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BP-44588 Permit No. BP 44588 - +r f 4 �ap ei , 0 1140%tl ila I LL.oaC 6 at l , TOWN OFrDARTI IO 'H ' - _ ' 4, 400 SlocuiRoad,Dartmouth,MA 4277 ' }} i s 9�s Phone (508 910 1820 ,- Fax (508)910 1838 p &0 fof i+b 33 k h a@ i, :,: I�l0 PERMISS r01' S 1IIRI.B GRANS J Coas .- 1-- use )nu e °r Contractor icense ' Phone'#: . �- � Rom'-`fig 3 " Engineer: Licenise� ; "- "Phone#: c s ' �400 s: _s = - Applicant: ;"! Phone#: "x TODD S SHORROGK ' (508) 994-1981 lip B E ):E,€. „,,_ � OWNER: LOURENCO FRANIK J& C .L LOURENCO DATE ISSUED: n• , x(, : "' • TO PERFORM THE FOLLOWING WORK: Add a 20'x 20' deck to rear of house TO BE IN ACCORDANCE WITH 780 CMR OF THE MASS STATE BUILDING CODE BUILDING PERMIT • Project Location: 13 MEDEIROS LN Approved/Issued By: ji I 1 DAVID BRUNETTE,LOCAL BUILDING INSPECTOR All work shall comply with 780 CMR 6TH Ed. (MGL Chap. 143) and any other applicable Mass. Laws or Codes and plans on file. POST THIS CARD SO IT IS VISIBLE FROM THE STREET SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. THIS 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/Zoningil P Signature of Owner/Agent: `� -- v NETT� RQ IR ,33 IESTI CIS ECT 3NComments l/ PRI '- * RRE- SPECION E ? BEP IDBE ( RECEIVINGANOTE NSPE T O "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD TOWN OF DARTMOUTH s BUILDING RECEIPTS `N'-' et '; ; / ) COLLECTOOFFICE R - / :- `i I t r r Name: t r t� Epoperty ,. Date: ,'� T r; ' Owner: Job Location: il ,, s e° - , f:� c f ' to Copy-Collectors Office Plot: / e-r Lot: rr -i Y.llow Copy-Customer's Receipt / _ ` s P Copy-File Copy j \ Gr en Copy-Building Department Phone: -� 1SSU E � - ' Description General Ledger Ws Ref: f r Amount ems/' t -' License&Permits-Building01000-44105 f.•'�F ! 2 'i F!-' License&Permits-Building Misc. 01000-44105 License&Permits Electrical 01000-44106 `',,, , License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 This is not a Permit or License for Building,Plumbing or Gas Received Ba TOWN OF ARTMOUTH BUILD NG RECEIPTS _ / COLLECTOR' ,OFFICE ' ,: _._.---/------ _ I y_.�1 f; r' ;" -{i X. Name f i( / I '_�. i Of ,�. , Property ,." 1' „,` r f'/7 { '+ Date i .:= ' '' ` °- } S 1 £ if a T: Job Location: ,/ / 4 '.;" s" c ''�/`� -, j — White-Copy-Collectors Office i' '' r as''` =Yellow Co Customer's Receipt Plot: Lot s . y Py-.'Customer's P �. it 1S1JE� �` PuA JCopyk File Copy Phonev 0 T p ' Copy-B 'ding Department s Description General Ledger#'s Ref:# - -Amount License&Permits-Building 01000-44105 fT^/ License&Permits-Building Misc. 01000-44105 �p ,` ' pit License&Permits-Electrical 01000-44106 \, .r`"' License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 '`' e • } This is not a Permit or License for Building.Plumbing or Gas Received BY: �, `-z.. 0 SPECIAL PERMIT(Per.:20 CMR 111.13) $25.00 APPLICATION FEE IS NON BE-FUNDABLE 8 NON-TRANS II ABLE pUTy_` DATE RECaIVED r;'`� DARTMOUTH BUILDING DEPARTMENT e N °1r% rid 400 Slocum Road, P.O. Box 79399 1. Dartmouth, MA 02747 `; �' 5 \�°�. yY' Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO C NSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING. THIS SECTION FOR OFFICIAL USE ONLY ) 1 RECEIVED BY: BUILDING PERMIT NUMBER: _ DATE SENT FOR REVIEW: DATE ISSUED: O.K.TO ISSUE SIGNATURE:;�� �ue_Q, DATE: Zoning District: ei3 Proposed Use: „, Zone:`ICJ C 0 B 0 A ElV Aquifer Zone• THE FOLLOWING AGE), ' ES 1 OU D BE NOTIFIED: p Board of: ,.and of 0 Cons. ❑Demo ❑DPW 0 Elec ❑Energy Report Affidavit Card Sent. Cut Off Follow-u A eats� Health �, Commission �� � p' PP * 0 Fire 0 Planning . '• 0 Sewer Card - '❑Water Card 0 Zoning ❑Other Chief Cut Off Board Cut Off.