HomeMy WebLinkAboutBuilding Permit # 10/12/2016 V%OR*H
ZD I'll, -
BUILDING PERMIT
TOWN OF NORTH AND0OVER
APPLICATION FOR PLAN EXAMINATION
Permit NO.
d-01 Date Received 6,
3!3
Date Issued: 1 0 1 0 1 ACHUS
IMPORTANT A licant must complete all items on this age
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building 'i-;- 6n—e family
P Addition Two or more family i Industrial
Alteration No. of units: i-I Commercial
VRepair, replacement Assessory Bldg I Others:
C Demolition i Other
c, f4 4/ -f 1004,n, 11-eLJ 'A S4 94can YN
-A,
J
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address A
''I'll. .........
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BU ING PERMIT. $12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $. 0 /Z) FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyind
..... ..........................
own o �� 6 over
No. a�1� _
h ver, Mass
COC MIC Ml M.KR
01.
�.q 00AslEo A '�5
S U
BOARD OF HEALTH
PERMIT . T L D
Food/Kitchen
Septic System
THIS CERTIFIES THAT A *9.0 N#V C: L L BUILDING INSPECTOR
has permission to erect .......................... buildings on ..... �... •.. ..........96........... Foundation
1.
to be occupied as ..k.t��14. F+f�f......RC.lihdf.C.... ..... M.! ..... *.L44.... OL, Rough
Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL I NSPECTOR.
LESS CONSTRUCT STA S Rough
Service
.
........ ... .... ...i�►.... .............. .....................,....... . Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit RfRuired to Occupy By Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Massachusetts Home Improvement Sample Contract
This form satisfies all basic requirements of the slate's florae Improvement Contractor Law(MGL chapter 142A),bill does not include standard
language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain it copy of"A
Ma."achusetts Consumer Guide to Hortic Improvement"before agreeing to any work oil your residence.You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information Contractor Information
Name Company Name
4:
Street Ad�rejes—si(d(o riot u"Se it Iost 07ce Bio address) Contractor/Salespeison/Owner Name
C ip�Code Business Address(toust include a street address)
ItyrFown State
Day
Phone Evening Phone city/Town State Zip Code
(I 03S
ArJ jae-X-JA
MadinpAddrevs(Itch I cut fron)above Business'—phone �7i'jdcral Employer ID or s.S.Nuill er
E*=
Law requires chat must Irame
vAd nghtxnlian—nbll
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,Mit�kfiflonal
t'f3CA�C 17X,)V11 Cleo-xxj ta� cc, C
Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will
and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work.
MGL chapter 142A.)
_fl Date when contracted work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work,furnish the material and labor specified above for the total so")of,
Payments will be made according to the following schedule:
S " uVon signing contract(not to exceed 1/3 ofthe total contract price or the cost ofspecial order items,whichever is greater)
S by or upon completion of .........
by or upon completion of_—------ ----------
SA&I-1/1—Apon completion of the contract, (Law forbids demanding full payment until contract is completed to both party's satisfaction)
rhe following inateriti/equipnient must bespecial sLiL-22—�,Xe Paid for-GA-14-
.............
ordered before lite contracted work begins in order
to met[the completion schedule.('`'*) to be paid for
NOTM(-)Including all finance charges(*-)Law requires that any deposit or down-payment required by the contractor before Work begins may
not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom noule material
which niust be special ordered in advance to meet the completion schedule. I
--o,tae—wan,, ;-,mo,mast ,attached-- to the e-c-o-mrnc 0
Express Warranty-is air express wnrrqjijty-b���ractor? 0 -.,ois
Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor. 'fire contractor further agrees to be solely responsible for all payment,;to all subcontractors for
materials and jabor ull(Igr(his aercement.._
Contract Acceptance-Upon signing,this document becomes a binding contract tinder law. Unless otherwise noted within this document,the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
Don't be pressured into signing the contract.Take time to read and fully understand it, Ask questions if something is unclear.
Make sure the cantraetor lid a valid lfone rit-Contractor Re dstration. The law requires most)ionic improvement contractors and
subcontractors to be registered with the Director ofilonre Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757.
0 Does(lie contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or tisk to
see a copy of "proof of insurance"document.
0 Know your rights and responsibilities. Read the Important information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel Otis agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the
third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!t
r%vo id"lleal copics of the conaract rimst be mr,pleted andsigned.One copy stwuld go I Ire.,her copyslionic,be kept try the contractor,
k", "o
py a
I forturowner's Signature (,-ot
—Z
Date Date
a .e
Eu
FOR
THE WOOD RESIDENCE
October 7, 2016
PREPARED BY:
"�FLOOD
STRUM I"UR I, ENGINEERING
Al
m
'
Job # Nam*
GheetDeeohp�on
�
Calculated/Drawn Date________
58Laurel Drive " HUd,sQD, K4AO1748
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Project ect Title:
Title Mack Line 1 j Project ID:
You can change this area Engineer.
using the"Settings"menu item, Project Descr:
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Title,Block Line C �M n��t;i rcrrT�rs�i r+zvn.t
._.4 _...._ _... File=f 1PROGRA-2TNERCAaI
1 q ...._ cNERcatc,lNc,l9ea 201 r�uld s 15.12
.9 Ver:615.12.9
Description: --None--
CODE REFERENCES
Calculations per NDS 2005, IBC 2b09, CBC 2010,ASCE 7-05
Load Combination Set:ASCE 7-.10
Material Properties, _
Analysis Method: Allowable Stress Design Fb-Tension €375 psi E:Modulus of Elasticity
Load Combination ASC E7-10 Fb-Compr 875 psi Ebend-xx 1400ksi
Fc-Prll 1150 psi Eminbend-xx 5'10ksi
Wood Species : Spruce-Pine- Fc-Perp 135 psi
,F)r
Wood Grade : No. 1/No. 2 ` 'ik Fv 135 psi
Ft 460 psi Density 26.21 pef
Beam Bracing : Beam is Fully Brpcod against lateral-torsion buckling
� o
i
D0.04)L0.16
2-2x10
r.
