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Miscellaneous - 9 Peachtree Ln (Lot 1)
WE IJJI Date.... f ! TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......1..!.. ....�d.. .�....................................................................... has permission to perform ....................,..?,-.................................................................... plumbing in the buildings of .......�/!���.�..... �!� .............................................. at.............................................. Feey�..�.- ?.............. Lic. No 01 S/. Check # ........................................................ North Andover, Mass. ..............................................:........................................ PILI JIBING INSPECTOR f Date ............................................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........... Q���.. �!.............................................................. has permission for gas installation .... /i....................................................................... in the buildings of .............q ................................................................................ at.................................................................................................. North Andover, Mass. Fee /66..-... Lic. No. Check # ........................................... `GAS�NSPECTOR (/ r FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFJOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER -dT—HER F INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JUNO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY N-1 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 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE #VSIGNATURE IMPMGF El JP [3 JG F 0 LPGI CORPORATION # PARTNERSHIP 0 #E LT LLC [J# COMPANY NAME: 1,71',� 1g_0 ADDRESS CITY 11 STATE ZIP d TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE =3L-2hj6j'j PERMIT JOBSITE ADDRESS X11 OWNER'S NAME GOWNER ADDRESS TEL FAX j TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Mf CLEARLY NEW.14. RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES F] NOD APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I DRYER FIREPLACE J FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFJOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER -dT—HER F INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JUNO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY N-1 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 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE #VSIGNATURE IMPMGF El JP [3 JG F 0 LPGI CORPORATION # PARTNERSHIP 0 #E LT LLC [J# COMPANY NAME: 1,71',� 1g_0 ADDRESS CITY 11 STATE ZIP d TEL FAX CELL EMAIL z O U W W o F1 z O yrl W } � W [Oi pw Z w W F- CC� U) W 5 a O LLI L �+ w w N a 0 a a a J H a a � a x w H zz 0 U P-( c�7 G� s 1 The Commonwealth of Massachusetts Department ofIndustrial Accidents I Congress Street, Suite 100 Boston, HA. 02114-2017 uq� www mass.gov/dia �M Sys workers' Compensation insurance Affidavit: Builders/Cont�ractors/Electricians/Plum ers. TO BE FI[.ED WITH THE FERMITT1NG AUTHOR1T Y. �- -- I Name Business/Organization/fndividual): Address: City/State/Zip: V /( Phone #: U1 Are you an employer? Check the appropriate box: J.V I am a employer _.employees (full and/or part-time).* 2I am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3.E] 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 ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.Q I am a general contractor` and I have hired the sub -contractors listed on the attached sheet. ees and have workers' comp. insurance.t These sub -contractors have employ y 6. Q 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.] Wfal Type of project (required): 7. ❑ New'construction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repays or additions 12. , .Plumbing repairs or additions 13•. [M] Ro6f repairs 14.n Other *Arty applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such i onfreo wn that check this box must attached an additional sheet showing the name of the sub -contractors and state whether c r not those entities have employees. If the sub -contractors have employees, They must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. O Insurance Company Name: rk Expiration Date, Policy # or Self -ins. Lic. #: . City/State/Zip: .,sgza a A �rr_ Job Site Address: 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 e. 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 WORD 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 luvestigations of the DIA for insurance coverage verification. Ido hereby certify un a pains and penalties ofperjury that the information provided above is true and correct. Of use only. Do not write in this area, to he completed by city or town official. City or Town: permit/License Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone i Information and Instructions 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 hife, 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 ofthe foregoing engaged in a joint enferprise, 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 ofthe 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(1) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. B e advised that this affidavit 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' compensatioii policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [y NO _( IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ( ` OTHER TYPE OF INDEMNITY © BOND Mi 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 Q AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ert' provision of the 1Massachusetts State Plumbing Code and Cha ter 142 of the General Laws. PLUMBER'S NAME—.