- Cut Off "REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: t. e2_J ,t.e. i ",_, Date: /V-0 Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: 0 Date: i Conservation Commission: Signature: Date: Other: Signature: � '�`- Date: Brief description of work being performed: t. �., SECTION 1 SITE INFORMATION 1.1 Property Address: 'Ar ,3 dr �A,c'17/ .r (, -1 1.2 Assessors Map& Lot Number: Nearest Cross Street: ()(.(C L•,- (1(;r7 t Cry Map '/' Lot / - Subdivision Name: ' I C-te'vi,.(d :) r'tZ Pi,4_S 1.3 Historical District 0 Yes 10 No Total Land Area Sq. Feet: 411 I ci_2C ._-_ I='i Has application been submitted to the Historic Commission? 0 Yes 0 No Date: 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal 14 Private Well 0 Municipal kf On Site Disposal System ❑ CONSTRUCTION PLANS J SITE PLAN ❑ ENERGY REPORT RESIDENTIAL SECTION 2 PROPERTY OWN5RSHIP/AUTHORIZED AGENT 2.1 Owner Record: Name(print) Contact Address Phone Number 7c12.2 Authorized Agent: C 5i j .� ",wvtc .7 ii . 7t 4-v- c i1 ii of 7Y / `..Name(print) Contact Address VIA IA O;7 t/ -) Phone Number SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: License Number: Cl) Address: Expiration Date: LLI Signature: Telephone: Z 3.2 Registered Home Improvement Contractor: Not Applicable 0 W VAre you a Home Improvement Contractor subject to(780 CMR-6)? 0 Yes 0 No —I _ If No,go to the next section! U. Are you darning exemption from the requirements? ❑Yes 0 No Q If Yes, submit the required affidavit! Company Name: Registration Number(if none, state"none"): Q Address: 0 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 ❑ I am a Homeowner performing all the work myself. Owners Name(print): ( CC,C' �1 L u-re I/1( C Signature: •J _ l'A:..,v...'Ll�c'- '-) By signing the above,the homeowner acknowledges that there will be no eligibility to the Guaranty Fund Date: l a - fit t - 'i`- I; , • 3.4 Homeowner Exemption-One&Two Family Only 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 1,1982,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. 11,1 4 If you are applying under this section sign below: Signature: U---Yi 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 c 152§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 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑New Construction* 0 Accessory Bldg. 0 Roofing/Siding 0 Other (Energy report required) (Shed/Garage) (Specify below) ❑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 ❑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 ,Description of proposed work: 4N7> IA z?-C)' X tC:'O' i �e_ le Cv.) vic") ►ee .