (tic,Nio EXt): (978)681-5700 FAX NO.:) 1320 Osgood Street ADDRESS: North Andover,MA 01845 PRODUCER CUSTOMER ID#• INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Atlantic Charter Insurance Company VDAC 44326 - Verdeco Designs,LLC INSURER B: INSURER C: One Elm Square INSURER D: Andover,MA 01810 INSURER E: INSURER F. COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSR WVD DATE(MMIDDIYY) DATE(MMIDDNY) (In Thousand) GENERAL LIABILITY EACHOCCURRENCE $ DAMAGE TO RENTED PREMISES COMMERCIAL GENERAL LIABILITY (Ea occurrence) $ CLAIMS MADE ❑ OCCUR ❑❑ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ POLICY ❑PROJECT ❑LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea Accident) ANY AUTO BODILY INJURY $ ALLOWNEDAUTOS F-1❑ (Per Person) '.,,.... SCHEDULED AUTOS BODILY INJURY $ (Ea Accident) HIRED AUTOS PROPERTY DAMAGE $ NON-OWNDED AUTOS (Ea Accident) (UMBRELLA F—] OCCUREACH OCCURRENCE $ LIABILITY '.. EXCESS LIAR❑ CLAIMS MADE AGGREGATE $ DEDUCTIBLE El 1-1 $ $ RETENTION $ WORKERS COMPENSATION AND WCV00951304 03/04/2015 03/04/2016 X Fs—TA TUTORY OTHER A EMPLOYERS'LIABILITY LIMITS ANY PROPRIETORIPARTNEWEXECUTIVE YIN OFFICER/MEMBER EXCLUDED? NIA ❑ Policy Coverage.State:NIA EACH ACCIDENT $ 1,000,000 Mandatory in NH Ifyes,describe under SPECIAL PROVISIONS below DISEASE-POLICY LIMIT $ 1,000,000 DISEASE-EACH EMPLOYEE $ 1,000,000 OTHER ❑❑ '.. DESCRIPTION OF OPERATIONSILOCATION9NEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) '.. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town Of North Andover EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL WRITTEN12 DAYS 1600 Osgood Street BUT FAILURETo DO SO SHALL IIEFT. IMPOSE NO OBLIGATION OR LIABILITY North Andover,MA 01845 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. UTHORIZED REPRESENTATIVE ACORD 25(2009109) Page 1 of 1 CERTIFICATE HOLDER COPY ©1988.2009 ACORD CORPORATION.All rights reserved. Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-105187 Construction Supervisor MARK J YANOWITZ ONE ELM SQUARE ANDOVER MA 0,1810 I Expiration: Commissioner 07/11/2017