—.m-_.._. IiLICENSE # SIGNATURE IMP Ex JP Q CORPORATION 0# i PARTNERSHIP Q# LLC X11 COMPANY NAME Tryj n�i� p (J j u& ; ADDRESS I/'✓�l�n ��� %Y I A �� ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY MA DATE Q PERMIT # JOBSITE ADDRESS�� OWNER'S NAME q ADDRESS TELIFAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL( NEW: IqRENOVATION: D REPLACEMENT: 0 PLANS SUBMITTED: YES ® NOF( FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBJ= CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM { ( ; ( { ! I -_.._. i DEDICATED WATER RECYCLE SYSTEM (_..._.._..I ._._.__._( DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY _ 211 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK _ __.( ( _..__._._.J J _— J __. _._I TOILET INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [y NO _( IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ( ` OTHER TYPE OF INDEMNITY © BOND Mi 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 Q AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ert' provision of the 1Massachusetts State Plumbing Code and Cha ter 142 of the General Laws. PLUMBER'S NAME—.—.m-_.._. IiLICENSE # SIGNATURE IMP Ex JP Q CORPORATION 0# i PARTNERSHIP Q# LLC X11 COMPANY NAME Tryj n�i� p (J j u& ; ADDRESS I/'✓�l�n ��� %Y I A �� ' o z W 0 - The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA. 02114-2017 www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/�lumbers. TO BE FILED WITH THE PERMITTING AUTHORITY- Name, (Business/Orgai&ation/Individual): Address: / U City/State/Zip A �Okhone #: Are you an employer? Check the appropriate box: i. I am a employer with_employees (frill and/or part-time).* 2.ij I am a sole proprietor or partnership and have no employees working forme in any capacity. [No workers' comp, insurance required] 3.0 lam 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. 1 will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractorand I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.T 6.n We are a corporation and itsofficers 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); 7. ❑ N6*'constr6d lon 8. (] Remodeling 9. ❑ Demolition 10 [] Building addition 11.0 Electrical repays or additions 12 =l ing repairs or additions 11E] Ro6f repairs 14.[] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy Other ------ information'. Homeowners who su, i.. is 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 attache int 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. g workers' compensation insurance for my employees. Below is the policy and job site X am an employer that is providin information. Insurance Company Name: v Expiration Date: Policy # or Self -ins. Lic. #: Job Site Address: 1 � �, �City/State/Zip: Attach a copy of the vc�oxkers' compensation policy declaration page (sho ing the policy number and expiration date). lat on Failure to secure coverage as required under rM enalties in the form of25A is a aSTOPnal zWO1RK ORDERIand fine of up to $250.00 a and/or one-year imprisonment, as p day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X cern er the pains and penalties of perjury that the information provided jabove is true and correct do hereby . in this area, to he completed by city or town official. Official use only. Do not write l. 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 Phone Contact Person: ♦- 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 hv're, 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 enierprise, and including the legal representatives of a deceased employer, or the receiver'& 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 b6 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 regitiired." Additionally, MGL chapter 152, §25C('1) 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 ofthis chapter have been presented to the contracting authority." Applicants Pleasb 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 certificates) 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 (ifnecessary) and under "Job Site Address" the applicant should write •"all locations in(city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date.. v.. �.................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. ........... .................................... ..-- has permission to perform............-^...........i....s--4—..................................... wiring in the building of........... ../.fit.. ..... �z` ....................................................................... at....�........1�...... ....P..C.k ....�.................... North Andover, Mass. Fee...er.3%............. Lic. No, -2 -LVW .................................................................................. p� ELECTRICAL INSPECTOR Check # �� O 17�,j,; �y,�--- Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. /-Z r7 3s j Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL )NFORMATION) Bate: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her Al,intention to perform the electrical work described below. Location (Street & Number) 9 P,V eh l r -e E 1 /v )a7-0--' a%-0 .� Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .4p ry i Cr- JA 11 P h v& h d Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Xn i r, 1" t 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- ❑ rnd. grnd. o. o mergency ig ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No, of Zones No. of Switches No. of Gas Burgers No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number � � _...... Tons �������������� KW .................. No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local FJ Connection El Other Connection No. of Dryers Heating Appliances KW Security S stems:* No. of �evices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: t/ 3 V mow_\ (v r -- Attach additional detail 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. 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 cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I'certify, cinder th�ep�p i.ns and penalties o perjury, that the information on this application is true and complete. FIRM NAME:�-- : I'+ai I r' c 1Lec lin`C—u C. :�erry i r e 5 LIC. NO.: Z / ti V A Licensee: h k6rt SignatureT f' � `� LIC. NO.: N4 (If applicable,ter "exempt" in the license number lin .) Bus. Tel. No.:Q 7 T'Ll Address: „ , An '.4-1 0 i Z— S c"7[? t,,, 00 2 0 3 0 7 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and maybe deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Id Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPE ION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: 0, �-- Date: FINAL INSPE ION: Pass M V Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 'J The Commonwealth of Massachusetts Department ofIndustrialA.Ccidents r X Congress Street, Suite 100 Boston, MA. 02114-2017 www mass.gov/dia o�M sv�V • Workers!, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbexs. TO BE FILED WITH THE PERMITTING AU I gORTi Y - TO v.:,,+ i Name (Business/Orgat&ation/Individual):. Address: r_ City/State/Zip: §Ct" , .Are you an employer? Check the appropriate box: Type of project (required): m to ees (full and/or pari time). 7. F1No VV d6nstrikion l.Wam a employer with P y 2. ❑ Iain a sole proprietor or partnership and have no employees Working forme in $. Remo deliiig any capacity. [No workers' comp. insurance required.] 9. DemolitiOn 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 ❑ Budding addition 4.❑ lam a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or aze sole 11.0 Electrical repairs or additions proprietors with no employees. 12 4Q.PJUrrlb3flg repairs or additions 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet 11 Q R06f repairs These sub -contractors have employees and have workers' comp. insurance.t 14 Other 6. ❑ We are a corporatiori and its. officers have exercised their right of exemption per MGL c. 152, §1(4), and We have no empldyees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those •entities, have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. workers' compensation insurance for my employees. X am an employer that is providing ?3elow is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: City/State/Zip: Job Site Address: 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 e. 152, §25A is a criminal violation punishable by a foie 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 veri covfication. ovhereby certify- under tlae pains and penalties ofperjury that the information provided above is true and correct Dat,.5 0 J 5 1J1 11tLLLLL V. Phone #: -_ 4 / l( 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact w Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for theiremployees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hit e, 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 receiv6for trustee 6fan 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 occiipaui 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 xequiired." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) name(s), address(es) and phone number(s) along with their certificates) 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 -insura'nc'e license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of"the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia • TH OF MASSACHUSETTS,-, C) A ® o N n A O v' O r C, T y 11 A A z d o y m m m It v „ v 3 a a a -o m A � � N 3 o y o C x CD x CD x IT w o w y N W N O N Z N N N � G O o w y 7 n �, x x x t'l a z y m � m O Mc,tz c, P Q A c�—D pr w < < < aqA O In rA rte+ J H 01 O O\ O RO tlQ OQ Ocn O \O mGO) m G m E d v b W � c K U Go) rn J 00 00 n A d d ti w Gn Gm ,� C1 a � O.y 6n J F O O J 01 Ui VWi --1 3t _. O O W W j cV Date � �.�� � �? .�..�...... . HORTp TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION a 1 +` S This certifies that ..``1 S ' t.. L .....t .... . has permission for mechanical installationPl-�.,:4�1.14 � .(..l. �/r" � in the buildings of : !.. �� � 6.71 ee,K- ..................... . atL:.. ........ , North Andover, Mass. Fee . )0. —7. Lic. No. � .---�:� ......... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer A 6 Commonwealth of Massachusetts Sheet Metal Permit Date: 3b S Estimated Job Cost: I a� o c> Plans Submitted: YES NO --)4 Business License # q 6 0 Permit # Permit Fee: $ ,� Plans Reviewed: YES _ Applicant License # C- -71 NO Business Information: Property Owner / Job Location Information: Name: CASWQI/ �►,acl ,+c4 Name: 5eWdrq 4- /ItiCdC. t -fa ir. Street: 3 ir,4 rd %) n if l? Street: 9 PAC4 4, -el, �•, s r -d City/Town: /l)��1 ��ry ,Qoc �- City/Town: Afe ,tel welndd,� Telephone: `171— 4 8 7'W 3 Telephone: '"17j ' 3b AY e 5 Photo I.D. required /.Copy of Photo I.D. attached: YES NO Building Type: Residential: 1-2 family ✓ Multi -family Condo / Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. ✓ over 35,000 cu. ft. Sheet metal work to be completed: New Work: ✓ Renovation: HVAC ✓ Metal Roofing Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: C fra'nsice lJ� t h, L, - -ta-va- I.5 /' t' Vol i i kq - I w INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes j'E"1'-No ❑ If you have checked Yes, indicate th type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box[], I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Progress Inspections Comments Final Inspection Date Comments T,y.,,pee of License: By_p [' aster Title \/ ❑ Master -Restricted City/Town Permit # ❑Journeyperson Signature of Licensee ElLicense Number: Fee $ Check at www.mass.gov/dpi Inspector Signature of Permit Approval Yes No V/ V Sheet Metal Residential Guidelines / Inspection Checklist N/A JDetailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", l maximum flexible run 8'-0" Flexible duct runs installed I4'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) ✓ Testing and Balancing report complete (final sign -off Sheet Metal Commercial Guidelines / Life Safety / Critical Systems Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampers with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) Grease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper c1dj`ances, fire rated enclosures and pressure testing required. f;�i . reN,.«ints instal hr3i :tdr quirecl on equipment and du:. v. Jr Duct penetrations in fh-e'idtcx itJall:r and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct nins installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -off) I r. The Commonwealth of Massachusetts . Department of IndustrialAccidents I Congress Street, Suite 100 ' Boston, AM 02114-2017 www .mass.goh/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legitbly Name (Business/Organization/Individual): C a 5 W e 1l M e C 0o ✓1 CcfL Address: 3 6 Rq f 9\ D uk "' 6 City/State/Zip: IV ew 9 u R i P0vT M A o q5 Phone #: 70 4 � a 07 0 � -- Are you an employer? Check the appropriate box: Type of project (required): l.Vam a employer with employees (full and/or part-time).* %. @-geW 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. El Demolition 3.. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole I L ❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. instrance.t 13.0 Roof repairs 6. ❑ 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.] 14.[_ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' ..below is the policy and job site information. Insurance Company Name: Q•evK Sh -'Yz hn1ti0wgY Gco- vl5u `�"1C� Policy # or Self -ins. Lic. #: C: /� W C S `6 5 � `(7 I Expiration Date: gc ` Job Site Address: l p f- l tye-t �C1 v wl5 "A 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 MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unller the pains and penalties ofperjury that the information provided above is true and correct. �, a JT 15 V7 r q �k.,A6 7�r3 . 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 #: +wrightsofta Duct System Summary AIH IST FLOOR For: PEACHTREE FARM, CASWELL MECHANICAL LOT 3, NORTH ANDOVER, MA Job: Date: May 27, 2015 By: Supply Branch Detail Table Name Heating Cooling External static pressure 1.00 in H2O 1.00 in H2O Pressure losses 0.31 in H2O 0.31 in H2O Available static pressure 0.69 in H2O 0.69 in H2O Supply / return available pressure 0.299 / 0.391 in H2O 0.299 / 0.391 in H2O Lowest friction rate 0.136 in/ 100ft 0.136 in/100ft Actual air flow 1172 cfm 1172 cfm Total effective length (TEL) LAV 506 ft Supply Branch Detail Table Name Design (Btuh) Htg (cfm) Clg (cfm) Design FR Diam (in) H x W (in) Duct Matl Actual Ln (ft) Ftg.Egv Ln (ft) Trunk LAUND c 1081 53 54 0.146 5.0 Ox 0 VIFx 29.5 175.0 st11 LAV h 533 21 4 0.136 4.0 Ox 0 VIFx 34.0 185.0 st11 KIT(DIN-A c 3097 125 155 0.190 7.0 Oxo VIFx 42.0 115.0 st8 KFUDIN c 3097 125 155 0.345 7.0 Ox 0 VIFx 11.5 75.0 0.178 MUD h 2046 83 27 0.197 6.0 Ox 0 VIFx 36.5 115.0 st7 GREAT RM -A c 3322 128 166 0.186 8.0 0x0 VIFx 20.5 140.0 st6 GREATRM c 3322 128 166 0.396 7.0 Oxo VIFx 10.5 65.0 M.BED h 2028 82 55 0.177 6.0 Ox 0 VIFx 23.5 145.0 st3 M.BED-A h 2028 82 55 0.180 6.0 Ox 0 VIFx 36.0 130.0 st6 WWIC h 499 20 4 0.178 4.0 Ox 0 VIFx 42.5 125.0 st7 M.BATH h 2438 98 55 0.191 6.0 Ox 0 VIFx 51.0 105.0 st8 DEN -A c 4275 159 213 0.197 8.0 Ox 0 VIFx 46.5 105.0 st8 FOYER h 1683 68 62 0.188 5.0 Ox 0 ShMt 28.5 130.0 st8 Supply Trunk Detail Table Boldritalic values have been manually overridden 2015 -Oct -05 09:34:04 �.wri htsofty Right -Suite® Universal 201515.0.15 RSUD2044 Page 1 ACCP rrients\WrightsoftHVAC\CASWELL-LOT3PEACHTREE.rup Calc =MJ8 Front Door faces: N Trunk Htg Clg Design Veloc Diam H x W Duct Name Type (cfm) (cfm) FR (fpm) (in) (in) Material Trunk st11 Peak AVF 75 58 0.136 280 7.0 0 x 0 ShtMetl st3 st3 Peak AVF 919 851 0.136 919 14.0 8 x 18 ShtMetl st6 Peak AVF 762 738 0.178 0 13.0 8 x 0 ShtMetl st3 st7 Peak AVF 552 516 0.178 710 13.0 8 x 14 ShtMetl st6 st8 Peak AVF 450 485 0.188 727 10.0 8 x 12 ShtMetl st7 Boldritalic values have been manually overridden 2015 -Oct -05 09:34:04 �.wri htsofty Right -Suite® Universal 201515.0.15 RSUD2044 Page 1 ACCP rrients\WrightsoftHVAC\CASWELL-LOT3PEACHTREE.rup Calc =MJ8 Front Door faces: N Name Grill Size (in) Htg (cfm) Clg (cfm) TEL (ft) Design FR Veloc (fpm) Diam (in) H x W (in) Stud/Joist Opening (in) Duct Matl Trunk rb5 Oxo 150 117 287.0 0.136 429 8.0 Ox 0 Peak AVF VIFx rt5 rb4 Ox 0 118 59 223.0 0.175 339 8.0 Ox 0 370 VIFx rt5 rb3 Ox 0 211 193 217.0 0.180 604 8.0 Ox 0 972 VIFx rt4 rb11 Ox 0 253 321 182.0 0.215 918 8.0 Ox 0 8 x 20 VIFx rt3 rb6 Ox 0 241 269 123.5 0.317 770 8.0 Ox 0 VIFx rt3 rb2 0x0 2001 213 92.0 0.425 610 8.0 Ox 0 VIFx rt1 Boldrrtalic values have been manually overridden Wil IItSOft 2015 -Oct -0509:34:04 � 9 Right -Suite® Universal 2015 15.0.15 RSU02044 Page 2 ACOA...ments\WrightsoftHVAC\CASWELL-LOT3PEACKMEE.rup Calc=MJ8 