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BP-47632 Permit No. BP-47632nn BUILD;ING/ PERMIT CIS# 7 3462 0 t , w'eo ¢a h a�fr/aM eetf M'ap 0066 TOWN'OF DARTMOUTHr Lots 0042 = 400 Slocum Road,Dartmouth,MA'02747 Sub'-I of u 0000 t - Phone (508)910-1820 •=Fat:(508)910 1838 . ategor$0 ? , -` RLPMR = roject# St-. 'C 8-007-001TS9 . .� PERMISSION IS HEREBY GRANTED To: Est.Cost < $700.00 00 'z` -sT.tee = .' 'See n Contractor: License - Phone#_; „East Class 1'lse Group: d ;"� Engineer. ,t t e, r • ,(,rc'en Phone#� Lot Size(sq.ft') ''"40:679 t ' w,,�- Zoning = SRB t � Applicant .,. "" • Phone#: New Const TWA THOMAS SA FERNANDES .,-fr (508)441-2461 Alt Conssi: Nit -j OwrveR: DateRypedL 01-25407 �. tl FERNANDESTHERESAE IF SST ,` "k DATE ISSUED : TO PERFORM THE FOLLOWING WORK: 'r . ,3 Repair roof line due to fire PER CODE Project Location: 125 REED RI)` Approved/Issued By: °f / '. DAVIDW MATTOS,LOCAL BUIIDING INSPECTOR&ZONING ENFORCEMENT OFFICER All work shall comply with 780 CMR 6ra Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON.COMPLETION OF WORK,FINAL INSPECTION IS REQUIRED. fUIS PERMIT WILL EXPIRE PER 780 CMR 111.8(NOT"MORE THAN 3 EXTENSIONS:WILL BE GRANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY PERMIT. I hereby certify that the proposed work is authorized by the owner of record and-I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met not withstanding the issuance of this Building/Zoning Permit. rs, Signature of Owner/Agent: itMi1 Comments: PERMJT..NUMBERTS'R'EQU1 D WH.,. E N .. ® S/RE--I NSPEcTlON FITES' e .. 'BFPO-) BEFORE .CEIVINGGANOTRER INSP ' {(YN/It . C. ' :G I:. -EQU[ D OF LOST t A'{TI "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service it: Footings: - Underground: Oil: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: -Sewer Service#: Rough Frame:. Insulation: Final: Final: Final: Cross Connection Final: Final _ - Treasury:;' Board of Health E-911 Additional.Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET TOWN_ OF DARTMOUTH ;. / BUIL-E NG RECEIPTS --)1 I N. COLLECTOR'S OFFICE ;t Name -' Property / - Date E= 7 i4. Job Location: ' ' /_ • White Copy-Collectors Office Plot: - t j- Lot: ti / Yellow Copy-Customer's Receipt Li' if t --_ ,/ Pink Copy-File Copy - Green Copy-Building Department Phone t; T �, t e.; ! A ate. i n # At sSSkJE0 — —___ Description + General Ledger#'s - Ref.# / Amount • License&Permits-Building 01000-44105 /%r` / ,{ ,/ t�. ~. G'^J iii License&Permits-Building Misc. 01000-44105 L_ -- License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 DARTMOUI H COLLe I.i v„"- Other Department Revenue 01000-42420 - _ r : k r� This is not a Permit or License for Building;Plumbing or Gas � i Received By: `r ,i - L ?'A' TOWN OF DARTMOUTH Jt . 47 B JIL•,D1NNG RECEIPTS , COLLECTOR'S OFFICE . T, Name: T/..) - �; Property r Date / �, t r I 11 AI ).Z. y2_,.'I aid(' C Owner: i' -L�.- -`G' . , ! C"_i Jji� i���, J Job Location: /::I/ ) / /2'O 6 iG' ,:\-__. White Copy-Collectors Office Plot: i Lot: / Yellow Copy-Customer's Receipt {J Co i .L / PinkCopy-FileCopy Green Copy-Building Department Phone: l erw• sa > Description . G Ref.