Span=13.750 ft
Applied Loads Service loads entered.Load t actorwal
.,will be applied for calculations,
Uniform Load: D=0,040, L 4.160', Tributary Width 1.0 ft Bi
MaxDESmU ren Bending SMMStress Ratio ' :- 1 X3`77: 1 Maximum Shear Stress Ratio = � y fo��
0.490 ; 1
Section used for this span 2-2x10 Section used for this span 2-2x1 A
fb:Actual - 1,325.79psi fv:Actual - 66.19 psi
FB:Allowable - 962.60psi Fv:Allowable - 135.00 psi
Load Combination +-D+L+H Load Combination +D+L+H
Location of maximum on span - 6.87511 Location of maximum on span - 0,000ft
Span#where maximum occurs = Span#1 Span#where maximum occurs = Span It 1
MaxiMUrri Deflection
Max Downward Transient Deflection 0.4137 in Ratio= 353<360
Max Upward'Transient Deflection 0.000 in Ratio= 0 <360
Max Downward Total Deflection 0.5134 in Ratio= 282
Max upward Total Deflection 0.000 in Ratio= 0<180
I
Maximum Forces Stresses for Load Combinations
.. _. _ _.
Load Combination Max Stress Ratios Moment Values Shear Values
Segment Length Span# - M V Cd G FN Ci Gr
Cm G t CL M.._ fb F`b V fv N
i l�+H 0.00 0.00 0.00 000
Length=13.750 ft 1 0.306 0.109 0.90 1.100 1.00 1.00 1.00 1.00 1.00 0.95 2135.16 866.2.5 0.24 13,24 121.50
+D+L+H 1.100 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00
Length=13,750 ft 1 1.377 0.490 1.00 1.100 1.00 1.00 1.00 1.00 1.00 4.73 1,32519 962,50 1.22 66.19 135.00
+D+Lr+N 1.100 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00
Length=13,750 ft 1 0.220 0.078 1,25 1.100 1.00 1.00 1.00 1,00 1.00 0.95 265.16 1203.13 0,24 13.24 168.75
+D+S+H 1.100 1.00 1.00 1,00 1.00 1.00 0,00 0.00 0.00 0.00
Length=13.750 ft 1 0.240 0.085 1.15 1.100 1.00 1,00 1.00 1.00 1.00 0.95 265.16 '1106.88 0.24 13.24 155.25
+D10.750Lrt0,750L+H 1.100 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00
Length=13,750 ft 1 0.882 0.314 1.25 1.100 1.00 1.00 1.00 1.00 1.00 3,78 1,060.63 1203.13 0.98 52.95 168.75
+043 1.100 1,00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00
Length=13.750 it 1 0.958 :0.341 1.15 1.100 1,00 1,00 1.00 1.00 1.00 3.78 1,060.63 1106.88 0.98 52.95 155.25
"
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Title Block Line 1 Project Title,
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C'rwled'7 r),7 31 4i 211•n.1
c 6 _ _.. _ _._ _ "FoeM1 CIPROGRA-2t.ENERCAw1 "
Title Blank Dine t
ENERCALC,INC.196.3 2015,Build:815.12.9,Ver6.15.12 9
"
Description -None--
Load Combination tins Moment Values Shear Values
Max tetras Ratios
_ _ _
Segment Length Span nrt V Cd GFA1 Ci Cr Cm C t CL M ftp,. F"b V fv F"v
._ _
-- ...