-e•bf_ ii ('_ C' %lexx)— 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) /6 17,7: SECTION 7A-OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (Please Print) I, -Tr-0, ' ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. `J k `.s. wig 1� i l i(_ C- Signature of Owner at SECTION 7B-.OWNER/AUTHORIZED AGENT DECLARATION I, O`)~ �a_vi cc.Jc , as Owner/A ized A e ereby 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. Sight - of Owner/Authori . Agent 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: dapseeL ( A�e4/4/ '_ Date: 4_ 4 SEC ON 9'-APPLICANT NOTIFICATION Applicant informed of o e: Date• J�Time; 7" Clerk Comments: ! (A/I7171 SECTION 10-OFFICE/INSPECTOR'S NOTES Less Application Fee:$25.00 Remaining Balance: $ $--- Total Permit Fee:$ SO • Other$Amount$ TOTAL FEE: Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: 19ci O 1)12b>���l� �G , D D SECTION 11 -ADDITIONAL COMMENTS/SKETCHES )ermit No. BP-44588 Project Location: 13 MEDEIROS LN Commonwealth of 11assachusetts • TOWN OF ,DARTMOUTH tiO h 4173�O iz n Niap 0079. 400 Slocum Road,Dartmouth,'MA 02747 l Ot miitrQ00okd 33 Phone: (598)910-1820 , Fax:.(508).910-1838= Olot ip BUIT ;DING PERMIT ticatehor � c .�ro`o ct ,�r J n,0 30fa FIELD INSPECTION Fee a . „, «Const Cia s Conti actor: ;,,:i4,...,,„1,..„,„,„,,,,,,,::,:,:,,:„. .,,.: ' ' ''' '' License: Ph ;;I: 1 Use Grau ",. one#. p4 ...: 'Lot Si e(s ft)� 1102 tip, diTllDx stiigt Engineer: License: Phone#. g is, ,„ New CTQst 440 sq ft Applicant. Phone#: Alt Cgnst, NIA 3 3 TODD S SHORROCK (508) 994-1981 Ceding; per OWNER: oWalls. LOURENCO ,J ` T CI-L LOURENCO it �ll FRANK li*NION:::::n /�/J(:' //([j�)��- .y�� ,, DATE ISSUED: TO PERFORM THE FOLLOWING WORK: Add a 20'x 20' deck to rear of house TO BE IN ACCORDANCE WITH 780 CMR OF THE MASS STATE BUILDING CODE ' IF• -•TIME -�-- ------ -- -- - - TYPE OF-IN PEi T ^ON&-R LMNMARKS- - - - - - - - ---INITT INITIAL • 6 /�/ c /O:7 Viz `� ID dk-s Cow (:.)X Pe2:,ei 0 SPECIAL PERMIT(Per 780 CMR 111.13) $25.00 APPLICATION FEE IS NON RE-FUNDABLE or.NON-TRANSf1 ABLE - DATE:ZIVED f,-40,10 -i `` DARTMOUTH BUILDING DEPARTMENT " -- r, T io5-1 cj 400 Slocum DartmouthaMA 0 2747ox 79399 _` , J'i _;� # I: LI5 °4.,fi54 Phone: 508-910-1820 Fax 508-910-1838 www.town.dartmouth.ma.us APPLICATIOI'1 TO C NSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 6 _ THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY BUILDING PERMIT NUMBER,D,:,?4,_,..,,,,7„,,,-..K--i .i,,,-.1,I--.2y:-..',...-.,,,,;:,:-,.;-.,,;-;_,:-:_,:c,•;..,•.--f. .-',.:',..1.:,,,...=:-,,),,--,,:;.:--',-;:,...':;,?.1.-•.1",--i.e.,44•,!* ,..e*„...:-._...-. .-_,- ,:...,,,i-::„.•.:._4,_-_-.:,:•-.,..r,..,,--:.::" „•,--,:::,:::::,...,-,_,-,;,,. .,,,,,=,,-:-,-._..-,_- ,:-..„••-„,:::--..,...-:.-,,„:„;--,,ri,--_-_.„,-_:-•:.:•-2-,• ,.--..).-: '''' - .: '..7--.--'-' :-2/ DATE SENT FOR REVIEW: DATE•ISSUED. O.K.TO ISSUE SIGNATURE:- DATE: Zoning Distnct Proposed Use Zone p C ❑ B. ❑A 0 V Aquifer Zone THE FOLLOWING;AGENCIES SHOULD CBE NOTIFIED:: ❑Board of r ❑Board of ❑Cons ❑Demo ❑DPW<, ❑Elec. ❑Energy Report Appeals v,Health Commission Affidavit Card Sent Cut Off Follow-up''. ❑'Fire i ❑Gas ❑Planning 0 Sewer Card 0 Water Card 0 Zoning - 0 Other Chief is-1' Cut Off Board Cut Off Cut Off 7 u z _ r Y ` = *REQUIRES INSPECTOR'S REVIEW.BEFORE THE ISSUANCE OF A PERMIT. -" =DEPARTMENTAL APPROVAL, Zoning Review: Signature: Date: I Energy Report: Signature: Date: Fire Chief: Signature: , ,��� Date: Board of Health: Signature: r'�/2 •fLLec Date: Z``0-/ Conservation Commission: Signature: Date: Other: Signature: Date: �3 Brief description of work being Performed f.,/)( t4 \- ( d e) Oil211,1, Sti7tew17 c, /-_--- . • SECTION 1 SITE INFORMATION 1.1 Property Address: :` ,d I7.