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BP-74153 Permit No. BP-74153 BUILDING ' �,' ,� .., GIS# 3494.00 COmt acrl dap 0066 +* o®0u 'cii �7e Lot 0973 ,3 ,s¢00$Ioc 9.d, th 111�747y, ,, " , !Sub-Lot .0000 lho (.is -1$. • aiSs ) -1 8 .,,V.„ Category 'SUNROOM ECK 1 : • f'\.-- -,C ' ', Project# 75-2015:000254 PERMISSIONI fl E `. / TO 'Ng";' t�,,, e 4 Est,Co $I50oo00 . - . , - - Contractor: nse ' t `= hone Ce: $350 00 JOSE M C ,A ( 22t 6 8 '.C4 Cf6 Engineer: �Y+ �w r upy'''h rIel#� 3 rse G oup.. 1 - ?r .i f y f yR '9 LotSize(sy ft) . :2343tl .� Applicant: " -iI- -Zoning: SO JOECHAVE aNS' •... CTION = - (5 to kt ifeiZone ZONE 3 OWNER: '- a siilocrdle_ ne 2`ONE% MENDONCA . ' PkWGift 252sq ft '.M, n� Mt Goff: Nt DATEISSUED t� �. ,' a Date Typedt s b7 29 2014' I : ' ' a'� o TO PERFORM THE FOLLOWING WORK: tz. se$9,4aaps4 4a;;s04' Construct a 14' x 14' sunroom(unheated)with a 4'x 14' deck to yam ject Location: 1221 REED RI) Approved/Issued By: J_.. aar DAVID BRINE BAL UIIAING OR All work shall comply with 780 CMR 81"Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on We. Schedule appropriate inspections as required. Upon completion of work,final inspection is required. 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 i Withstanding the issuance of this Building/Zoning� Pernik Pernik n Signature of Owner/Agent: �- 2C-C---_, ' "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of B.D.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: Underground: Oil: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Serviced: Rough Frame: Insulation: Final: Final: Final: Cross Connection Final: Final: Board of Health E-91I 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 1 TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 74408 PHONE: 508-910-1820 FAX: 508-910-1838 &la ) S ` ' Property Ow :O TAXiIS 3 fName: [ f//` Job Locatioi 1, �/ 1?L ' Map: oft,,, �% Lot: 73 I Description General Ledger#'s Ref. # Amount Building& Building Misc. 01000-44105 .ar302 S --- Electrical 01000-44106 ���k10F Dills Md Plumbing& Gas 01000-44107 1Trench Safety 01000-44129 i L Other Department Revenue 01000-42420 8 White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By.C j( iga/i�2�+, ,/ THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS i TOWN OF DARTMOUT BUILDING DEPARTMENT RECEIPT 74153 PHONE: 508=91 1 0 FAX 508-910-1838 -i c t, I*� r o Name: j r / L oa ai Leib NI( ad,Properly Ow'ner;“ t C� Date: ( i Job Location: I?Z I /4/1 4 wi,1L Map: 66' Lot: 73 Description General Led ''s i al Hr. Ref. # Amount Building & Building Misc. 01000-4 105 !. A, 4- j JUL F0201 Electrical 01000- 106 Plumbing & Gas 01000-4 Og. 6 wi Trench Safety 01000-44129 rocOt LECws Other Department Revenue 01000-42420 White-Collector's Office Yellow Copy ��"�__J-Customer's Receipt Pink Copy-Building Department Received By /) THIS IS NOT A PERPAITILICENSE FOR BUILDING, ELECTRIC 1 PLUMBING OR GAS RESIDENTIAL 0 Phased Approval(R106.3.3) $25.00 APPLICATION FEE IS NON RE-FUNDABLE & NON-TRANSFERABLE pUTN.y� DATE RECEIVED „L.,- qs, DARTMOUTH BUILDING DEPARTMENT,— » (Ea ') 400 Slocum Road I z as...