HomeMy WebLinkAboutBuilding Permit #507 - 44 LISA LANE 2/10/2010TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
TYPE OF IMPROVEMENT
PROPOSED USE
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Residential—Non-
Residential
New Building
One famil
Addition
Two or more family
Industrial
Iteration
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
Septic`UVeII
Floodplain UVetlands
Watershed District
Water/,Suer.
DESCRIPTION OF WORK TO BE PERFORMED:
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OWNER: Name:
Address:
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $_ -L �'(, �� 9) FEE: $
Check No.: Receipt No.: dr)
NOTE: Persons contr acting with onregis rpq co tro ctor s do not have access to the Qukr funs
Signature of Agent/Owner /,%
Sjgnature of contras
R
Plans Submitted Plans Waived Certified Plot Plan
Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales +
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
{ COMMENTS
Zoning Board of Appeais: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer ConneCtion/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 364 Usgood Street
FIRE DEPARTMENT -Temp Dum,pster op` site yes po
Located at 124'Main Street.
Fire De,partrne.nt:s ghatuare/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: . Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
i
Doc:.Building Permit Revised 2008
J
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008
Location �_
No. Date
40*Th TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
Building/Frame /Frame Permit Fee $
�ss__.....e 9
Foundation Permit Fee
Other Permit Fee
TOTAL
Check #
L12
24 4„
Building Inspector
.41
Date ...�. .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... r'�) "Vae
................................... .............. ................................
has permission to perform .....
........... ....
wiring in the building of ................ D.e. .... W ...... .....................................................
at ................ L/Y .... Z-/. 5./
.. .. ... ..... ... .
... North Andover, Mass.
...... ..... ��'/ . ..........
Fee.< () . . ....... Lic. No. ............. t'.Z. ...........
Check 'I ELECTRICAL INsPxCr0Rj
9252
D
—t\, Commonwealth of Massachusetts Official Use On]y
Department of Fire Services Permit No. el Z-5-2-
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] f1eo.,nl.1_1,N
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code( EC), 527 CMR 12.00
(PLEASE PRINT W INK OR TYPE ALL INFORMATION Date: ' Q
City or Town of: NORTH ANDOVER
To the Inspector o Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & N ber) S rA L
Owner or Tenant e Y n n I \
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
No, of Recessed Luminaires
No. of Luminaire Outlets
of Luminaires
No. of Receptacle Outlets
o. of Switches
o, of Ranges
o. of Waste Disposers
o. of Dishwashers
No. of %ersof er
Heaters �'
No. Hydromassage Bathtubs
W OTHER:
Telephone No.
Yes 0 No ❑ (Check Appropriate Bog)
Utility Authorization No.
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Completion o the
Of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above ❑
No. of On Burners
No. of Gas Burners
No. of Air Cond.
Space/Area Heating KW
Heating Appliances KW
1140. 01
Ballasts,
No. of Motors Total HP
M
may be waived b
the Ins ector of Wiresof
Totalnsformers
KVA
erators
T
KVA
o mergency
e Units
ig g
FIRE ALARMS INC. of Zones
of Alerting Devices
. of Self-contained
teetion/Aler(ing Devices
Ud ❑Municipal
Connection ❑Other
:urity Systems:*
1Vo. of Devices or Equivalent
to Wiring:
No. of Devices or Equivalent
ecommunicahons Wiring:
No. of Devices or Ennivalr nt
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 0��,
(When required by municipal policy
Work to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANC BOND ❑ (Specify:)
I certify ❑ OTHER
under the ains and penalties of perjury that the information on this application is true and complete.
FIRM NAME. �,j S-aC LIC. NO.:
Licensee:
(If applicab ter "07-6
" in the license nu a line.) Signature LIC. NO.: %
Address: f147
Bus. Tel. No.:��_ �lq/ J
*Per M.G.L ,.1, security work requires D ty „ „ Alt
Tel. No.: V7$ �
OWNER'S INSURANCE WAIVER: I am aware that the Lice a does not ehave the lI liability Lie. No.
rance normally
required by law. By my signature below, I hereby waive this requirement. I am the (c
Owner/Agent heck one) ❑owner co❑ owner's agent.
Signature Telephone No. PERMIT FEE: $
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
•N f{1 600 If'oshin ton Street
;V /11 _
Boston, MA 02111
\ j www.nxassgov/dia .