FrontDooriaces: N Trunk Htg Clg Design Veloc Diam H x W Duct Name Type (cfm) (cfm) FR (fpm) (in) (in) Material Trunk rt5 Peak AVF 268 176 0.136 482 14.0 8 x 10 ShtMetl rt4 rt4 Peak AVF 479 370 0.136 718 14.0 8 x 12 ShtMetl rt3 rt3 Peak AVF 972 959 0.136 972 8.0 8 x 18 ShtMetl rt1 rt1 Peak AVF 1172 1172 0.136 1055 18.0 8 x 20 ShtMetl Boldrrtalic values have been manually overridden Wil IItSOft 2015 -Oct -0509:34:04 � 9 Right -Suite® Universal 2015 15.0.15 RSU02044 Page 2 ACOA...ments\WrightsoftHVAC\CASWELL-LOT3PEACKMEE.rup Calc=MJ8 FrontDooriaces: N --•wrightsoft° Duct System Summary AIH 2ND FLOOR For: PEACHTREE FARM, CASWELL MECHANICAL LOT 3, NORTH ANDOVER, MA External static pressure Pressure losses Available static pressure Supply / return available pressure Lowest friction rate Actual air flow Total effective length (TEL) Heating 1.00 in H2O 0.36 in H2O 0.64 in H2O 0.310 / 0.330 in H2O 0.130 in/ 1 00f 739 cfm Job: Date: May 27, 2015 By: Cooling 1.00 in H2O 0.36 in H2O 0.64 in H2O 0.310 / 0.330 in H2O 0.130 in/ 1 00f 739 cfm 494 ft Name Design (Btuh) Htg (cfm) Clg (cfm) Design FR Diam (in) H x W (in) Duct Matl Actual Ln (ft) Ftg.Egv Ln (ft) Trunk BONUS -A h 4220 123 104 0.130 6.0 Ox 0 ShMt 44.0 195.0 st13 BONUS h 4220 123 104 0.130 6.0 Ox 0 ShMt 44.0 195.0 st14 BATH 1 h 857 25 23 0.130 4.0 Ox 0 ShMt 44.0 195.0 st13 WIC2 h 664 19 6 0.130 4.0 Oxo VIFx 44.0 195.0 st15 BATH h 2298 67 34 0.130 6.0 Oxo VIFx 44.0 195.0 st15 BED RM 2 c 2240 88 95 0.130 7.0 Ox 0 VIFx 44.0 195.0 st5 BEDRM3 c 2796 85 118 0.130 7.0 Oxo VIFx 44.0 195.0 st4 LOFT -A c 1471 53 62 0.130 6.0 Oxo VIFx 44.0 195.0 st4 LOFr-C c 1471 53 62 0.130 6.0 Ox 0 VIFx 44.0 195.0 st5 BEDRM4 c 3131 103 132 0.130 8.0 Oxo VIFx 44.0 195.0 st4 BolcVitalic values have been manually overridden r' wrightsoft' Right -Suite® Universal 201515.0.15 RSU02044 ACCP ...ments\WrightsoftHVAC\CASWELL-LOT3PEACHTREE.rup Calc=W8 FrontDoorfaces: N 2015 -Oct -05 09:34:04 Page 3 Trunk Htg Clg Design Veloc Diam H x W Duct Name Type (cfm) (cfm) FR (fpm) (in) (in) Material Trunk st4 Peak AVF 512 543 0.130 691 12.0 0 x 0 ShtMetl st5 Peak AVF 227 197 0.130 289 12.0 0 x 0 ShtMetl st15 Peak AVF 87 40 0.130 248 8.0 0 x 0 ShtMetl st5 st13 Peak AVF 272 230 0.130 499 10.0 0 x 0 ShtMetl st4 st14 Peak AVF 123 104 0.130 226 10.0 0 x 0 ShtMetl st13 BolcVitalic values have been manually overridden r' wrightsoft' Right -Suite® Universal 201515.0.15 RSU02044 ACCP ...ments\WrightsoftHVAC\CASWELL-LOT3PEACHTREE.rup Calc=W8 FrontDoorfaces: N 2015 -Oct -05 09:34:04 Page 3 Return Branch Detail Table Boic0talic values have been manually ovenidden 2015 -Oct -05 09:34:04 wrightSOW Right -Suite® Universal 2015 15.0.15 RSU02044 Page4 RCCA ...ments\Wrightsoft HVAC\CASWELL-LOT3PEACFF REE.rup Calc= MA Front Door faces: N Grill Htg Clg TEL Design Veloc Diam H x W Stud/Joist Duct Type Name Size (in) (cfm) (cfm) (ft) FR (fpm) (in) (in) Opening (in) Matl Trunk rb9 Ox 0 149 126 254.9 0.130 425 8.0 Ox 0 126 VIFx rt7 rb1 Ox 0 155 128 254.9 0.130 444 8.0 Ox 0 692 VIFx rt2 rb8 Ox 0 226 236 254.9 0.130 676 8.0 Ox 0 VIFx rt6 rb7 Ox 0 72 68 254.9 0.130 132 10.0 Ox 0 VIFx rt2 rb10 Ox 0 138 180 254.9 0.130 517 8.0 Ox 0 VIFx rt6 Boic0talic values have been manually ovenidden 2015 -Oct -05 09:34:04 wrightSOW Right -Suite® Universal 2015 15.0.15 RSU02044 Page4 RCCA ...ments\Wrightsoft HVAC\CASWELL-LOT3PEACFF REE.rup Calc= MA Front Door faces: N Trunk Htg Clg Design Veloc Diam H x W Duct Name Type (cfm) (cfm) FR (fpm) (in) (in) Material Trunk rt6 Peak AVF 512 543 0.130 691 12.0 0 x 0 ShtMetl rt2 rt7 Peak AVF 149 126 0.130 272 10.0 0 x 0 ShtMetl rt6 rt2 Peak AVF 739 739 0.130 692 14.0 0 x 0 ShtMetl Boic0talic values have been manually ovenidden 2015 -Oct -05 09:34:04 wrightSOW Right -Suite® Universal 2015 15.0.15 RSU02044 Page4 RCCA ...ments\Wrightsoft HVAC\CASWELL-LOT3PEACFF REE.rup Calc= MA Front Door faces: N oar 66MBEW&_, 57`15k ISSUES T," FOLLOW rt Rt"b AS A PLI t i_Jl'E..F.FRfY B CAS4E&' fi V"'C'KSW&LL PVEC#xCAI -INC [�,GRAF UNIT YPORT ._,MA 01950- 6 MAW— '.` &USETTS; State of New Hampshire =1 I W " ljwj3m� GAS FITTERS LICENSE VF L WORKERS NAME: JEFFREY CASWE-tt L WING :tIt E N S E, U RESTRICTED ENDORSEMENTS: STN, STP DATE ISSUED: 03/05/2013 DATE EXPIRES: 03/3112015 LICENSE #:GFE0802900 gi 0-460111`1' 183603 A sffi SAMR012 0 HAIIIIIIIIISIV 0.1"Z;"'lt AUREAUPF BUILDING DING I SAFETY,& C6NSf R-'U'CTIOU, {''CENSE: PLUMBING SAFETY SECTION ESS NAME: JEFFREY B CASWELL l ui. LIC 4671 M iz .- EXPIRES: 03/31/2015 L v" � � FE MAW— '.` &USETTS; State of New Hampshire =1 I W " ljwj3m� GAS FITTERS LICENSE VF L WORKERS NAME: JEFFREY CASWE-tt L WING :tIt E N S E, U RESTRICTED ENDORSEMENTS: STN, STP DATE ISSUED: 03/05/2013 DATE EXPIRES: 03/3112015 LICENSE #:GFE0802900 gi 0-460111`1' 183603 A sffi SAMR012 0 HAIIIIIIIIISIV BOARD F PLUMBER -'�ZAN:,05- GASF I,TTERS, is SUES THE FOLL ENSE EN AS A MWA,STER PLUMBER I NG CORP .- B CASWE�L -A 3 GRW1W. ',-460� j**0RT M 0 1950 6 785 ', 99 A,- 154 50 ;..199786 STATE OF MAINE DEPT OF PROFESSIONAL & FINANCIAL REGULATION PLUMBERS EXAMINING BOARD LICENSE # MS 0014390 JEFFREY B. CASWE LL LICENSED MASTER PLUMBER ISSUED Apr 0l,2014 EXPIRES M601,2016 f - wrightsoft° Load Short Form AIH 2ND FLOOR For. PEACHTREE FARM, CASWELL MECHANICAL LOT 3, NORTH ANDOVER, MA Job: Date: May 27, 2015 By: Htg Clg Infiltration Outside db (°F) 2 88 Method Simplified Inside db (°F) 70 74 Construction quality Tight Design TD (°F) 68 14 Fireplaces 1 (Average) Daily range - L Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 30 HEATING EQUIPMENT Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 95AFUE 0 Btuh 0 Btuh 0 OF 913 cfm 0.035 cfm/Btuh 0 in H2O COOLING EQUIPMENT Make Heil Trade HEIL Cond N4A330A(G)KC` Coil ENH4X36L17"*++TDR AHRI ref 6415880 Efficiency 10.5 EER, 13 SEER Htg load (Btuh) Sensible cooling 23290 Btuh Latent cooling 4110 Btuh Total cooling 27400 Btuh Actual air flow 913 cfm Air flow factor 0.050 cfm/Btuh Static pressure 0 in H2O Load sensible heat ratio 0.87 126 ROOM NAME Calculations Area (ftp Htg load (Btuh) Clg load (Btuh) Htg AVF (cfm) Clg AVF (cfm) BONUS 333 8786 5128 304 255 BATH 1 53 891 563 31 28 BED RM 4 182 3654 3278 126 163 WIC2 27 688 154 24 8 BATH 2 88 2441 850 84 42 t BED RM 2 170 3122 2345 108 117 1 BED RM 3 210 3024 2927 105 146 I !