-wD+0.60W-Ft-I 1.100 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0,00 0.00
Length=13.750 it 1 0.172 6,061 1,60 1,100 1,00 1,00 -1.60 1.00 1.00 0,95 265,16 1540.60 0.24 13.24 216.00
+D+0.70E+H 1.100 1.00 1.00 1.00 1.00 1,00 0.00 0.00 0.00 0.00
Length=13.750 It 1 0,172`°^`0.061 1,60 1.100 1.00 1100 1.00 1.00 1.00 0,95 265,16 1540,00 0.24 1124 216,00
+0+0.750LrA,750L+0.450W*H ;„ 1.100 1.00 1.00 1.00 1A0 1.00 0.00 0,00 0.00 0A0
Length=13.750 it 1 0.689 13,245 1.6fl 1.100 1,00 1,00 1,00 1,00 1,00 3,78 1,060.63 1540,00 0,98 52.95 216.00
+17+0,750L+0.750S+0A50W+H1.100 1.00 1.00 1,00 1.00 1.00 0.00 0.00 0.00 0106
Length=13"750It 1 0,689 0.245 1.60 1.100 1.60 1,00 1,00 1,00 1.00 3.78 1,060,63 1540.00 0.98 52.95 216.00
iD+0,750L+0350S+0.5250E+H 1.100 1,00 1,00 1.00 1.00 1.00 0.00 0.00 0.00 0,00
Length=13.750 ft 1 0.689°`"` V2,4, i 1.60 1.100 1.06 1.00 1.00 1.00 1,06 3.78 1,060.63 1540.00 0.98 52.95 216,00
+0,60D+0.60W+0,60H 1,100 1.00 1.00 1,00 1,60 1.00 0,00 0.00 0.00 0.00
Length=18.750 it 1 0.103 0.037 1.60 1.100 1.00 1,00 1.00 1,00 1.00 0.57 159,09 1540,00 0.15 7,94 216.00
+0.60D+0.70E+0,60H 1 1.100 1,00 1.00 1,00 1.00 1,00 0,00 0.00 0.00 0,00
Length=13.750 ft 1 0.103 "`� "0:03-1 1.60 1,100 1.00 1.00 1.00 1.00 1.00 0,57 159.09 1540.00 0,15 7,94 216.00
Load Combination - . Span _
overall l a;cirntlrn Deflections'
Max "Deil Location in Span Laad,Combination Max."+'"Defl Location in pan
..... 0,0000 6:060
0,5841 6.925
Vertical Reactions Support notation Far left.is#1 Values in KIPS
Load Combination Support 1 Support 2
overall MAXI mum - 1,1323 1.375 _
Overall MINimum 0.165 0.165
0„275 0,275
.,D",f.+H 1:375 1,375
+p44-r+H 0.275 0.275
+D+,S+H 0,G75 0275
+D+0150Lr+0,750L+F§ 1,10Q 1.100
+D+0.750L 0.750S+}1 1 100 1.100
+D+O,60W+H 0,275 0.275
+D+0,70E+H X0,275 0.275
+D+O,75OLr+0,750L+0.450W+H '.1(100 1,100
+D-rO.75OL+0.750S+OA50W+H °"1.100 1,100
•r0+0.750L+0.750S+0.5250E+H 1,,`4!00 1.100
+0.60D+0,60W460H 0.p165 0.165
+0,60D+OTOE+0,60H 0.165 0.165
D Only 0:275 0,275
Lr Only
L Only 1,100 1,100
S Only
W Only
E Only
H Only
�gti A,
..rye
Title Block Line 1 �„� ��� Project Title:
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Pa r Ut 7 r418 Q, 7,F1�
.-.. w......... . ....._.... r
Title Ln ,,, eae=c�Pr�actta-�2tiEnter�cA�1„
II Wood-- '� � ENERCAi.G,ING,1983.2015,6uild:6.15.12.9 Ver.6.15.12 9
Description: `-None--
CODE,REFERENCES3
_ _ ...._.,., - __._.
Calculations per NDS 2005,,862000, CBC 2010,ASCE 7-05
Load Commination Set :ASCE 7'101
Materialroper- .e
Analysis Method: Allowable Stf*659' esign Fb-Tension 2600 psi E:Modulus of Elasticity
Load Combination ASCE 7-10 Fb-Compr 2600 psi Ebend-xx 19OOksi
Fc-Prll 2510 psi Eminbend-xx 965.71 ksi
Wood Species : il-evel Truss Jist. Fc-Perp 750 psi
Wood Grade : Microl-arn LVL 1.9 E Fv 285 psi
Ft 1555 psi Density 42 pcf
Beam Bracing : Beam is Fully ra :dagainst lateral-torsion buckling
U O.04 G 0.16
V
2-1.75x9.25
Span=1$,750 ft
Applied Loads Service loads entered.Load Factors will be applied for calculations.
Uniform Load: D=0,040, L=010, Tributary Width-1.0 ft
D;rwSIGNSt1�'MARY °"
Maximum Bending Stress Natio = 11.437` 1 Maximum Shear Stress Ratio - OA99 : 1
Section used for this span 2..1.75x9.26 Section used for this span 2-'1.75x9,25
fb:Actual _ 1,136.39 psi fv:Actual 56.73 psi
FB:Allowable , - 2,600.00psi Fv:Allowable 285.00 psi
Load Combination +D+L+H Load Combination +D+L+H
Location of maximum on span = 6,875ft Location of maximum on span - 0.000 ft
Span#where maximum occurs - Span#1 Span#where rnaximum occurs = Span 111
Maximum Deflection
Max Downward Transient Deflection 0.295 in Ratio= 559
Max Upward Transient De#lectibq 0.000 in Ratio 0 <360
Max Downward Total Deflection,`" 0.369 In Ratio= 447
Max Upward Total Deflection 0.000 in Ratio= 0 <180
tNaxiturri Forces Stresses for.,v Corrtbinatiarrs
._..__ ..... . .