# /� Amount License&Permits-Building 01000-44105 (f ;; ; , ' License&Permits-Building Misc. 01000-44105 / ' License&Permits-Electrical 01000-44106 \ j License&Permits-Plumbing&Gas 01000-44107 1 Other Department Revenue 01000-42420 le R This is not a Permit or License for Building,Plumbing or Gas Received By: _ 7 1 `' V ❑ SPECIAL PERMIT(Per 780 CMR 111.13) 'I $25.00 APPLICATION LW fin. ON RE-FUNJAOLE & NON-TIIANSFEIIAIILE Qo-MOUTH."'q '',i DATE RECEIVED /��� DARTMOUTH BUILDING DEPARTMENT .,. ' !4(4/ ant 400 Slocum Road, P.O. Box 79399 o x: 37 ` Dartmouth, MA 02747 2• \'?O\R6 j` Phone: 508-910-1820 Fax: 508-910-1838 ' ?L www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY / RECEIVED BY: i�GRS/ QLi� BUILDING PERMIT NUMBER:T 7to3c) - DATE SENT FOR REVIEW: /j r�7to 1 DATE ISSUED: O.K.TO ISSUE SIGNATURE: ,( E/ "ki � DATE: /-s/ 7 Zoning District: J A Proposed Use: f` 17 Zone: III C. O B O A ❑V Aquifer Zone: THE FOLLOWING AGENCIES SHOV/,`D E NOTIFIED: ❑Board of oard of/'" vAD Cons ❑Demo 0 DPW 0 Elec. 0 Energy Report Appeals Hea h / Commission Affidavit Card Sent: Cut Off Follow-up* ❑Fire Q Gas'' 0 Planning d Sewer Card 0 Water Card CI Zoning ❑Other Chief ' -...Cut Off Board Cut Off Cut Off *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. EPARTMENTALAPPROVAL qq Zoning Review: Signature: l -Lit VU /k-' Date: 7/Z 51 7 Energy Report: Signature: Date: Fire Chief: Signature: Date: V Board of Health: Signature: 6il'f,,c, /C Date: Conservation Commission: Signature: Date: Other: Signature: Date: Brief description of work being performed: /2D/hitt-ea Jjts,io/PD a �/ / ,l f'r[nQ i- �j 2CQ < G� rT� REED 1 -SITE INFORMATION V1 Property Address: I of S REED RO 1.2 Assessors Ma_p/&Lot Number: Nearest Cross Street: H I ( U I LLE. RD r` Map /i/(P Lot V) Subdivision Name: YYY��� 1.3 Historical District 0 Yes ❑ No Total Land Area Sq. Feet: Has application been submitted to the Historic Commission? 0 Yes 0 No Date: 1/t'Water Supply(MGL cA 4): 1. ewage Disposal Sis : ,V/ ❑ Municipal Private Well 0 Municipal On Site Disposal System 0 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT I RESIDENTIAL SECTION 2-PROPERTY OWNERSHIFiiYDT bRIZED AGENT 1 Owner Record:/ • 'THHEPES4 1= cFYAPPOQOCS LICc EST6c,CV15 S {itZRiRooKL R0 SD1YYI act* ( Name(print) Contact Address Phone Number 2.2 Authorized Agent: 11-1orvt65 5A REP-1Q A-to 0 Es SM 7147/ .2yO/ me(print) Contact Address Phone Number SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number: nAddress: Expiration Date: Li Signature: Telephone: n Z 3.2 Registered Home Improvement Contractor: Not Applicable ❑ U Are you a Home Improvement Contractor subject to(780 CMR-6)? 0 Yes 0 No J If No,go to the next section! L Are you claming exemption from the requirements? 0 Yes 0 No D If Yes, submit the required affidavit! ►' Company Name: Registration Number(if none,state"none"): L D Address: i Signature: Telephone: Expiration Date: 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton Place-Room 1301, Boston, MA 02108, 617-727-8598 0 I am a Homeowner performing all the work myself / e7/ iy er Y ` f� // Oxrs Name (print): 71Y ? ( . ( V {F Signature: �f"�.