-..„?..„.„;;;" Dartmouth, MA 02747 20m� cll. I 0 p I: 03 � Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING II THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: ICS. &n Ii BUILDING PERMIT NUMBER: DATE ISSUED.` /iii SIGNATURE: / ,t__ %LG/t DATE: ' JUL 201 Building Commissioner/Inspector of Buildings Zoning District: Si 0 Proposed Use: Zone: I X ❑ B ❑A ❑V Aquifer Zone: ' THE FOLLOWING,AGENCIES SH BE NOTIFIED: DPW CI Board of Board of ons. 0 Planning ❑Address ❑Engineering ❑Cross-. Appeals Health Commission Card - Connection ❑fire ❑Gas ❑Electric -❑Other -❑Water Card `- ❑Sewer Card • Chief Cut Off Cut Off ` Cut Off Cut Off DEPARTMENTALAPPROVAL((S)) 7 Board of Health: Signature: a ..e93 ric/' _.e Date: //-- d ,/y Conservation Commission: Signature: b (�Date: - 30 - (y D.P.W.: Signature: Date: Fire Chief: Signature: Date: • Other: Signature: Date: Brief description of work being performed: 3\\ Y—UQj\'V\ C ]1-1 l as,c, b Qv::"3 A,/ �flj C%r (Il / SECTI 1 -SITE INFORMATION A.1 : l Property Address: y� ,C� ` 1.2 Assessors Map& Lot Number: ✓Sontact Persons \ )(t;`.S\c� t& �L(� C� / /P Map 0 l. Lot /3 - 1Phone Number: SQ 6� 7 ( // 9 1.3 Historical District ❑Yes No ' 7.� /. Year Built/?e 'e Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal 0 Municipal ❑Altering more than 25% per side of building Private Well \On Site Disposal System Has application been submitted to the Historic Commission? `\ 0 Yes 4No Date: / / /,6 �/ �/& erased 5/13 €� CONSTRUCTION PLANS L�'J SITE PLAN ❑ ENERGY REPORT RESIDENTIAL SECTION 2=PROPERTY OWNERSHIP/AUTHORIZED AGENT t i1 ner Record: [� L _jiz,e ote.441,tjKcLa iLj e a */ /Old ( /(3E Uf 4 Name(print) Contact Address �� obc,937( 2,PhoneNNuumber 2.2 Aur t.o0_ ✓ 5 r) / >L5 6-f—et /" Sw nV"m Name(print) Contact Address ���9P�n�e N,ttmbeail I SECTION 31�CONSTRUCTION SERVICES / l �-' tgi 3.1 Licensed Construction Supervisor/Specialty License: ?g /1I — License Number: ��,4�( �l l Company Name/Contractor Name: zrn eit it ve& aksiii t0�U � 1 /J y uu Address: 1 f I JG 67..e S f 11I e)2-7'C 2 Expiration Date: /y�/Gv l� Vi r Signature: Telephone: 3O fSZh6 , 3.2 Homeown r Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 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 this section sig low: Signature: SECTION 4,-WORKEWSCOMPENSATION=INSURANCE AFFIDAVIT(MGL c 152 06) ;; .; . 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: ❑Yes 0 No s SECTION 5-DESCRIPTION OF PROPOSED WORK(Check altapplicable) , "'' J 0 Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove 0 New Construction* 0 Accessory Bldg. K Addition ❑ Roofing/Siding 0 Replacement window/door (Energy report required) (Shed/Garage)) (Energy report required) No.of windows Doors ❑ DEMOLITION (specify): hip 9EV'kD LocatfJn of debris removal (per MGL C.40 Sec 54): 0 Dumpster on site ❑ Dumpster On Street '` I�, lef— Facility Name: k E Location: U (1�)T� 7'-� m;..t&QN ,z7 jb *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 ❑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(specify): ❑Air