-r 1)C.' ?l0a (...) 1.2 Assessors Map&Lot Number: Nearest Cross Street: ()C (( •c.,- _ n tip:,�� -(_"ri Map / Lot - / Subdivision Name: ,)I L(.,'<a.-L' I;i=�rZ rytr(s,_ L+ 1.3 Historical District 0 Yes I No Total Land Area Sq. Feet: I/ I C5_2(` ._S ; /=-r Has application been submitted to the Historic Commission? 0 Yes 0 No Date: 1.4 Water Supply(MGL c40 s54): ¢• t . ._ 1.5 Sewage Disposal System: 0 Municipal ril Private Well 0 Municipal ki On Site Disposal System ❑ CONSTRUCTION PLANS I I SITE PLAN 0 ENERGY REPORT MAP LOT 6 `/O _NIT;\ TOWN OF DARTMOUTH •30 ,�� INSPECTION CHECKLIST Date: e V 6 ❑ New Home ❑ Addition ❑ Alteration peck or Shed Permit # t/Vs- 8- Address: /2 i�?�"ia� i� Gs ' Inspector. 2) FOUNDATION/FOOTING/SONO-TUBES Pass Fail Description Code Section As-built&approved 110.10 Frost Depth 3604.3.1A #1 Foundation walls braced 3604.4.1.3.1 Footings on undisturbed soil 3604.3.1A #4 Spread footings 3604.3.1A #3 Foundation wall grade clearance 3604.4.1.3 Pad location size and size per plan 3605.2.3.3B (table) Damp proofing/water proofing 3604.6 Anchor bolts/ties& straps 3604.3.1A #5 Thermal break/insulation in place 3604.3.1 All footings&pads free of foreign material 3604.9.3 Columns rust-inhibitive paint&structure 3604.8 Crawl space ventilation/ 1 sq. ft. = 150 sq. ft. 3604.9 Sono-tubes 3504.3.1 Comments: 1 l // co,vo To zg'k S. - it fjp.VU I / /. / I I I / / / / LOT 8 i /.. 41,020 SQ. FT. I::: / /41 % ......, I__ ......_ . i,r- :41cNi ) . __ __ I DRAII4AGE t , , 0; I EASMENT Nt- / 6) or -/-- —_ EXISJING "cf? t... 1.1 /. / I rill__ gi •-.... / I i -....._/ - _psi , ....... A .„. // /1-1:,'C'7: 73ectwesw. t Q!;),.t...- :2 1,0::;-,. , I' . . 237- EXIST. 410.---/--- Ig• / c."-- - T.O.C.=146.7 0 64' —— / / / ' \--1-A .. / / / * / • o .-...----,5••—.... / / , N.airk / / L=88.47' R=160.00' o,sv LANE • 7.4..,,0 ,C A,--Z.,', /---•-7- Z i%^--f -...) (' i te 0--, (,; ),-'•-- ___. .;-,..'- Mill 1-j 'iC; j CO 7- C- --ir t I Lk)(t.,,S ' °UT H.4 Dartmouth Building Department , ov °" �'-f n i 400 Slocum Road \:. -4 y P.O. Box 79399 508-910-1820 Sy Dartmouth, MA 02747 FAX 508-910-1838 REQUIRED INSPECTIONS FORM #115 README: The applicant is responsible for calling this office when scheduling inspections. Please refer to the list below for required inspections. - --..a =� /s ,..... i .a7 _1777.__i/ Mil P` d Address /3 /1 e'J b6 j��,-c— Date 6//s/b 4 *FOUNDATION (as-built needed): Notice *BEFORE INSPECTION,FOUNDATION BRACING MUST BE INSTALLED. *SONO-TUBE INSPECTION: *INSPECTION IS NEEDED BEFORE THE CONCRETE IS POURED. *ROUGH/FRAME (with approved plans). *AFTER ALL ELECTRICAL&PLUMBING HAS BEEN INSTALLED&INSPECTED n FIREPLACE: ❑ Footing(If separate) ❑ Throat ❑ Before cap is installed INSULATION(with approved energy report): NOTE: N.F.R.C.LABELS MUST BE ON ALL WINDOWS AND DOORS OR USE DEFAULT CHART VALUES. n FINAL (with approved plans and energy report): '/ _I PLICA H copy c:Iwpdocslformslinspreq.wpd Revised February 1,2001 The Commonwealth of Massachusetts Department of Industrial Accidents 1 A ,l Office of Investigations W i 600 Washington Street w �' . Boston, MA 02111 ‘tirme s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers plicant Information Please Print Legibly 4esS:e (Business/Organzation/Individual): Ir 1/4 C y 6_(-4 t '(�t✓t,'C(_5,p / ✓i rc(c., trio'. („A Ail:,. ity/State/Zip: . J. i r:1. -boa 1 ---..; i?