Workers' Compensation Insurance Affidavit Builders/Contractors/Electriciaus/Plambers
Applicant IRfornl;ation
n
Name
Address: C3 �4
City/sw'e/Zip: sz'l of 'I
1 ,,J1fb Phone #: G 911
employer? Check the appropriate bo71n
employer with �
FMT
4. T� of proJed (required):
❑ Inera) contractor and Iees
(full and/or part-time).*
..sole proprietor or
hd the sub -contractors 6. ❑ New construction
partner_
ship and have no employees
listed the attached sheet. x 7. ❑ Remodeling
T&contractors haveworking
forme.m any capacity.
[No workers' comp. insurance
wcomp. insurance. 8 ❑ Demoittton
5. ❑ Wcorporation and its 9. ❑ Building addition
required.oave
i ama homeowner doing
exercised their 1Q•❑ Electrical repairs or additions
all work
rrayself. [No -workers' comp.
rixemption per MGL 11.❑ Plumbing repairs or additions
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers' 12.❑ Roof repairs
COMP. insurancr.requimd.] 13.❑.Other
'Any appiicattt that checks berl #I must also fill out the section below showing their workets' ao
t Homeowners who submit this affai avit indicating they am doing at1 work and the hire outside cmvn�'wi- policy information.
tCottbactots that check this box must attached submitta
an additional sheet showing the name of the sub.conft r, ,must new affidavit indicating such.
r,N. iOlicy inmm�adon.
! ars an employer that is.
proufdcrrg:workers' comperrsatian insrrranee or
information. f m1' employees, Below is the policy =d job site
Insurance Company Name:
Policy # or Self -ins. Lie. #:
/ Expiration Date:
Job Site Address: Ll `� CII C;4'
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 A of MGL C. 152 _
fine up to $1,500.00 and/or one-year riimprisonment, ass well tis civil penalises in the lead form of a STOP WO ORtion Of DER
ptnalties of a
Of up to $250.00 a day against the violator. Be advised that a copy f o this statement may be forwarded to the Office and a fine
Investigations of the DIA for insurance coverage verification.
I do hereby c u e
of perjury that the iRfnrmatioa provided above is true and conecx
Si tore:
Date. � a
phone #:
Official use nn" Do not write in this area, to be completed by citt, or town o�cic(
City or Town
Permit/License #
Issuing Authority (circle ooe):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector S. Plumbing Inspector
6. Other
Contact Person:
Phone #:
From:M&M Assurance/Mason&Mason Ins 603 356 9290 02/06/2010 17:53 #491 P.002/003
A2= CERTIFICATE OF LIABILITY INSURANCE
02/09/2010
PRODUCER (781)447-SS31 FAX (781)447-7230
Mason & Mason Insurance Agency, Inc.
4S8 South Ave.
Whitman, MA 02382
Gwen Vosburgh
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE MAIC #
INSURED John A. Buttaro, Inc.
181 Salem Street
Woburn, MA 01801
INSURER A: Western World 000071
INSURERS National Grange Mutual 14788
INSURER c: Associated International Ins.
INSURER D Travelers 000066
INSURER E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
DO'
TYPE OF INSURANCE
POLICY NUMBER
POUCYEFFECTIVE
DATE IMMIDDIM
POLICY EXPIRATION
LIMBS
1600 Osgood St
OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES.
GENERAL LIABILITY
NPP1204199
06/12/2009
06/12/2010
EACH OCCURRENCE $ 1,000,0
DAMAGE TO RENTED $JOO,
COMMERCIAL GENERAL LIABILITY
MED EXP (Any one person) $ 5.0
CLAIMS MADE � OCCUR
PERSONAL & ADV INJURY $
A
X
GENERAL AGGREGATE $
GENL AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
POLICY JEC F7 LOC
AUTOMOBILE
LIABILITY
ANY AUTO
M9596SO9
07/03/2009
07/03/2010
COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,0()c
BODILY INJURY
(Per person) $
B
X
X
X
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
N014 -OWNED AUTOS
BODILY INJURY
(Per accident) $
PROPERTY OAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY
CUBW2734609
06/12/2009
06/12/2010
EACH OCCURRENCE $ 1.00 00
AGGREGATE $ 1,000,0
-5q OCCUR a CLAIMS MADE
$
C
$
DEDUCTIBLE
$
X RETENTION $ 10, 00
WORKERS COMPENSATION AND
XOUB824K784209
10/17/2009
10/17/2010
WC STA TU- OTMR
E.L. EACH ACCIDENT $ 500 0
D
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECLMVE
OFFICER]MEMBER EXCLUDED?
OFFICER IS INCLUDED
E.L. DISEASE- EA EWLOYEE $ S00,00c
If yes, describe under
SPECIAL PROVISIONS below
E L. DISEASE - POLICY LIMIT $ 500'0
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS
operations: home builder
r�nr�orwrr unr nee 9 -Aldi I ATMM
ACORD25(2001I08) FAX: (978)688-9542 (DACORDCORPORATION1988
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Town of North Andover
10 DAYS wRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn Brian Leathe
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
1600 Osgood St
OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES.