conditioning-(separate unit) ❑ None of the above to be provided 0 Hot Water: Gas Electric Fuel Oil Other SECTION.6-ESTIMATED CONSTRUCTION COST Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 5. Total= (1 +2+3+4) /5000'0-ca ✓ SECTION TA-OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (Please Print) P I, oft-i//� ,CtieA.J1li a C IT ,as Owner of the subject property hereby authorize3OS ` , C to act on my behalf, in all matters relative to work authorized by this building permit application. Si ature of Owner Date SECTION 7B-OWNERIAUTHORIZED AGENT DECLARATION - v 4-0 eS , as Owner/Authorized Agent hereby declare that the statements and information y)fon the foregoing application are true and accurate, to the best of my knowledge and belief. Si.ne• nder the s and penalties of perjury. 6/3Dh Signs Y re of Owner/Au ized Agent Date ' SECTION 8-OFF'10E/INSPECTOR'S NOTES- ; Less Application Fee:$25.00 Remaining Balance: $ Total Permit Fee: $ 35 b Other$Amount$ Gross Area-New Construction total sq.ft. r2 SZ-- Gross Area-Alteration total sq.ft. Permit Issued to: ( lIL/ST/COEr a-, /95LwV s (i i/GiLCJa1I/L ( ram,(/fill v-'D /`7v a . , ,SECTION 9:nDEESCRIP]'[ON OF' ORK,i;EIN.G'RR fSRN)ED d-t;SxJ-0- /\/ovi_—A LLCM et /xis Ozck, S / `7 Jy S�-r , m � str ,X, ZS Gat /7ix 70-6 //) f 1 e el- CeRjilti 7 z ?-/<76 i • RESIDENTIAL ❑ Phased Approval(R106.3.3) $25.00 APPLICATION FEE IS NON RE-FUNDABLE & NON-TRANSFERABLE p, RECEIVED ,z'�u-°9 DARTMOUTH BUILDING DEPARTMENT •CART. ; (° - —' i) 400 Slocum Road Dartmouth, MA 02747 .� v4;. 201q JUL -2 A i0 Opt — /. Phone: 508-910-1820 Fax: 508-910-1838 \,.1 tt, ice 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: BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: DATE: Building Commissioner/Inspector of Buildings Zoning District: Proposed Use: Zone: DX U B ❑A ❑V Aquifer Zone: - THE FOLLOWING GENCIES SHOOAT BE NOTIFIED: it DPW Board of oard of d'-ons. 0 Planning 0 Address . Oa _ - rig 0 Cross Appeals Health - Commission- Card a Connection El Fire -0 Gas 0 Electric 0 Other El Water Card 0 Sewe and • Chief '' Cut Off Cud Off Cut Off Cut Off EPARTMENTAL APPROVAL(S) 2-1 Board of Health: Signature: ' Cc Date: 1 Conservation Commission: Signature: ,./ - . Date: &- 30 - / 7 r D.P.W.: Signature: /J! Date: Fire Chief: Signature: Date: Other: Signature: Date: Brief description of work being performed: J-L\'l `p uCI\Vl ( A-11. I3,c_, ssQt> t),',/' jR,UI C, Qh �1 } SECT 1 -SITENFORMATION ✓1./1 Property Address: I!3 r� ` T1s Ck1/4 . 1.2 Assessors Map /to& Lot Number: L'C J� S'ontact Persons \\ f)V / U CS ( C Map .0 C Lot 73 - 1hone Number: SU c ci ! / 9 / 1.3 Historical District 0 Yes 0 No • r/ Year Built 41 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: 0 Municipal 0 Municipal 0 Altering more than 25% per side of building ❑ Private Well 0 On Site Disposal System Has application been submitted to the Historic Commission? 0 Yes 0 No Date: / / / EV-442-- OCtc/d,� /Lc/ evised 5/13 Et CONSTRUCTION PLANS E SITE PLAN ❑ ENERGY REPORT alf Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-065066 JOSE M CHAVES- 13 GREEN ST � BERKLW MA 012775 l �%�,.