�•�s,�j..a�i�� ;---- By signing the above,, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund Date: 1 / 9/o /� -:e, 3.4 Homeowner Exemption-One&Two Family Only V FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0,effective July 1,1962,no individual shall be engaged in directly supervising persons engaged in construction,reconstruction,alteration,repair,removal or demolition involving the structural elements of buildings / or structures,unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a Homeowner. If you are applying under under this section sign below: Signature: ;v .f211�ter+ % Your signature carries certain responsibilities,including but not necessarily limited to,general liability NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction Supervisor,whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c152§25) Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 0 Yes 0 No SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable) .. ❑Deck 0 Pool 0 Repairs ❑Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑New Construction* ❑Accessory Bldg. ❑Roofing/Siding 0 Other (Energy report required) (Shed/Garage) (Specify below) 0 Addition 0 Replacement window/door 0 Demolition (Energy report required) No.of windows_ Doors (Specify below) *If new construction, please complete the following: Single Family: No. of Bedrooms No.of Baths Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 0 Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑ Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑ HVAC(combined unit)-primary fuel, natural gas,propane,electricity,other ❑Air conditioning-(separate unit) ❑ None of the above to be provided ❑Hot Water: Gas Electric Fuel Oil Other 9escription of proposed work: R s(x6 p�),,,,A ni' -V — ,( o� E+f- CP a THi / /�! q �� .�lt hcJ =1 L — u&La.. t (Ta1V ' LIGCTRICAL- lit) IVi1Nb E SECTION 6-ESTIMATED CONSTRUCTION COST Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 710 ..fib ! i - 5. Total=(1 +2 +3+4) SECTION TA-OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (Please Pript /� � r ,^ - a- 5, � I./ �✓ U ✓� / / of the subject property hereb authorize T 'MRIS 5 A F&R/V<9v�. f /R act on my behalf, in all matters relative to work authorized by this building permit application------- p egnature o Owner Date / // r SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION rM AS S A EE+�A)/}f`1 0&S as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. , - l/l!��aco7 Signature of Owner/Authorized Ag n Da SECTION 8-INSPECTOR'S REVIEW/COMMENTS -. — `; 1. Date plan reviewed: 2. DENIED (see project review worksheet): Date: 3. HOLD Reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: ' Inspector's Signature: A 2 . 1 .c. 122 Date: �1 l> 7 ECTIONN APPLICANT NOTIFICATION Applicant informed of above: Date: / A� / T. Y //5HJ Clerk:( Comments: dC/ �.� DU ./' -. (A) SECTION10-OF ICE/INSPECTOR'S Less Application Fee: $25.00 Remaining Balance: $ S-0 6 Total Permit Fee: $ 'CO,0 6 Other$Amount$ S TOTAL FEE: �C-0 , J 0 Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: / jt / /?