Load Combination Max Stresf,Ratios Moment values Shear Values
Segment Length Span# M .V Cd C FJv C i Cr C m C t CL M ib Fb V F v-
---
+D+j 0.00 0.00 0.00 0.00
Length=13,750 it 1 0.097 0.944 0.90 1.000 1.00 1.00 1,00 1.00 1.00 0.95 227.28 2340.00 0.24 11.35 256.50
+D+4_+ft 1.000 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00
Length z 13.750 it 1 0A37 'x"^0.199 1.00 1.000 1.00 1.00 1.00 1,00 1.00 4.73 1,136.39 2600.00 1.22 56.73 285.00
+D.,Lr+Hr 1,000 1.00 1.00 1.00 1.00 1.00 0.00 0,00 0.00 0.00
Length=13,750 it 1 0.070 M,a° 0,032 1.25 1.000 1,00 1.00 1.00 1.00 1.00 0.95 227,28 3250.00 0.24 11.35 356.25
D.� +}1 1.000 1.00 1.00 1.00 1.00 1.00 0,00 0.00 0.00 0.00
Length=13.750 it 1 0,076 0.035 1.15 1.000 1.00 1.00 1.00 1.00 1.00 0.95 22.7,28 2990,00 0.24 11.35 327.75
40,47501-r+0.7501-+H 1.000 1.00 1.00 1,00 1.00 1.00 0.00 0,00 0.00 0.00
Longth=13.750€t 1 0,2.80 0.127 1.25 1.000 1,00 1.00 1.00 1.00 1.00 3.78 909,11 3250.00 0.98 45,39 356,25
+D+0.750L+0,750S4I ° ° f, 1.000 1,00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00
Length=13,750 If 1 0304. 10,138 1.15 120 1.00 1.00 1.00 1.00 1.00 3,78 909.11 2990,00 0.98 45.39 327,75
Yb
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Title BlockLine 6 Pani d I0CT 016 �
�R
Wood
Bear �o _. _ _-- .........__ ENERCALC,INC,t963-20t5`8u fd6.15,12 9 Very ,5 J'
Description: --None--
Load Combination Max Strdss,Ratios Moment Values Shear Values
Segment Length Span# M V Cd C FIV C i Cr C rn C t C L M ib F b V tv F'v
_... _ .............. _... -.__.._ _,__.. -- .__ ..... _. -......
rD+0.60W+H 1.U00 1.00 1.00 1.00 1,00 1.00 0.00 0.00 0.00 0.00
Length=13,"750 ft 1 O.U55 "°0,025 1.60 1.000 1.00 1.00 1.00 1.00 1.00 0.9.5' 227.26 4160.00 0.24 11.35 456.00
+D40.70E+H 1.000 1.00 1.00 1,00 1.00 1,00 0.00 0.00 0.00 0.00
Length=13.750 ft 1 0.055"": 0.025 1.60 1.000 1.00 1.00 1.00 1.00 1.00 0.95 227,28 4160.00 024 11.35 456.00
+1)+0.7501-r+0.760L+0,460W-+H1.000 1.00 1.00 1.00 1.00 1.00 0.00 0.00 U0 0.00
Length=13.750 ft1 0.219 .p 0,100 1.60 1.000 1.00 1,00 1.00 1,00 1.00 3.78 909.11 4160.00 0.98 45.39 456.00
+D40,750L+0.750S+0A50W+H W 1.000 1.00 1.00 1.00 1.00 1.00 0.00 0,00 0.00 0.00
Length..13.750 ft 1 0.219 0,100 1.60 1.000 1.00 1.00 1.00 1.00 1.00 3.78 909.11 4160,00 0.98 45.39 456.00
+D4750L+0.750S+0,5250E+H 1 « 1.000 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0,00
Length=13.750 it 1 0.219,,, 0.100 1.60 1.000 1.00 1.00 1.00 1.00 1.00 3.78 909,11 4160.00 0.98 45.39 456,00
+0.60D+0.60W+0.60H 1.000 1.00 11.00 1.00 1.00 1.00 0.00 0.00 0,00 0.00
Length_13.750 ft 1 0.033 ',"a 0.015 1.60 1.000 1.00 1.00 1.00 1.00 1.00 0.57 136.37 4160.00 0.15 6,81 456,00
+0.60D+0.70E+0,60H * 1.000 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00
Length=13.750 ft 1 0.033 0,015 1.60 1,000 1.00 1.00 1.00 12 1.00 0.57 136,37 4160.00 0.15 6.81 456.00
OverallMaximum eflectlana
Load Combination Span Max. 2 Defl Location in Span Load Combination Max +"Deft Location in Span
+D+L+t.._ 1... 0.3689 _ 6.925 0.6000 0.000
Verticaleaction Support natation:Far left is#1 Values in KIPS
....-.-.- ..., ...__. .. .. .-_. _._ ...._,.._ ... __ ..._. _ . . ._...
Load Combination Support 1 Support 2
OvoratftNAkirnum 1:315 _.._..._1.375
OverallMINImum 0.165 0.165
+D+H 0,275 0.275
+D4L4-H 1�75 1.375
+D+Lr+H 0,275 0.275
+D+S+H ,"0.275 0.275
+D+0,750Lr+0,750L+H 1.100 1,100
+D40.750L+0.750S+H 1.100 1.100
+D+0.60W+H '0,275 0.275
+0+0.70E+H 0.175 0,275
+D+0.750Lf•+0.750L+0.450W+H 1:100 1.100
+4)+0.750L40.750S+0.450W+H . 1`t100 1,100
+D40.750L+0.750S+0.5250E4-H 1,100 1.100
-*U0D+0,60W+0.60H 0.165 0.165
40.60D470E40.60H 0.165 0.165
D Only 0"276 0.275
Lr Only
L Only 1.100 1.100
S Only
W Only
E Only
H Only t"
w�
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Title BI4ek Line 6 ,
� �
- - Fifa-QTROCaFW�11FNERC,A�1
� f:NFRCALC,INC.19932015 BuiIdG15.12.9 Ver.6.15.i29
a as a6 m�" e� a At
lii 1,11
Description: Nona
CODE REFERENCES
Calculations per NDS 2005, IBC.2009, CBC 2010,ASCE 7-05
Load Combination Set :ASCD�-10
Material l ro er ie
Analysis Method: Allowable Stress-D,esign Fb-Tension 2600 psi F Modulus of Elasticity
Load Combination ASCE 7-10 Fb-Compr 2000 psi Ebend-xx 1000ksi
Fc-Prll 2510 psi Eminbend-xx 955.71 ksi
Wood Species : it-evel Truss,t'c tk, Fc-Perp 750 psi
Wood Grade :MicroLa1:9� Fv 255 psi
rn LVL
Ft 1555 psi Density 42 pcf
Beam Bracing : Beath is Fully.Bra d against lateral-torsion buckling
17(Ct.2E3)L(1.1)
D(0,07)Lt0.25)
v v
2-1.750.25
Span=11.50 ft
Applied La ads Service loads entered Load Factors will be applied for Calculat�orrs.