+ die . n n� Expiration Commissioner 12/08/2015 • J4e fom monu:eed o/fr71¢JJacAOie/YJ Office of Consumer Affairs&Business Regulation L-a uHOME IMPROVEMENT CONTRACTOR =.Je((� Registration: 130392 • Type �r xpiration: 3/2/2016- DBA k 3 Joe Chaves Construction Jose Chaves V1 13 Green St.9 Q g tJAO " _ Berkley, MA 02779 Undersecretary • a ,. • _ • N thi i 1 1' � wat: PI 10�tm1 [n .1 III11 ®®mi �N : z � e I :e91 4 SS ri \ r= 1. \ ,1 ;I L I rev- ii} Iill 1 4'd' \ 14'8' -6 1p! j}_ o LL : • `� -t -a.F ICS16 1 {- N s �I(1t 1 �ii - o § E • '�"J g b s yy@ a& 11 • I I 1 1 11 11j1 / , ,.... . c-J ' I S ! ill 'F., _ '.....E C_ Z :i !IIi i`' i .F O gg F • j1 E& £ a c g b k g-. g i 2e I B i ; E- 2 i sll i i 3O 001 2iF jg TILT 11 !twi§I. ry,2 1 q i is E. Hhi a M th m g � - m m g'. Ili `; 's}a, a€;€f z ' EMI ®-§ I ►_ IIi I.ii ! ij3 o I2�� `i € IIi i 3i ii; a.t I•ii z MEIN _ il�M�mllA•I MENDONGA m m RR a m Home Plan Designs I _ 1221 REED RD m - N m ' g.4 r `Ea. Taunton, MA.O278O 'a /,1 4. DARTMOUTH.MA 02741 E A p m moo-. m =_$ 5p&gg5-T894 rY 'p } wwI-lCY0CP18,16D19ufl.wM �• \. -• Job truss Truss Type Oty Ply Scissor Trusses 40426 S01 SCISSORS 12 1 Job Reference(optional) Quick Build Truss Co.,Inc.,Swansea,MA,Manny Arruda 7.430 5 Jul 25 20131vtTek Industries,Inc. Mon Ma 191422:57 2014 Page 1 ID:jn8GeCBTN38adZPsiRk00Bz0Var-LRo6VGICO91_SSCc. Mon 0OD 2:572014 EwVy -i-0-O8-1-2 7-0-0 14-0-0 &1 15-0-0 100 I 7-0-0 I 7-0-0 1-0-0 Scale=1:25.4 4x4= C 6.00 12 T7 T1 F 56= tf m D B E ao a. = 3.00 12 3x5% 3x5= 8-1-2 8-1-2 7-0-0 • I 14-0-0 7-0-0 7-0-0 LOADING(psf) SPACING 1-4-0 CSI DEFL in (Ioc) I/deft Ud PLATES GRIP TCLL 30.0 Plates Increase 1.15 TC 0.66 Vert(LL) -0.07 B-F >999 240 MT20 197/144 (Roof Snow=30.0) Lumber Increase 1.15 BC 0.44 Vert(TL) -0.20 B-F >828 180 TCDL 10.0 Rep Stress incr YES WB 0.14 Horz(TL) 0.09 D n/a n/a BCLL 0.0 ' Code IRC2012/TPI2007 (Matrix) Weight:39 lb FT=1 BCDL 10.0 LUMBER BRACING TOP CHORD 2x4 SPF No.2 TOP CHORD Structural wood sheathing directly applied or 3-11-15 oc pudins. BOT CHORD 2x4 SPF No.2 BOT CHORD Rigid ceiling directly applied or 10-0-0 oc bracing. WEBS 2x4 SPF No.2 MiTek recommends that Stabilizers and required cross bracing be installed during truss erection,in accordance with Stabilizer Installation guide. REACTIONS (lb/size) B=518/0-3-8 (min.0-1-8),D=518/0-3-8 (min.0-1-8) Max Harz B=43(LC 15) Max UpliftB=53(LC 10),D=53(LC 11) FORCES (Ib)-Max.Comp./Max.Ten.-All forces 250(Ib)or less except when shown. TOP CHORD B-G-1124/33,C-G=-1027/45,C-H=-1027/64,D-H=1124/51 BOT CHORD B-F=25/968,D-F=24/968 _ WEBS C-F=0/584 To NOTES NOTES 1)Wind:ASCE 7-10;Vult=11 omph(3-second gust)V(IRC2012)=87mph;TCDL=6.0psf;BCDL=6.0psf;h=25ft;Cat.II;Exp C;enclosed; �.. MWFRS(envelope)automatic zone;cantilever left and right exposed;end vertical left and right exposed;Lumber DOL=1.60 plate grip it DOL=1.60 i--- 2)TCLL:ASCE 7-10;Pf=30.0 psf(flat roof snow);Category II;Exp C;Partially Exp.;Ct=1.1 3)Unbalanced snow loads have been considered for this design. C� 4)This truss