\CT/U A l l A -7G 4774 OA07 4-'14 c w 4— Calculations approved byACCA to meet all requirements of Manual J 8th Ed. �. wrightsoft" Right-Suke® Universal 2015 15.0.15 RSU02044 2015 -May -28 1Pag 45 Page 4 ACC%...ments\WrightsoftHVACtCASWELL-LOT3PEACHTREE.rup Calc=MJ8 FrontDoorfaces: N A/H 2ND FLOOR d 1537 26379 18331 913 913 Other equip loads 5661 1137 Equip. @ 1.00 RSM 19469 Latent cooling 2891 Tf1TA I C 4 c47 '30fnen nn a nn V1/ "L 1JJI JLJYv LLJVv 01J X710 Calculations approved byACCA to meet all requirements of Manual J 8th Ed .. wrightsoft'" Right -Suite® Universal 201515.0.15 RSW2044 2015 -May -28 1Page 5 z Page 5 ACCP...ments\WrightsoftFNAC\CASWELL-LOT3PEACHREE.rup Calc=MA FrontDoorfaoes: N - - w' rightsoft® Load Short Form Entire House Job: Date: May 27, 2015 By: For. PEACHTREE FARM, CASWELL MECHANICAL LOT 3, NORTH ANDOVER, MA HEATING EQUIPMENT Htg Clg Outside db (°F) 2 88 Inside db (°F) 70 74 Design TD (°F) 68 14 Daily range - L Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 30 HEATING EQUIPMENT n/a Make n/a Sensible cooling 0 Trade n/a Latent cooling 0 Model n/a Total cooling 0 AHRI ref n/a Actual air flow 0 Efficiency n/a 0 Heating input Static pressure 0 Heating output 0 Btuh Temperature rise 0 OF Actual air flow 0 cfm Air flow factor 0 cfm/Btuh Static pressure 0 in H2O Space thermostat n/a Infiltration Method Construction quality Fireplaces Simplified Tight 1 (Average) COOLING EQUIPMENT Make n/a Trade n/a Cond n/a Coil n/a AHRI ref n/a Efficiency n/a Htg load Sensible cooling 0 Btuh Latent cooling 0 Btuh Total cooling 0 Btuh Actual air flow 0 cfm Air flow factor 0 cfm/Btuh Static pressure 0 in H2O Load sensible heat ratio 0 913 ROOM NAME Area Htg load Clg load Htg AVF ClgAVF (ftp (Btuh) (Btuh) (cfm) (cfm) A/H 1ST FLOOR d 1734 28619 23240 1133 1133 A/H 2ND FLOOR d 1537 26379 18331 913 913 Entire House d 3271 54998 41102 2046 2046 Other equip loads 10646 2139 Equip. @ 1.00 RSM 43241 Latent cooling 4009 -r^-rA 1 C- I nn -74 CCCAA A7n LA nAAC nn A!_n Calculations approved byACCA to meet all requirements of Manual J 8th Ed. wri htsoft" 2015 -May -2s 11:44:45 ,1� Page 1 9 Right -Suite® universal 201515.0.15 RSU02044 ACCh ...ments\WrightsoftWAC\CASWELL-LOT3PEACFrREE.rup Calc=MJ8 FrontDoorfaces: N Level 3 Job #: Performed for: PEACHTREE FARM LOT 3 NORTH ANDOVER, MA Scale: 3/32" = TO" Page 3 Right -Suite® Universal 2015 15.0.15 RSU02044 2015 -May -28 11:45:00 t HVAC\CASWELL-LOT3PEACH. Level 2 Job #: Performed for: PEACHTREE FARM LOT 3 NORTH ANDOVER, MA Scale: 3/32" = 1'0" Page 2 Right -Suite® Universal 2015 15.0.15 RSU02044 2015 -May -28 11:45:00 t HVAC\CASWELL-LOT3PEACH.. -- wrightsoft® Load Short Form AIH 1ST FLOOR Job: Date: May 27, 2015 By: For. PEACHTREE FARM, CASWELL MECHANICAL LOT 3, NORTH ANDOVER, MA HEATING EQUIPMENT Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 95AFUE 0 Htg Clg Outside db (°F) 2 88 Inside db (°F) 70 74 Design TD (°F) 68 14 Daily range - L Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 30 HEATING EQUIPMENT Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 95AFUE 0 Btuh 0 Btuh 0 OF 1133 cfm 0.040 cfm/Btuh 0 in H2O Infiltration Method Construction quality Fireplaces Simplified Tight 1 (Average) COOLING EQUIPMENT Make Heil Trade HEIL Cond N4A336A(G)KB3 Coil EN(A,D,W)4X42L21""++TDR AHRI ref 6416970 Efficiency 11.0 EER, 13 SEER Htg load (Btuh) Sensible cooling 28900 Btuh Latent cooling 5100 Btuh Total cooling 34000 Btuh Actual air flow 1133 cfm Air flow factor 0.049 cfm/Btuh Static pressure 0 in H2O Load sensible heat ratio 0.86 241 ROOM NAME Area (ftp Htg load (Btuh) Clg load (Btuh) Htg AVF (cfm) CIgAVF (cfm) LAU N D 52 1300 1075 51 52 LAV 28 523 86 21 4 KIT/DIN 466 6088 6161 241 300 MUD 56 2019 546 80 27 1 GREAT RM 320 6292 6617 249 323 1 M. B E D 228 3965 2098 157 102 M.WIC 54 489 80 19 4 M.BATH 120 2398 1090 95 53 DEN r-/1Vr1r] 200 non 3882 4-1-10 4252 4nOC 154 GG 207 GA Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. wri htsoftPo 2015 -May -2811:44:45 9 Right-Sufte® Universal 201515.0.15 RSU02044 Page 2 /CCA...mentsWrightsoftWAOCASWELL-LOT3PEACHTREE.rup Calc =MJ8 Front Door faces: N A/H' 1ST FLOOR d 1734 28619 23240 1133 1133 Other equip loads 4986 1002 Equip. @ 1.00 RSM 24242 Latent cooling 4023 TIITAI t% 477A 77G/1A 7o7GG 441" 4411) V IP1LQ 1 I J7 JJVV7 LVLVJ 1 1 JJ 1 1 JJ Calculations approved byACCA to meet all requirements of Manual J 8th Ed. Wrht$Oft^ 2015 -May -2811:44:45 l ^ti 9 Right -Suite® Universal 201515.0.15 RSLI02044 Page 3 ACC%...ments\WrightsoftWAC\CASWELL-LOT3PEACHTREE.rup Calc=MJ8 FrontDoorfaces: N Level 1 Job #: Performed for: PEACHTREE FARM LOT 3 NORTH ANDOVER, MA Scale: 3/32" = 1'0" Page 1 Right -Suite® Universal 2015 15.0.15 RSU02044 2015 -May -28 11:45:00 A HVAC\CASWELL-LOT3PEACH.. ASW n d(Q 3 Graf Road Unit 8 Newburyport, MA 01960 Name i' Address ! William McKay Construction Mgmt 4 Powdermill Sq. Unit 101 Andover, MA 01810 Estimate Date Estimate # 6/8/2016 2894 Phone: Terms Project Void