/ i; f O d Pr I i Ai E 4 Or / F/ x` t- F/2-7, SECTION 11,-ADDITIONAL COMMENTS/SKETCHES i 0 SP QIAL PERMIT(Per 780 CMR 111.13) 525.00 APPLICATION FEE IS'VON RE•FIINRARLE 4 NON-TRANSFERABLE DATE RECEIVED ��MauiH.y1 DARTMOUTH BUILDING DEPARTMENT .. �:+c •ypfll 400 Slocum Road, P.O. Box 79399 !z Dartmouth, MA 02747 • - 7 n 2: 37 '�O\ -v Phone: 508-910-1820 Fax: 508-910-1838 /56a www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING. THIS SECTION FOR OFFICIAL USE ONLY - RECEIVED BY: i{ ( BUILDING PERMIT NUMBER:Y/&3c DATE SENT FOR REVIEW: / Pf a 7 BAT,E ISSUED: O.K.TO ISSUE-SIGNATURE: ( �-✓l C -72z4 Zoning District: .?A 4 Proposed Use: /Z r' Zone: O B 0 A OV Aquifer Zone: - - THE FOLLOWING AGENCIES SHOULD E NOTIFIED 0 Board of oard of dy7 O Cons. 0 Demo 0 DPW 0 Elec. 0 Energy Report j Appeals Hea h ` l� Commission Affidavit Card Sent. Cut Off Follow-up' 1 0 Fire 0 Planning 0 Sewer Card ,0 Water Card 0 Zoning 0 Other '' Chief . Cut Off Board Cut Off Cut Off *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. .DEPARTMENTAL APPROVAL _/ / Zoning Review: Signature: 1`� •i i �l C' /T&- t 1-7- �" Date: / T 'i/!' i Energy Report: Signature: Date: FJ're Chief: Signature: 1 Date: I../Board of Health: Signature: A..) S (`J' \ Date: Z . / • 000 2 Conservation Commission: Signature: J Date: r Other: Signature: Date: Brief description of work being performed: /21•h4t1e/ At. i/71.4-('t y7/of � a . 4ri 1; SECTION 1 -SITE INFORMATION 1.1 Property Address: I *Sri- REED RC) 1.2 Assessors Map& Lot Number: Nearest Cross Street: H I X \..) I LS L R V Map //247 Lot � - Subdivision Name: `C� 1.3 Historical District ❑Yes El No Total Land Area Sq. Feet: Has application been submitted to the Historic Commission? ❑Yes ❑ No Date: Water Supply(MGL c4 4): 1. ewage Disposal Sysn ID Municipal Private Well ❑ Municipal On Site Disposal System 0 CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT °T" TOWN OF DARTMOUTH 1 , _I 400 Slocum Road — Room 210 .a.;.i DARTMOUTH, MA 02747 DARTMOUTH (508) 910-1820 BUILDING DEPARTMENT FAX (508) 910-1838 BORROWING AFFIDAVIT FORM Date 1 /9/07 I a2n./14, cAA42-ft , borrowed a set of plans for the property I own at f OS7 RQatQ R Q , Plat ar Lot(& -Lea. I understand that I must return the set of plans within the fourteen (14) day time period otherwise my $75.00 deposit will be forfeited to the Town of Dartmouth. Deposits in monetary for { /] will be deposited and a voucher for reimbursement will need to be filled ou E • I ° I plans are returned. 1 �- � H. ►) �1-lam IE Signature: x�j 41, J 'i1/no-vr�'Borrowers Address: / J t t2 � Telephone Number: DS`L/g Lib' (,V Plans due back on: cr Clerk's Initials: 4 is- - -1 1'�- � 1� 47 VOUCHER FOR REIMBURSEMENT Vendor Number: Vendor Name:\Jf Vendor Address: Number&Street City&State Zip Code Telephone Number: Social Security Number or Corporate I.D. Number: ---- . , ..,....... - • --- , czi—Th _ . t, ,-, ,, ..--• e-i: 78 _ - . - ' .---% - __ . c_. ,..k...; . a \ L7\ 0 \ fw.• \ ----S C) \ et(4 . -LA • _E \ ..• \ _ F --- \ \ -c>U-5 e- z5 -.._.) C Ctr‘ \ , . ...,-, .11 1 ,..‘' - ' =„.. 73 ill C (-N., : •:}(;-, ., LI\ ..„_._ v--- > r' .4,,„; -----..w.1 ;•••4,,di r--. c :-.i:ii: )1,•-•v c ( t:1 -,E'')—-1----,V4c ' ^--''': i*--_4 •v- r*I -:•'''''::-)LY,' ;•-•:•::'•7:---Thr'IMIN :.r..) I 7 -61\ ---:,?':n. ill --\--- W 1-3, ' ..r , .. ... '-::',:.'.. 0-) Erg --:-..,,, -F.., ,,,,,v ..,(":-S __ ., -'---- 1 2,-';`, - - C-- ,4,--; F? ritcl;i: e----- ,.-41i7 1:-.t..i (IN e63 rn ..4f.-, . "..'N-: ,,,t,t,; _ C. f •\„„jj ----i e-•p,----,. -,- ,•:1:!.:1'tti .:71,4 e ,f .„_... n sin r-1 0 \ ") C.1) 1‘, C2, cmst re‘ , c,-A" etc' -ci. -4-- la' cCk . 3.. \--.7.• a -Kr ‘4, as• cr >ermit No; BP-47632 Project Location: 1257 REED RD Commonwealth of Massachusetts TOWN OF DARTMOUTH M P . . 