-
Point Load. D=0.280, L=1 10 k°(rt7 670 ft
Uniform Load: D=0 070, L 0.,20 ktlt,Extent °7,570- >11.50 ft, Tributary Width=1.0 ft
D SION SUMMARY
Maxirrtum Bending Stress Ratio ;° = 0.484 1 Maximum Shear Stress Ratio - 0.288 : 1
Section used for this span "�°' `1.-1.75x9.25 Seaton used for this span 2-1,75
fb:Actual 1,257.38 psi fv:Actual _ 82,16 82.16 psi
FB:Allowable - 2,600.00psi Fv:Allowable - 285.00 psi
Load Combination +D.+1 +H Load Combination +D.L+H
Location of maximum on span - 7.681 It location of maximum on span 101,745 ft
Span#where maximum occurs.,, ",; = Span#1 Span#where maximum occurs - Span#1
Maximum Deflection
Max Downward Transient Oefle"ction 0.182 in Ratio= 758
Max Upward Transient Defkectig,n 0.000 in Ratio= 0 e360
Max Downward Total Defle6tioh' 01.228 in Ratio= €:305
Max Upward Total Deflection:° 0.000 in Ratio= (:) <180
Maximum Forces&Stresses ff(Ir�oad Combinations
_....
Moment Values Shear Values
Load Combination Max Stress Ratios ___ ._... .
Segment Length Span# 'V V C d C FN C i C r C m C t C L M. fb F b V fv F'v
.._. _ 0.00 0,00 0.00 0,00
Length=11.50 ft 1 0.109 , 0.065 0,90 1.000 1.00 1.00 1,00 1.00 1.00 1.06 253.93 2340.00 0.36 16.56 256.50
+D+L+H 1.000 1.00 1.00 1.00 1.00 1,00 0.00 0.00 0.00 0.00
Length=11,50 ft 1 0.484,,, 0.289 1,00 1,000 1,00 1.00 1.00 1.00 1,00 5.23 1,257.38 2600.00 1.77 82.16 285.00
+D+Lr+H 1.000 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 .
Length=11.50 ft 1 0.07$' 0,046 1,25 1.000 1.00 1.00 1.00 1.00 1.00 1.06 253.93 3250,00 0,36 16.56 3566.2255
+D+S,�H 1,000 11,00 1.00 1.00 1.00 1,00 0.00 0.00 0.00 0.00
Length=11.50 ft 1 0.085 " 0.051 1.15 1.000 1.00 1.00 1 z 1.00 1.00 1.06 253.93 2990.00 0.36 16.56 327.75
.tD+0,750Lr+0,750L+H 1.000 1.00 1,00 1.00 1,00 1.00 0,00 0.00 0.00 0.00
Length=11.50 It 1 0.310+" 0.185 1.25 1.000 1.00 1.00 1.00 1.00 1.00 4.19 1,006.51 3250.00 1.42 65.76 35615
0,00 O.qO
+D+0.750L-+0.750S+FI 1.000 1:00 1.00 1.00 1.00 1,00 0.00 0.00
° Baa
Title Block Line I Project Title:
You can change this area Engineer: Project ID:
using the"Settings'menu item Project Doscr:
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Title Block Line 6PrinIM: 700 2016",UPI!
.............
File GAPROGRA-MNERCA-1
' Wood Beam
ENERCALC,INC.1983-2015,Bulld:6.15.1Z%z- Vet
,6.M`12,9
-ice"
Description -None-
Load Combination Max Stress,f atios Moment Values Shear Values
Segment Length Span# ivl V- Cd C FN C I Cr C m C I G L M fb Fb V N F'v
...........