has been designed for greater of min roof live load of 16.0 psf or 1.00 times flat roof load of 30.0 psf on overhangs non-concurrent with other live loads. .. -t 5)This truss has been designed for a 10.0 psf bottom chord live load nonconcurrent with any other live loads. �.. '.J � 6)'This truss has been designed for a live load o1 20.0psf on the bottom chord in all areas where a rectangle 3-6-0 tall by 2-0-0 wide will fit between the bottom chord and any other members. '7 7)Bearing atjoint(s)B,D considers parallel to grain value using AIJSI/TPI 1 angle to grain formula. Building designer should verify - o F t-1f capacity of bearing surface. -d 8)HI 0 Simpson Strong-Tie connectors recommended to connect truss to bearing walls due to UPLIFT at jt(s)B and D.This connection is IVJ • for uplift only and does not consider lateral forces. - 9)This truss is designed in accordance with the 2012 International Residential Code sections R502.11.1 and R802.10.2 and referenced standard ANSIITPI 1. 10)"Semi-rigid pitchbreaks including heels"Member end fixity model was used in the analysis and design of this truss. LOAD CASE(S) Standard /uc kg-19C- . I d s o Toseah C% moo,fogs cfly� sg,c oo O o (26 /5 0 . 2 s o . . oo I 5 o yI 30 61 • I *� /Soto! �I Q SQ.FT c� 2a430 t 54• FT " l �e y • 1 o b 01 S h , oy o .se�1 CO ,i. /oo.00 t.,.•• 52. /2 9 :¢ o.28 •a=1 •_` 5 D.AlIn S.P 3 3 .1/4 4C ° 6.8 1-I/or GERALD <Ny, - R .. E D 1"4o F vy/per MICHAEL {y T p O ftV FITZGERALD t,n+1 F • ` .4 O ri .� No. 19333 T 'U SL`,A / Av/5ro:>rvr/inden subdivision Con/cc/ Low not ce9uired. a "RTM (617N ANN/n/C iSOARD .. SUED/Y/S/ON OF LAND hy Del RTMO UT71, /MASS. SURVSVED FOR 1401/N a,vo PERCY //41VS01V • • SCALE 1"= 40' DULY 28 /967 SoargeAST5/Z/v ZevQ/w,q/Nc COP,? .5o,vi.ER 5E7' 4f.4sS, s Toseoh C//. /1-/o,fa/s S %, S&.00 • c 0,p' y/�0 /so 2s. $ o ko I _ 5 •30 I oy� � el \ (0 • Q 1'4KCfL. J fyARCE4 cf\ ‘C /5020'SO.FT C.01 234 0 ° Sq.F7; U 0 LA I 1 5� we u O M 111111 I S 1 s LI 18g r7f30 S =o • �� �` • 1 307't g9 vp \ - ia' 'S /oo. oo f:- 52. /2 4 o 9.28 5 AN In S.P 36./2 o . S.B$r�GERAL � A? E E D (40 .4.7W/o. toIG HAEuL L2,"' ' 11 o �j Dj FITNZGERALD y� .peo 9333O G/S7 e?i4§- -a/0)1g under subdivision Coai'io/ Low oaf required. O RTM• - TN 1 ANN/NC 8OAR12 Kt. 4I" I,U,.:J._t, f SUBD/Y/S/ON OF LAND • % �Itl/ i /N DA RI/WO 1.177/, MASS. SURVs yEO FOR JOIN in, PERCY /-44WSOA! • SCALE l"= 40' DULY 28 1367 Souri eASTEA?t, LNG/WEER/INQ Con. Sos4E$ SET, A-P.9ss. - ._. _ -.. The Commonwealth of Massachusetts t_- Department of industrial Accidentsvii, j" Office of Investigations 1// ig ''` i" 5 •mil 1 Congress Street, Suite 100 f. tl!=2� Boston,MA 02114-2017 .� et. . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): cr-e v p-5 ar a e I , oiki Address: /3 &Z -/0)) ��1c37- (� City/State/Zip: ,&G/ZX2 y�M 279 ',Phone#: 5? / zz 4,6 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.Q I am a sole proprietor or partner- listed on the attached sheet. ` 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.