346600 400 Slocum Road,Dartmouth,MA 02747 Lot::: 0042 Phone: (508)9101820• Fax:--(508)910-1838 Sublet: 0000 BUTT ,DING PERMIT Category REPAIR •Project# JS-2007-001769 Est.Cost $70000.00 FIELD INSPECTION Fee $50.00 Const. Class: ' UseGroup: R4 Contractor: _. License: Phone#: Lot Size(sq.St.) 40679.: Zoning: SRB Engineer: License: P/ione#. NewConst.: N/A Alt .Consk .;:- N/A Applicant: Phone#: THOMAS SA FERNANDES (508) 441-2461 Ceiling: Walls: OWNER: Floor•. FERNANDES THERESA E L E EST Glazing: DATE ISSUED: ��/ " 7 TO PERFORM THE FOLLOWING WORK: ©�Jvdr l '1T _,p,, Repair roof line due to fire PER CODE DATE TIME TYPE OF INSPECTION&REMARKS INITIAL 3-6-o7 3 `lam gro-hc._ /eMei .- AlLetre_ l tic ok U641;-ffrfa1.1-±Si " UYJ t4Y✓/L y . �J:F'17�CC '1 -f�c ....] , T r v r o TJ �' - ,) °3-/9-OD St O'.irw�,- 4'at ,2 , �l/a74:212 nnterl``�-Ul ��wntAz9 '-kl rI , 7-5,,A_2.7. -0- Z-) U e__if /iC o 97P2 dyJir�C.7a 6 /!�' 07• r O-TIP ei s .,i.4n i n /iii/d-6- /�// in.52 ,6 J I e/ ((c. edi-ri4Gete"q , , 6,,e,/7y-;i im ..A. im.e, '7 /y2--n7 y z s' ee.i/e 4¢.. - -77/1/0AZ 4 1 tO 7-- J-'D) P]gAz4,-;A et zt - // nle_�-A- .L -4e- ¢ /} GN/.. /I 6Jt,"IJ P / �l'�! /.U?fL./ s /77 C/2/A7 3 eta o(e.yi �j2,4_,k_-{ L ein1'1nr6!? 7;777 MAP l 6 LOT Y z, urH. "`i TOWN OF DARTMOUTH y INSPECTION CHECKLIST W-Aa, P/W- ,. I664'S/ Date: 5_.79-0 7 ❑ New Home ❑ Addition Alteration ❑ Deck or Shed Permit # 3 2 Address: /2 ,r7 ¶e,J , rc),- Inspector: INSULATION Pass Fail Description Code Section Residential MASSCHECK/Energy Report on site J5.2.1B "R"Values J1.1.2.3 No crushed insulation J6.22B #A U Insulation properly stapled& fastened J1.5.1.3 C/ Insulation curling J4.2.1 No gaps at bottom&top of wall bays J4.3.3 -- / Vapor barrier in place except basement/attic J4.2.1 All tears and cuts taped J4.2.1 All exterior wall penetrations foamed J4.3.3 U-value rating on windows J1.5.3 Comments: , -r3 /th0X j2 geejemi D11 , � The Commonwealth of Massachusetts 'ail �lJ' Department of Industrigl Accidents _,ti,,wer i= ' Office of InvestigationsSit `�_ -a 600 Washington Street Or �� t Boston, MA 02111 � en I www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers An licant Information Please Print Legibly ip t/Kame (Business/Organization/Individual): lit p •.���,��'lvl,/15 dress: I a 52 ILES) Q0 ty/State/Zip:T . Dkankodttlift 00.747 Phone #: 5 0% ® gg5- -GI 5 S Are you an employer?Check the appropriate box: Type of project(required): 1.n I am a employer with 4. n l am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 72.El I am a sole proprietor or partner- listed on the attached sheet. _ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. n We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3 I am a homeowner doing all work iXright of exemption per MGL I1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy# or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. .10 hereby certify Fiy under the pains and penalties of perjury that the infarmatro provided above is true and correct. �/Si ature: S Date: // 90/67 hone#: col' cite 5--(et 5(?e� Official use only. Do not write in this area,to be completed by city or town official rtn7 I City or Town: Permit/License# ,, I., U iu ii W Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as-...