Length 11.50 ft 1 0.337 0,201 1.15 U00 1,00 UO 1.00 1.00 1.00 4,19 1,006,51 2990,00 1,42 65.76 327,75
+D+0,60W-+H 1 1.000 1.00 1,00 1.00 1.00 1.00 0.00 0.00 0.00 0.00
Length=11.50 It I uol "0.0,36 1.60 1.000 1.00 1,00 1,00 1,00 1,00 1.06 253.93 4160.00 0,36 16.56 456,00
+D-t0.70E+H 1.000 1.00 1.00 1,00 1,00 1,00 0.00 0.00 0.00 0,00
Length=11.50 ft 1 0.061 0.036 1.60 1,000 1.00 1.00 1.00 1.00 1,00 1.06 253,93 4160.00 0.36 16.56 456.00
+D40.750Lr-+0.750L+0A50W+H 1,000 1.00 1.00 1.00 1,00 1,00 0.00 0.00 0,00 0.00
Length=11,50 ft I 0.242 '0.144 1.60 1,000 1,00 11.00 1.00 1.00 1.00 4,19 1,006.51 4160.00 1.42 65,76 456,00
+11401501-t0,7508+0.45OW-4-1 1,000 1.00 1,00 1.00 1,00 1.00 0.00 0.00 0.00 0,00
Length=11.50 ft 1 0,242 0A44 1.60 1,000 1.00 1.00 1.00 1.00 1,00 419 1,006.51 4160.00 1.42 65.76 456.00
-tD-+0.750L-+,0,750S10.5250E-i H 1,000 1.00 1,00 1.00 1.00 1,00 0.00 0.00 0,00 0.00
Length=11.50 It 1 X0.242 r 0.144 1.60 1,000 1.00 1,00 1.00 1.00 1.00 4.19 1,006.51 4160.00 1,42 65,76 456.00
+0,60D+0.60W+0,60H : 1,000 1.00 1,00 1,00 1.00 1.00 Ho 0.00 0.00 0,00
Length=11,50 ft 1 0.037 0,022 1.60 1,000 1,00 1.00 1,00 1.00 1.00 0.63 152,36 4160,00 011 9,93 456.00
+0.60DA.70E-4601-1 1.000 1.00 1.00 1,00 1,00 1.00 0.00 0.00 0,00 0.00
Length=11.50 ft 1 01037% 0,022 1.60 1.000 1,00 1,00 1.00 1,00 1.00 0.63 162.36 4160.00 0.21 9,93 456,00
Overall Maximum Deflections
Load
6a.d Combination 1. I I I- 11 S 1 p gn -Max,I Deft Location in Span Load Combination Max,'-O'Dell Location In Span
+D-H I--+H 1.11-1....1-- 0.2279 6.336 0,0000 0.000
Vertical Reactions w Support notation Far teff is#1 Values In.,KIPS
-1-.-..............
Load Combination Support I Support 2
Overall MAXiinum
p.q83
Overall MINimum 0ffl3 0,246
+D+H q.1138 0,410
+D-PL+ 1.683 2.038
+D+Lr4H 0.138 0.410
+0+S+H '0.138 0.410
+D40,75OLr-+0.750L+H 0.547 1,631
+D40.750L+0,750S+H 0.547 1,631
4D+0.60W+H 0,138 0,410
-4DA,70E-#H 0.138 0,410
-i-D,0.750Lr-t0,7501..,0.45OW-,H 0147 1.631
+D+0.750L-q0J50S+0A50W+H 6:647 1.631
+D.4-0.7501..,,0,7605-+0.5250E+H 047 1.631
+0,60D460W40.60H 0,683 0,246
+0.60D+0,70E-t0.60H &.083 0,246
D Only '0.438 0,410
Lr Only
L Only 0 X45 1.527
8 Only
W Only
E Only
H Only
Title Block Line 1 Project'ritle:
i
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using the'Settings"menu item Project Descr:
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Title Block"selection,
Title Block Line 6
..........
-2ENE
Fife CAPROGRA
RCR.TA-1
Steel Bearn
ENERCALC,INC,1983-2015,Budd 615,12.9 Ver 615,12.9
Description .-None--
CODE REFERENCES
Calculations per RISC 360-05, 113C2009, CBC 2010,ASCE 7-05
Load Combination Set:ASCE 7-10
Material Properties ------ ..............
Analysis Method: Allowable Strength Design Fy Steel Yield: 50,0 ks!
Beam Bracing Beam is Fully Grac,od against latorat for-donal buckling 17:Modulus: 20,000.0 k3i
Bending Axis Major Axis Bendinig
Load Combination ASCE 7-10
oio.25)LLU.75)
span-1 5.260 ft
INW4
Applied LoadsService loads entered.Load Factors will be applied for calculations.
.............
Beam self weight NOT internally calculated and added
Uniform Load: D=0.250, L=,0160 k/ft, Tributary Width=1.0 ft
DESIGN SUMMARY
Maximum Bending Stress Rat)"O' 0.504: 1 Maximum Shear Stress Ratio= 0A 96
Section used for this span W8x24 Section used for this span W8x24
Ma:Applied 29.070k-ft Va:Applied 7.625 k
Mn I Omega:Allowable 57.635 k-ft VnIOrnega:Allowable 38,857 k
Load Combination +D+L+H Load Combination +D+L+H
Location of maximurn on span 7,625ft Location of maximum on span 0,000 ft
Span#where maximum occurs Span#I Span#where maximum occurs Span#I
Maximum Deflection
Max Downward Transient Deflection 0,382 in Ratio= 478
Max Upward Transient Deflection, 0,000 in Ratio 0 <360
Max Downward Total Deflection 0.510 in Ratio= 359
Max Upward Total Deflection 0.000 in Ratio= 0<180
Maximum Forces&Stresses for'1_6ad Combinations ..................