# 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself,[No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no 12.0Roof repairs employees. [No workers' 13.❑ Other comp. insurance required.] *My applicant,that checks br#1 musk` o' ill out the section below showing their workers'compensation policy information. I'Homeown re s who submit is aftidav c' ating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors'hat check tills b �a ched an adhitional sheet showing the name of the sub-contractors and state whether or not those entities have employees. rt'thesub-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: Rtl tctn�-� Policy#or Self-ins.Lic.#: , .--s 6ortbio,gip 0 4-13 Expiration Date: /2-20 P Job Site Address: J'Z ey �e") JeJ City/State/Zip: pitCola(d-1 I r O 2 Pc? Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer nder the pa' s and e alties of perjury that the information provided above is true and correct Signature: . Phone#: S'Q / °L a 6{=, cc 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#: 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia maHart.i>_iz.t:i7 mz, ,.rjn oe,t I iii,,,4, ri-<.• ::1 c-4 El N4:1 C44 t.a, 7:3 3 33C Z 0 82-tr° ..- =4 rIrzes' E p-i n c o u, b c o o cA-.... 'q, n Tit 0 R,izt t rii< ez 0 co esi , •?,, '.,' .<., o -4 a MS ' - 0 !:61:' 0 -I t-, -ft' „tti n ... g_ Pi N re 4, *4 702 0 0 to m RI E) o — n cab ,,,k,ti. br -33 '3', 2 - '3-, .3 3. 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CSt$kk•--t s rd••+ ££ i'41�t11 S.-1� ES. t .t'�' Applicant .., a , ,, V,---;• Phone#: e aJOE CHAVES E ONSTR,U'C FI ' (508) 922-6626 : n `_ OWNER: ca _ 1 kC 0 " �F ° � i�4 MENDONCA DA a ,✓ 74 ro itr AI DATE ISSUED: . cPT TO PERFORM THE FOLLOWING , it'I ',� " �_ Construct a 14'x 14' sunroom (unheatec :tha 4' 7�14' deck to rear DATE TIME TYPE OF INSPECTION&REMARKS I INITIAL ot-C y.//11 roiLJ 4��5''�`t' �3D /4 C�ivi. ©�� tee N h t , 1- OUTH - BUILDING DEPARTMENT RECEIPT 75110 1 508.910-1820 FAX: 508.910.1838 , Name/20 ( (O'✓✓t° 6the'd- Property Owner: /%(2M O6.6)4 'GL. Date I J 3 //Lf 2 / J et (6 / JJ ✓ Job Location: �� l Map: � �' Lot: 73 t Descri tion eneral Led er#'s . Ref.# Amount P pF t OART�0G g Building &Buiidi o iscMDR 4 000-44105 C°(" ' / J 16 0 Electrical SFP 3 0 2114 01 00-44106 Plumbing & Gas 0 000-44107 Trench Safety T C5 -A'S* 1000-44129 Other Department Revenue 01000-42420 White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By'�� fL '--"`^��.• THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GASI I_ —_ It1 J I ,� IJ 1 In z �. �� lb LL 1 J7 Ai 4 1 \ 1 ,i..11 . _,_,,, _I--,. ._ 1 =., ,E, t „, , _ L I I=1E < I `-, - - J I rFr / 1u ^` _ r- e �_ .‘\ a yU (6¢ 44 y �.I3ll - 11 0Pi - I Li _ --rr Vh X. il a tt iyejF • l� is IP } iIIF _ _-, it pi t F P1I ii I ill I �tl '5 Mendonca Nac m m Home Plan Designs F //7 _ 1221 Reed Rd „ ,r 2 ti m o (31 _ Taunton,MAA2"f80 s i• ��, J Dartmouth,MA 02141 I\'.S. - !? n =_ 50B 4969e44 lc, usw HouaePanaaraun.GOm \ a i , . -a -t) 1 0 1 ' ,— x n — .[_. II , _ - pJ L.. - ' > a-1 rvi t, fl, Li I ' = ' 1 I r i , -- PAH ,1 / inrs! 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