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,•construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.govidia The Commonwealth of Massachusetts w Department of Industrial Accidents _,?lj�t_ l Office of investigations 600 Washington Street —t't I • � Boston, MA 02111 •Y �vow www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ap t licant Information Please Print Legibly ame (Business/Organization/individual):_jT C;. -- y yzre cti` A/0 15 4dress: ! Q- St? Q.€ ) QS •ty/State/Zip:'�'`.i, D/ "n40i7 440, 00-7 f 7 Phone #: 5 t'6 ` qq 5 `Ca S v Are you an employer?Check the appropriate box: Type of project(required): i.❑ I am a employer with 4. n I am a general contractor and I 6. n New construction employees(full and/or part-time).* have hired the sub-contractors 2.n I am a sole proprietor or partner- listed on the attached sheet. + 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. workers' comp. insurance: 9. n Building addition [No workers'comp. insurance 5. n We are a corporation and its required.] officers have exercised their 10.n Electrical repairs or additions 3 I am a homeowner doing all work Sright of exemption per MGL I l.n Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box I/I must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date:_ Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fare up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. hereby certify under the pains and penalties of perjury that the informatio provided above�� is true and correct. o lature: ...9 ✓a •-- a" ,- Date- I/ /o7 hone#: ✓ Let '"� I 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#: JAN-16-2007 09:39AM FROM- T-025 P.001/D05 F-725 cat) `-2vSC (S fl, 19 ) 1 CD`t—j 1'C5 3 c�thr-3 D >t) - 4 �1- 41 kflr CcIA(2 LI CSkiVaLl ( a < grev ✓c, Lr r JAN-16-2007 09:39AM FROM- T-025 P.002/005 F 725 ---^ M• ., rragri Lr'A]t Jab .4 _ rwa689311111 FINK _.. i,a"!P , . 1 ern• ag 4ai RR r.an al , ee1. .,•• •age 1 634 1�1.0 6-3-416e•0 23-0.12 S2-0.0 74-12 7-8-12 6-34 1-00 erde=l:B1.• cm iz 4r10= . c 3rec ��� i.flr4 q 4�'/ \• j 3 i \ 15W// 1E 20 Si0� s 12 13 11 14 10 SdO� :v8= &v- 10-0.0 t 1564 22-0-0 32-04 t 10-0.0 5&4 8-2-12 1 1 Plate Offsets(X,Y): 12.0-2,2,Edde7,(8:0•2.2,Edgel 11a:q•4-O,p4 1.t12;0a•04gp1 1� LOADING(ps0 SPACING TCLLOEFL In (lac) Udell Lid PLATES GRIP NWT Plates Increase 1.15 CSI 0.95 Vert(LL) •0.26 0-10 a718 240 MT20 197144 TCOL 10.0 Lumber Increase 1.18 BG 0.83 yert(TL) -tea 9.10 >276 180 tBGLL 08 • Rep Stress Inv YES WB g60 Horz(TL) 0.12 8 Na n/a RCDL 10,0 - Code IRC2008ftp12002 (Matrix) LUMBER Welghb 1171b TCP CHORD 2%4 SIT 2700F am"Except` BRACING T32 X4 SPF 2400El e,T42 X4SPF 2400E 20E TOP CHORp pl ling. lwood xhealhing dlreldly applied or 2•24o. COT CHORD 2 x 4 SPF 1860E 1,6E ROT CHORD Rigid ceiling diredl WEBS 2 X 4 SFF isapF 1.6Ey applied or 7-316 oc bracing. , REACTIONS (Ib/slze) 2=1840/0-6g,8=184114-8-0,11=3331044 Max Harz2,+•188(load case 0) Ma UPIi6 823(load case 8),Sr.884(Ioed case 8) Max.Orev 2r•2212(load case 2),9.221200dd case 3),11•03300ad case 1) FORCES (Ib)•Maximum Conyression/Maxinum Tension TW CHORD 1.241/80,2-18;3317/1303,18.1E-1088M316,3-18=.2886t1337,3-4—289v1371, 4-17=2816/1386,8-17m.2001f1402,8.18ed801/1402,6.1004e1w 1396,8-75-2881/1371, 7-10=-21160/1337, ROT