...Loa I d CoMbInat!"on fax Stress Ratios
os Summary of Moment Values Summary of Shear Values
Segment Length Span# M V_- - Mrnax_-4- 'Mmax- Ma-Max Mnx Mnx/Omega Cb Rm Va Max Vnx Vnx/Omega
Dsgn.L= 15.21 ft 1 0,126 0,049 7,27 7.27 96.25 57.63 11,00 1.00 1.91 58.29 38,86
Dsgn,L 0.04 ft 1 OZI 0,049 0.08 0.08 96,25 57.63 1.00 1.00 1.91 58.29 38.86
+D+L+H
Dsgn,L= 1521 ft 1 0,504 0,196 29.07 29.07 905 57.63 1.00 1.00 7,63 58,29 38.86
Dsgn.L= 0.04 ft 1 :1 0.006 0A96 033 0,33 96.25 57.63 1.00 1,00 7.62 58.29 38.86
40+Lr+H
Dsgm,L 1521 ft 1 0,126 0,049 7.27 7.27 96.25 57.63 1.00 1.00 1.91 58.29 38,86
Dsgn.L= 0,04 ft 1 «0.00'1 0.049 0.08 0.08 96.25 57,63 1.00 1,00 1.91 58.29 38.86
+D+S-H
Dsgn L- 1511 it 1 0.126 0.049 7.27 7.27 9615 51.63 1.00 1.00 1,91 68,29 38.86
Dsgn.L= 0,04 ft 1
."0.001 0,049 0.08 0.08 96,25 57.63 1,00 1.00 1.91 58,29 38.86
+D+0.750Lr+0.750L+H
Dsgn,L= 15.21 It 0.410 0,159 23,62 23.62 905 57.63 1.00 1.00 6.20 58.29 38.86
Dsgn.L= 0.04 ft 10,005 0,159 0.27 0.27 96,25 57.63 1.00 1.00 610 58.29 38.86
+D+0150L+0.750S+H
Dsgn.L= 15.21 ft 1 0.410 0.159 23,62 23,62 90.25 57.63 1,00 1,00 6.20 58.29 38.86
Dsgn.L= 0.04 ft 1 0,005 0,159 0,27 0,27 96.25 57,63 1,00 1,00 6.20 58.29 38,66
+D+0,60W+H
Dsgn.L- 15,21 ft :«+0.126 '0.049 7.27 7,27 96.25 57.63 1.00 1.00 1.91 58.29 38.86
Dsgn,L= H4 ft 1 HIM 0,049 0,08 0.08 96.25 57.63 1,00 1.00 1 91 6819 38.86
-t0+0.70E4JJ
Dsgn,L= 421 it 1 0.126 0.049 7.27 7.27 96.25 57,63 1.00 1.00 1,91 58,29 38,86
Ligon,L 0,04 ft 1 0,001 0,049 0.08 0.08 96.26 57.63 1.00 1.00 1,9 1 58.29 38,86
Title Block Line 1 Project Title:
You can change this area Engineer: Project ID:
using the"Settings"menu item µ, Project Descr:
and then using the'Printing&
Title Block"selection.
Title_Block Line 6 r r,n cd.P)r r 2N 9.4 it
f _. . .. F " 11LN E{15.1__. �
...;
Steei
rte=C 1PR�JC�RA� CA 19
a ?
--- _._.....
t;N�RCALC,INC.1983-2015,Build 6.15.12,9 Ver 6
Description hone--
Load Combination Max Stress Ratios Summary of Moment Values Summary of Shear Values
Segment Length Span 4 M V Mmax+ Mmax- Ma Max Mnx MrrxfOmega Cb Rm Va Max Vnx Vnx/Orrzega
bi3O.750Lr+0.750E+0.450W+H 1"
Dsgn.L= 15.21 ft 1 0.410 0.159 23.62 23.62 96,25 57,63 1.00 1.00 6.20 58.29 38.86
Dsgn.L= 0,04 It 1 0.005 0.159 0.27 0.27 96.25 57.63 1.00 1.00 6.20 58.29 38.86
4D+0,750L+0.750S+0.450W+H
Dsgn.L= 15.21 It 1 .0,4'10 0.159 23.62 23.62 96.25 57.63 1.00 1,00 6,20 58,29 38.86
Dsgn,L= 0.04 ft 1 ;,0.005 0.159 0.27 0.27 96,25 57.63 1.00 1.00 6.20 58.29 38.86
-+D+0,750L+0.750S+0,5250E+H
Dsgn.L-- 15.21 ft 1 0.410 0.159 23.62 23.62 96.25 57.63 1.00 1.00 6.20 58.2.9 38.86
Dsgn,L= 0.04 ft 1 0,005 0.159 0.27 0.21 96.25 57.63 1,00 1.00 6.20 58.29 38.46
+0.60D+0.60W+0.60H
Dsgn.L, 15.21 ft 1 0.076 0.029 4.36 4,36 96.25 57.63 1.00 1.00 1.14 58.29 38.86
Dsgn.L= 0.04 ft 1 "•0.001 0.029 0.05 0.05 96.25 57.63 1.00 1.00 1.14 58.29 38.86
+0.60D+0,70E+0.60H ""
Dsgn.L= 15.21 It 1 10.076 0.029 4.36 4.36 96.25 57.63 1.00 1.00 1.14 58,29 38.86
Dsgn.L= 0.04 ft 1 0,001 0.029 0.05 0.05 96.25 57.63 1.00 1.00 1 A4 58.29 38.86
Overall Maximunn Deflootiarts . .:
----_-_ ---- .. -- _.......