�IK Phone #: Z %7� y- % 3 7 C2 C 1v2 1`-i 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 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- Listed on the attached sheet. # 7. n 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. ❑ We are a corporation and its equired.] officers have exercised their 10.0 Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.0 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ;.'iSignature: id,, It L ,t t C I,l.a...lL -- Date: L.•'ti i t -Lc c v Phone#: it F- Q ct f.-13.7 f 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#: t./V " ry ., 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 Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia ,....3..........:.,z,„•; );.• c,.:,,1.t""'4Z, ..,. :V o .0...:;7'.. . '... ...:,...„. g - ,,,,,,,.:::, ..,-,,, . 0•,.N• • , • mIX,0,,T•• • ... -I - E 4 ,t•=1 nn .. A.0 .:.• 00 Zor0zi o c:. ro :L.: r....w-.1,---4 - , t'l•,;:i',...,. vt DO . v''C'-')00s. ''.4s1 0:1;•::.. 4 (":•/ *.xla C44 e.' n.,,,,,,T, -- •. 1`,1,:ft _ •, ›-,••••: >c/ m Xi,: m = r.-1111 6),. g- ,,,,, ? ...o,.....,-,. 2 ---'-- - M1•f"", • ;:!tF; . -, •..1-7; .11 ,':', ,..., .. 11.4 a,rt ,....,. > :.... • ,..E.,-,...4.,,::• ›- -, ,.‘:-,•--:': k..)t4 C.,,',..'*; ...., 4'',34:m ';:.,1'.',•: ©,.=z ;. .'.,-.: .41 ttl k Lt•I . al, m .. :•, . tl • ,..,-• '.. 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SHEET NUMBER *NOTE THESE PLANS FOR PROPOSED CONSTRUCTION ARE FOR REFERRAL ONLY DRAFT PERSON DOES NOT TAKE ANY RESPONSIBILITY FOR THE SAFETY, CONSTRUCTION PROCEDURES, TECHNIQUES OR THE FAILURE OF ANY CONTRACTOR (G.C. OR SUB) TO CARRY OUT WORK IN ACCORDANCE WITH ALL APPLICABLE CODES & REGULATIONS r rx/541dV M:V. Stepson Strong -Tit LUS28 7YPIGAL J0157" timem IN5rA LRrION vin- L OfCK SfCTION l8term TYPt & P057W I NV57-AUA "ION DL7/UL Simpson iRson Strong -Tie AB 77MAt- P 5C INSr/tLL,V-ION DP; NL rMX DCUM C I5rN5 XDWR DLYOND -1 2_X12 F 1. ac -.btSrrN 5" O 1X127r#1 Dot ryl JoInT - r25r,1E j015rTOvf," `-� C312X12 vGS'J 6x6 rt7>r Z' DE7 1/L l J,Ot f 14,12' - I-,T Ix r-05nr v 2 Irv, 5 JPlrJC » A r"r" DL' XfJ6 ofrfil,2, 'C OtZ H17, - r-C7 I_DfC1K 5rAiP 5EC_FION TJLTAIL 3 *NOTE THESE PLANS FOR PROPOSED CONSTRUCTION ARE FOR REFERRAL ONLY DRAFT PERSON DOES NOT TAKE ANY RESPONSIBILITY FOR THE SAFETY, CONSTRUCTION PROCEDURES, TECHNIQUES OR THE FAILURE OF ANY CONTRACTOR (G.C. OR SUB) TO CARRY OUT WORK IN ACCORDANCE WITH ALL APPLICABLE CODES & REGULATIONS STAMP 01 05/10/06 I PREDWINAR! INO.1 DATE jFPVASfoN H CO Vb F+ . C�i x co (� 0 NA"r'E­ co O r z w A W ^ N O V) A � � F W z 0 10-4 U) w w 0 x a DATE: 05/tto/06 SCALE. NOTE '0 DRAWN BY: T:ODD SHORROCK These droviVngs ore the propertyy of Professional] Design & Builder Inc.. 'and are not to be cased in whole or in, part without the, 'written consent of: Professionall Design & Builder Inc. SHEET �i4UMBER A 3