CHORD 2-182s/2760,1 1 213e 7a1186r,,11133=.7&1557,11.14•478Me87,10-14=478/1857, 8-10=-8261278a • WEBS 3.1z-1039/466,6-12=16011441i,0-10=-461/1446 7-S-1 30/486 • NOTES (10) 1)Wind:ASCE 7-02;12Orrph;henft;TCOL•B,opsf;BC01.4.Opsf;Category II;Exp C;enclosed;MWFRS gable and Zone and C-C Elderler(2).1.6-0 to I-S-B mterlor(1)se-are 724.10,Exterior(2)12410 to 16-0.0 ,aLer1 0')19sWso�a .1zone; antileverleft and right exposed: Lumber OOLstGOpltle grip specified designedC for members and horns,and for NIWFRg for reactions 2 TCLL:ASCE 3)Unbalanced snow loads have srbeen consgut roof idered for this Category II; esigr C;Fully Exp.;Ct=1.1 4)This trust has been designed for greater of min roof live load of nil parer 1.00 times Oat roof load of t 36,0 psf on overhangs nan•eoncarrent with other live loads. Continued on page 2 JAN-16-2007 09:39AM FROM- T 025 P.003/005 F-725 Jab 'truss Truss'type II dry Ply I1402677,Penedos-.Vlad 01 I"led Structures,Inc., industries,Biddeford, FINK 0.400 eSelo 72000 M(iek lnni Mon 1610.24:262007 page 2 Job Rafersnee( lion NOTES (10) 6)This hugs has been designed for a 10.0 pst bottom chord live lead nausea current with any other Iive load& 171 This truss requires plate 010000 ion pn the Tooth Count Method When this truss is chosen far quality assurance inspoolloh, 7)'This truss has been designed for a live load of2a0psf an the bouarn chord in all areas where a rectangle a-we tall by I-SOwide will 6t between tho bottom chord and any other mentors. a)Provide mechanical connection(by others)Ogress to hearing plate capable nfwhhstanding S8I lb uplift at joint 2 and S84Ib uplift at julnt b)Tills truss Is designed In accordance with the2004 International Residential code s9L11Ons R6a211.1 and RaOt1a2 and referenced standardANSIRPI 1. • 10)Drawing prepared exclusivelyfa manufacturing by Wood Structures Inc LOAD CASEIS) Standard JAN-16-2007 00:40AM ROM- _ P.004/005 F-725 _ -o.00 HAUL: 4/5 Rightl:AX • R•ze77, era:. .. Ian `10 a•• .r. ' . ,r.,i. Job R. -,' .,l9 :ep n faraaa ,8anm --` 1 - •a nix 'on ci ay.:- W. -age 16-0.0 324341 1$D 1644 16-0-0 94-0 6I6=1:61.. C00 ny 4i9= t0 S a✓4 C•131415` 1@717 \� to19-123 22 21 20 am-� Ss6= 5e= 32-0Q Plata Offsets Y: 2:0.2.100-'0' 320-0 LOADING(pig 18:0.2100.1 2$;0.4 03a, B:OS.p 0-1-0 TCL4 300 SPACING 2-0.0 CMDEPL In (loc) i/de0 Lid PLAINS GRIP (Ra1"111:19r+36.0) Plates increase 1.16 TC 0.20 Ver9LL) -0.02 19 an 180 MT20 197/144 TCOL 10.0 Lumber Increase 1.15 BC 0.09 Vat(TL) -0.07 18 Nr 120 BCLL 0.0 Rep Stress frier yes WE 0,19 Han17L) d01 18 Ma nla BCCL 10_0 Coda IRG2003rTP12992 (Matrix) LUMBER Weight:163Ib TDP CHORD 2 X 4 SYP 2700E 2.2E'Except' BRACING 732 X 4 SPF 2400F 2.0E,T4 2 X4 SPF 2408E 2.0E TOP CHORD Sblictural wood sheathing Grady applied w 8-0.9°- DOT CHORD 2 X 4 SPF 1660E 1.6E SOT CHORD RI dd ceding WreW INNERS 2X4SPF1860F1.6E 8 YaPPltadm70.0.0o0bradng, REACTIONS (Ib/size) 2=308/300.0,18=368/32.0.0,26=291/32.0.0,27c2s8/32-e4,29=300.132.0,0, 29.391/3241-0,30.277/32-0.0.31•145//2-0.0,32•3W3241-0,26•208132-0-0, 74=300/32.04),23a3011324-0,22277/32.0.0,21=14E/32.04 204394132.0-0 Max Herz 20-188(load case 6) Max Llpli02.233(load case 8),18a-261(102d case 9),27e-7$(Ioad case ID,28a108(Ioas case 9), 29=05(l0ad case 8),30=.105(load case 9),31=-108(laad case 8),32=2600oad