After 30 Days Peachtree Farm Lot 3 (978)_462-5858 Description Ulm Cost Total The furnishing, fabrication and installation of two gas systems 22,769.00 22,769.00 with air conditioning units setup as one zone each. One serving the first floor and one serving the second floor using Heil equipment as follows: 1st Floor * One Heil 95% efficient single stage furnace model# N9MSE0401712A. * One Heil 13 SEER 3 ton R41 0 -A condenser model # N4A336AKB. * One Heil 3 ton evaporator coil model # END4X36117A. 2nd Floor * One Heil 96% efficient single stage furnace model# N9MSE0401712A. * One Heil 13 SEER 2.5 ton R410 -A condenser model # N4A330AKB. * One Heil 3 ton evaporator coil model #ENM361-17A. This includes two drains to suitable sites, two programmable thermostats. The main supply and return distribution trunk will be galvanized steel, insulated with 2" FSK insulation and sealed per MA code. All branch runs will be insulated fle)oble duct connected to ceiling and floor mounted boots. Also a containment pan with float switch will be installed, which will shut the unit down in the event the pan becomes plugged. Complete less gas piping and wiring. Note: This home was sized as a HERS rated home with a cooling temperature differential of 14 degrees. Phone: Fax: E-mail Web Site (978) 462-8783 (978)_462-5858 jeffacaswelimechanical.com www.ceAvellmechanical.com Page 1 CASWELL. 3 Graf Road Unit 8 Newburyport, MA 01850 I Name / Address i William McKay Construction Mgmt 4 Powdermill Sq. Unit 101 Andover ,MA 01810 Estimate Date Estimate # 6f8f2015 2894 Phone: Terms Project Void After 30 Days Peachtree Farm Lot 3 (978) 462.5858 Description U/M Cosi: Total Note: If the roof is not insulated with the attic space being outside the thermal envelope, the furnace in the attic must be enclosed within an insulated box to prevent condensate from freezing. Base price of plumbing; All waste pipe to be done with schedule 16,000.00 16,000.00 40 PVC pipe. All domestic water to be piped in Pex tube. Showers to be single function. Multiple functions not included in quote. Lavatories to be vanity style. Wall faucets not included in quote. (Please note price does not include fixtures). 4 Toilets. 6 Lavatories. 3 Tubs. 1 Shower. 1 Laundry hook-up. 1 Kitchen sink. 1 Dishwasher. 1 Ice maker. 2 Silcocks. Sparco thermostatic mixing valve if personal shower added to 400.00 400.00 soaking tub. Copper pan allowance for one pan. 550.00 550.00 75 Gallon natural gas power vented water heater. 1,975.00 1„975.00 Gas piping range, water heater, 2 furnaces and fireplace. All 2,500.00 2,500.00 piping schedule 40 steel pipe. l Phone: Fax: E-mail Web Site (978) 462-8783 (978) 462.5858 jeff@caswe[lmechanical.com www.caswellmcchanicai.com Page 2 CAS�VELL 3 Graf Road Unit 8 Newburyport, MA 01950 I Name / Address 1 William McKay Construction Mgmt 4 Powdermill Sq. Unit 101 Andover ,MA 01810 Estimate Date Estimate #� 618x2015 2894 Phone: Terms Project Void After 30 Days Peachtree Farm Lot 3 (978) 462-5858 Description Ulm cost Total Exclusions: Concrete cutting and patching. Cutting and patching of roof. Structural supports. Engineering. Affidavit forms. Meters. Backflow. Taxes. Permits. Electrical wiring. Balance testing and flow reports. I Premium portion over time hours. Prevailing wage. Trenching. Backfilling, Fire stopping. Custom_,er ceptance of Estimate and P edule .� Date LAX }7 QO Phone: Fax: E-mail Web Site (978) 462-8783 (978) 462-5858 jeff,@=welimechanical.com www easwellmechanical.com Page 3 z 0 D�-=i O O Z 0 Z 13 wMCL 2 D � n T N CD 92i;g Cl) 01 n * b�= m racr�j'o r"6wc m OD ooCo�'-+ zwoa 11 �CT0N (f1AAN Q D -4 o_ Scn 21 7— _ O N 3 3 r CD O LE D � co _ ra N o m cu m�.cr®v m OD r— o c ^� Co w M Ia A 0 >-4 o 0 = 25 C, [ - 4 3 OW N O v m z O W m r O s co m 0 � r e� 4� N 0 lI N O v m z O W m r O s I I I N I t I I I' 4; nr. I ox a� 90-4' i 1,8 xq. 1,9)( cOj I 9 � Z f� I I c►? !Y1' c. x I I LI ------------------ --- — ------------------------------ 9._2. I -----------t-- QE • 3m03�� In MM ' M M 4 m DOD 0 3 rn OD 0 rn DDD 9-4 'I ` R'; W \ a Q 03 Z 7Q � 6'=0" II' -0' 6'-2' `''- 5-8' 1:::6!-1 24X 7 Vi --- 00 �-- U, O-r ..O 18'_1• p O w Z o; 8--o- A. 2--7- s o. 8,_0•_cf� -------- -5' 91-6TO w , , 0 r w << > +� 1� r ® Iz r' 0 °7-9 1 6-10 7-1" :`16 2 4 I a 0 I I 1� °kq +1 1 V 7-2 wL 2._0. 6._8. X\ O 1 I ai _..._ D I I �D O ...... . oQ 1 I I NQ �D LL00 I I I I I I I it I I I I I I I I I I I I I W I 0 Z I C I I 70 I 0 I t---- 0O I I 87/32- 3!-45 7/32'3'-4' '-2' I I — WDA 3 A 6' w 2._0. p77 N I7-10. 0 • A N 0 N 8'-10' N 10s I. w I I I I I I i I I I I I I I I I I I I I I I I I I Mffl� ►� 12'-4 3/4' m ca 03 .. 0 0 a TrIs N 15'-9' I F1 Date. TOWN OF NORTH ANDOVER PERMIT FOR WIRIN This certifies that��' has permission to perform .,..� C'e-- wiring in uilding of.......:/,,,,,/�t�L� �L.�', ..... ,� orth Andover, Mass. /A Fee`:.... �........... Lic. No .................. ...........................{/4.................................... .. ELECTRICAL INSPECTOR Check # ��` ht4)s://doc-Os-00-apps-viewer.googieuser... 4 Official Use Only s� Permit No. Occupancy and Fee Checked BOAR© OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE RRIN7"ININK oR ME ALL INFORMATION) Date: 5/8/15 City or Town of: Nnrlh Antinver To the Inspector of Wires: By this application the undersign Ives notice of his or her intention to perforin the electrical work described below. Location (Strect & Number) QQLA Mr. Our. Owner or Tenant Tcl No Owner's Address is this permit in conjunction with a building permit? Yes ® No ❑ (Ch4 Appropriate Box) tit Purpose of Building Dwelling Utility Authorization 110.19391855.