Load Combination Span Max. "Defl Location in Span Load Combination Max +"DeIi L 11 ocation in Span
-+D+L+H . ._. ...__ 7,669 0,0000 0,000
1 0.5097
Vertical leactlrt values in tciPs
Support notation Far left is fR1
<.._. ._ . ........._ _..__. ..._
Load Combination Support 1 Support 2
Ovorall Mk nium -..... '' 1.626 -- 7,625
Overall MINlmum 1:144 1.144
+D+H ^1.906 1.906
+D4L+H 1.625 7,625
-D+Lr+H 1.906 1.906
+D+S+H 1.906 1,906
+D+0.750t_r+0.750L+H 6.195 6.195
+D+0,750L-g0,750S+H x.195 6.195
+D+0.60W+H 1.906 1,906
-+D+0.70E+H 1. 06 1.906
+D+0,750Lr+0.750L-+0,450W+H 6.195 6.195
+D-4)350L40,750S-+0.450W+H 6.195 6.195
+D+0.750L40.750S40.5250E+H 096 6.195
40.60D40.60W+0,601-1 1144 1.144
40.601)+0,70E4601-1 f.144 1.144
D Only 4.906 1.906
Lr Only i`�
L Only 5.719 5.719
S Only
W Only
E Only
11 Oniy
w
:a
a
d
Vz-'
f Y�i 1/1 j
c
q
%tD
17
C-7
ti
4.
OVERHANG ABOVE
r-y
RRST FLOOR�
-----------4
r
c6DC
I V
i
I
-- d7}
�!
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR
OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE
BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE
INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN
BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU
CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF
THE TRANSACTION WILL BE CANCELLED.
IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT
YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN
RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR
SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF
THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE
SELLER'S EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE
SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF
CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT
ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE
TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER
AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR, PERFORMANCE OF ALL
OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND
DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN
NOTICE, OR SEND A TELEGRAM TO [Name of Seller], AT [Address of Seller's Place
of Business] NOT LATER THAN MIDNIGHT OF LU—/6 (date).
I HEREBY CANCEL THIS TRANSACTION.
,,,
Date:
Buyer's Signature.�
Contractor Arbitration
The Horne Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a
contractor,however. The contractor would have to resolve any dispute lie/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitration asprovided In Massachusetts General Laws,chapte 42A.
s SiD—!
,,owne 'v�
'es,Signature Can tact iature
NOTICE:The signatures of the parties above apply only to the agreement oftic�partics to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights ,
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure then-own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in duplicate
ate and should not be signed until a copy of all exhibits and referenced
docurnents have been attached. Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to
be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing
and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of
the contract,and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deans him/herself to be financially insecure. However,in instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of unds from said account would require the
signatures of both parties.
Additional Information
If You have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline
Office of Consurrier Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCA13R website at I Up: %, %vrna - ov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law,contact:
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the HIC website at I" .�nass.�qy�ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
/h me i ruent/licenseelist a
—1-1)p sqj
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800,508-755-2548 or 413-734-3114
Version 2.1-11/22/2010
The Commonwealth of Massaehusetts
s Department of hidustrialAecidents
4 Congress Street,Suite 100
Boston,MA 02114-2017
www.rnass.gov/dia
r•M SV
� 'orlcers'Compensation.Insurance Affidavit:Builders/Contractors/Electricians/.Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information I Please Print Legib
N,aMe (Business!Organization/Individual): t rl
Address: f),—lib -
City/State/Zip: Phone#: 17 �1 C/ -70 7-7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New nstMetion
2.E]I ain a sole proprietor or partnership and have no employees working for me in 8. emodeling
any capacity.Ivo workors'comp.ursurnnce required.]
9. ❑Demolition
3.❑lama homeowner doing all work,myself[No workers'comp.insurance required.]"
10E)Building addition
4.❑lain 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.❑Plumbing repairs or additions
5.0 1am a gen al contractor and 7 have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
Ther contractors have employees and have workers'comp.insurance.'.
14.❑Other
6, a are a corporation and its officers have exercised their right of exemption per MCL G.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box ii l must also fill out the section below showing their workers'compensation policy information,
r iiorneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now affidavit indicating such.
/Contractors that cheek this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees, tribe sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insuraltce for rrty employees Relon,is the policy and joh site
information.
Insurance Company Name: C L V,
Policy##or Self-ins.Lie.#: A B— } Expiration Date: f
Job Site Address: r )�6 a✓ 644 City/State/Zip: _
Attach a copy of the workers' mpensation 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 tap to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORTS.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 i ider the pains and penalties of'perjury that the irtforrraation provided above is true and correct.
Signature: Date: —1
Phone
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#:
e, Office of Consumer Affairs and Business Regulation
%i 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 167632
Type: LLC
Expiration: 10/13/2016 Tr# 259828
AXIS BUILDERS LLC.
ADAM BUNNELL
14 A NORTH SALEM RD
HAMPSTEAD, NH 03841 _____.
Update Address and return card.Mark reason for change.
C.._..� Address ] Renewal Einployment F Lost Card
SCA 1 Co 20M-05/11 '
_ Massachusetts.��,a,....�f�oare! of Building�..:..��:,v�
Department of Public Safety
�
tl p
Regulations an S,kgnd arils
License: CS-086557
r
Construction Supervisor
ADAM S BUNNELL
14 A N.SALEM RC7l1
k°I{ P'STEAD NH, 0 -�
1. Expiration:
Commissioner 08/20/2017
i
I