case 8),26=•T3(load case e),24=-109(1oad case 9),230 g5Q0ad ease%22e#0s loaad ease 8 21=-108(load case 9), Max Gray 21(loed --casse22),186 1(I dOcaase 4j,26=2$1(10ad case 1),27-404(load case2), 28493(lead case 2),29393(foad rase 2),30b7$(load case 2),31.211(load case 2), 32e566(load case 2],26=404(lgad case 3),25r309(load case 3),23=303(1°ad case 3), 27^$76(laad case 3),21211poad case 3),20=e661laad case 3) FORCES (Ib)-Maximum Cornpresslcn/Maxlrlum tension TCP CHORD 1.2:11188,2-33•-192/105,3.33v-163/121,3.-1071152,4-34.-741182,6-$4•-E01189,E-C--81/3O3 11-38 wsb 41=-22 3s 8-36=-80/607,0-36=20612,9-10=-041642,10-11=-84184.1, ?, 50/507,12-132.422/396,13-14=80A58,14-16•-911003,16-37•-22/199, 19-37=741192,19-17=-107/124,17-38=09/27,18-38,145/11,18-18=0I88 ROT CHORD 2-32=0/280,31-3200/290,30-31=01280,20-00001289,28-28e0/250,27-28=0(290.28-27=0/280, 26-20,0/280 24-25=01290,23-24=0/290,22.23=0/280.21-22=91200,20-21=0/290,18-29=0/290 WEI38 10.25=25710,9.27=2831289,8.25•-214/230,6.28c 190,2 _ 7 12,3-32-.g57/338,11-26e 2831259,12-24=,274/239,14-23a. 6911g0,16fg--290/212,�� ' 16-21=198/147,17.20=,467/333 Continued al Raf1e 2 JAR 16 2D07 09:40AM FROM- T-025 P.005/005 F-725 •-- �• night/IAA Tnir ,s Truss Type Rty Ply t 2$ , ,ran .s-- ad 102 GABLE 1 1 allures, ne, Job R4 a aP or tq.oc. lion �.•. NOTES (14) �' n age 1)Wind;ASCE 742;;120nph;hgaf;TCDLea.Opsi;BCOL=l,Opsp Category II;Exp C;endnaed;MWFRS gable end zone and C-C Corner(3) -1-s.o to 141-6,Extenoqui 1-S-6 to 12-6-10,Cvnw(3)12•10-10 to 1&49,Exterior(2)10-2-6 to 202-10 20ne;cantilever lea and Mpgexposed; 2)Tru Lumber DOL21.60 plate D nlhepl This truss is dsady�tor CC ror CWd�hers and farce and Tw M FRS ter rem:Oans epedaedL End Doiall" exposed to wind(normal to the Taco),see Welt'Standard Gable 4)Unbalanced snow loads have been considergal roof ed foror this Category C;Fully Exp.;Dt=1.1 a)This truss has been designed for greater of rift roof live load of 1t0 par or 1410 times fiat roofload of 3t0 piston overhangs non-concurrent With other live loads. 6)Thistruss has been designed fora 10.0 as/bottom chord live lead nonconwmrerl with any other,live loads. 7)AII plates are 1.624 MT20 unless otherwise Ind-Icated. &)This trussrequires plate inspection per the Tooth Count Method when this truss Is chose for quality assurance inspection. 9)Gable requires continuous bottom chord bearing 10)Gable studs spaced at 2-0.o oc 11)"This truss has been designed fora live load of 20.epsf on the bottom chord In all areas where a rectangle 3-0-0 tall by 1-0.0vede win tit between the bottomchord end any other nearer, 12)Provide mechanical connection(by others)of truss to bearing plate capable of withstanding 23916 uplift at joint 2,261 lb uplift at jolts 1A 79 lb uplift at joint 27,109 lb uplift al jdnt 22,36lb uplift at joint 29,10a Ih uplift at Joint 30,10216 uplift at joint al,260 lb uplift at joint S2, 73 lb uplift at joint 26,1091b uplift at joint 24,0416 uplift atjoint23,106 lb uplift at joint)$103 lb uplift at jont2l and 260 14 uplift at joint 20. 13)This truss is designed in accordance with the 2003International Residential Code sections(150Z11.1 and R002,10.2 and referenced standardANSI/tpl 1. 14)Drawing prepared exclusively for manufacturing by Wood atruaWredirta LOAD CASES) Standard