-1/ Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters New Service 1 (tft Amps 1 1 / 24( Volts Overhead ❑ Undgrd No. of Meters I Number of Feeders and Ampacity Location and Nature of Proposed Electrical Worst: Tewin Service Completion of the follouine table mat, be xait ed by the Insnector of Wires_ No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) pans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ nd. ❑Baste 0. o mergency Lighting iUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners 0.0 etechon an Initiating Devices No. of Ranges No. of Air Cond, Total Tons No. of Alerting Devices g No. of Waste Disposers eat Pump TZ otals: Number ._............ Tons ................ KW ................ No. o Sei ontamed Detection/Alerting Devices No. of Dishwashers SpacelArea Heating KW Local ❑nmcap 1:1 Other Connection No. of Dryers Heating Appliances Security Systems:* Nob of Devices or Equivalent No. of WaterNo. KW of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wm- -ng: No. of Devices or E uiva-ilent OTHER: Attach additional detail ijdesired, or as required ky the Inspector of Wires. Estimated Value of Electrical Work: NA (When required by municipal policy.) Work to Start: 5/g/1 Inspections to be requested in accordance urith MEC Rule 10, and upon completion. INSURANCE CIVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provi es proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [f BOND ❑ OTHER ❑ (Specify:) Hardord, Travelers 10/2/15 7ifi 1 cer,, under the pains and penalties of pedury, that the information on this application is true and comp e1e. FIRM NAME: LIC. NO.: Licensee: Ronald I Kirk Signature 7VZ t LIC. NO.: (if applicable, enter "exempt"in thelicertse numberfne_) Bus. Tel. No.: 1 Address: 129 Rabbit Rd Salisb Ma. Alt Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, l hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signaturegent Telephone No. PERMIT FEE. $ N Page 1 of 1 2015-05-1109:09 + '1""—. - ELECTRICIANS �� ISSUES THE .FOLLOWING LICENSE JOURNEYMAN ELECTRIYCIAN ' AS A: REG � RONALD J K I RK e, ,l; t ' D: ?® RABBIT RD 01952-1300 SALISBURYMA 07/31/16--x— 57 8-2 0 79913 E -_- lC;r -WSS CHUSETTS DRIVER'S LICENSE END dJ NUUBSP, i3H27AQ13 NONE S94837$47 ,i E(P DM `" 8:2018 00 �u-'i962 ?F' t� a m 1 :. REST i5 SEX M 1tYHGi'J-�� RONALD J 129 RABBIT RD SALISBURY, MA 01952-1300 00.7&1013 Rev07-15-2009 77te Commonwealth of Massachusetts Dqwrftent of Industrial Accidents 1 Congress Street, Suite 100 Boston, J" 02114-2017 www.massgov/dia UV)A,'orkerS7 Compensation Insurance Affidavit: Builders/Contractors/Electricians/Flumbers. To BT FILED wrm THE PER OIT NG AUTHORITY. Applicant Information Please Print I,ezibly Name (Business/Organization/Individual)- Ronald J Kirk Address: 129 Rabbit Rd Salisbury,Ma 01952 City/state/Zip: Salisbury Ma 01952 plwe #.978-423-2591 Are you an employer? Check the appropriate hos: Type of project (required): 1,121 'am a employer with 1 employees (full and/or part timer 7- IJ New Construction 2-Q 1 am a sole proprietor or partnership and have no employees working forme in 8, 0 Remodeling any capacity. [No workers' comp. irks-- required-] 9. ❑ Demolition 3.❑ 1 am ahomeowner doing all work myself. [No workers' comp. insurance required.] t 4.[3 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 $wilding additiop ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. ®plumbing repairs or additions 5-❑ 1 am a general contractor and I have hired the aub-conawtors listed on the attached sheet. 13. hoof repairs Tiuse subcontracts -shave employees and have wot%crs' comp. ipsuranee.t 6. Q Weare a corporation and its officers have exercised their riAt of examaption per MGL c. 14- Other 152, 41(4), and we have no employees. [No workers' comp. insurance required.] `Amy-applicaattharchcckstox #1 must also fill out the section below showing their workml compensation policy information. I Howcownm who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidevit indicating such, tContmctomma that check ttds 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 roast provide their workers' comp- policy number. 1 am an employer that U providing workers' eompensadon insurance for my employees, Below is the policy and job site information. Insurance Company Name_ Travelers Policy # or self ins. Lie. #: 2E52538-5 )Expiration Date: 10/21115 Job site Address: lot 1 Peachtree Ln city/state/zip: North Andover, Ma. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date), Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the ]DIA for insurance coverajte verification. Y do hereby certify under the pains andpenalties efperjury that the information provided above is true and correct. zo , OJIM41 use only. Do not write in this area, to be completed by city or town of wiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Buil ug Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• NQ FD '1040'' Date ... P/ � // TOWN OF NORTH ANDOVER RECEIPT k...�- Thiscertifies that ........................................................................... A 1C)bblb (-SbL'-' e�C- haspaid .................................... ... .... .. . ...................... ................... 0 e .......... .......... for ..*4� .......... ........... ...... ...... Receivedby� --R ..................................................................................... Department ............................ WHITE: Applicant CANARY: Department PINK: Treasurer C'� L —4— HA a co rn 00001* ro vvco 0rn LOLO(D d Z N N N Cl) �U) racy N Z a s m LL c; E O U GI C LL d Z N m �U) racy Y�x