D REPRESENTATIVEvid
FD-
NO Andover, MA 01845
H Mason
ACORD25(2001I08) FAX: (978)688-9542 (DACORDCORPORATION1988
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Andover
89 North Main Street U:; ' 11 Kenneth M. LaRose
Andover, MA 01810
•° F � `� . � m.President
buil' s, enc.
,.Build ng,-�our home as if it were ounown!
Tel: 978-470-4753 Fax: 978-470-0258 www.andoverequitybuilders.com
2/04/2010
Dawe Living room and Kitchen
Proposal
• AEB is pleased to provide a proposal for the scope of work described
below.
• A town of North Andover Building permit is included.
• A disposal container that will also be placed off site to dispose of all
waste materials.
• Dust protection will be used to help keep dust from migrating into non
work areas.
• AEB will remove all the wood base board trim in the Living room and on
the kitchen wall that will have the openings cut.
Frame three openings in the wall between the Living room and kitchen
actual size to be determined. AEB will install the structural header to
adequately support the second floor framing over the openings.
• These openings will be trimmed with blue board w/metal corner beads
and a plaster skim coat troweled to a smooth finish. Wall cap to also be
plastered. Other options are available and could be priced accordingly.
• The living room will have a Brosco crown molding # 8013FJP 4 5/8"which
is primed applied at the ceiling wall line. This molding will be on four
sides including in front of the built in bookcases on either side of the fire
place. Bookcases are as follows : 2 -20" deep lower cabinets with 10"
deep upper bookcases. Cabinets are to be 88-1/2" tall with overlay doors
and 3-1/2" applied base. Approximately 31-1/2" wide on left side and 28-
1/2" on the right side . Shelves will be wood or glass adjustable.
`14
Fireplace hearth treatment to be determined.
Painting is as follows : Prep work consists of the following Kitchen,Living
room and First floor hall. Patch walls and ceiling holes and cracks,re-
texture ceiling as necessary. Fill nail holes and caulk gaps in wood work
,sand wood work lightly, tack cloth and clean surfaces as necessary. Spot
prime new wood with primer. Finish painting is as follows: apply 1 coat of
Benjamin Moore latex flat to all ceilings. Apply 1-2 coats of BM latex
eggshell to all walls. Apply 1-2 coats of BM latex semi -gloss to all wood
work, existing and new including the new built in book cases.
Labor to remove and replace the existing window and door trim is
included. The new window and door trim is to be 3-1/2" colonial casing
clear pine. Remove and replace the Sunroom door trim on the dining
room side. Remove and replace front entrance door trim. Supply and
install two (2) cased openings from living room to hall and to dining
room. Supply and install wood trim for the cut outs between the kitchen
and the living room (2) square half columns and (2) full columns. Wall
cap to be of 5/4" clear pine boards with a nosed edge. Supply and install
wood base board is 4 1/4" clear pine with a 13/8" base molding applied.
Patch in a small area of red oak hardwood flooring in the hallway.
• Sand and refinish the patched floor as well as the living room and dining
room with three coats of polyurethane.
• Electrical is as follows:
Living Room
• Supply and install (4) recessed wall washers
• Supply and install (4) recessed lights with white baffle trim
• Supply and install (1) three way dimmer for wall washers
• Supply and install (1) three way for wall washers
• Supply and install (1) three way for recessed lights
• Supply and install circuit for above lighting
Lower Hallway
• Supply and install (1) 5" recessed old work with white baffle trim in place of
existing ceiling fixture
Upper Hallway
• Supply and install (1) 5" recessed old work with white baffle trim in place of
existing ceiling fixture
• Wire and install (1) customer supplied hanging fixture over stairway
• Supply and install (1) single pole switch for hanging light
4'.
Service
• Supply and install (1) 8ckt sub panel beside existing panel
• Supply and install (1) 60amp breaker
• Supply and install (1) 60amp feeder to sub panel
Permit
• Supply (1) permit fee up to $50
Not included:
Removal of items or floor boards in attic
• Paint or patch of ceiling or walls
• Chase way to get circuit to where we need it to be
• Overtime hours
• Multiple trips due to job being done in different phases
NOTE:
• Recessed light on lower and upper hallway may not be centered due to
Framing.
The TV and installation is to be determined. This will be done as a change
order with a 10% management fee applied.
Items not included in this proposal that will be done by other
• TV and wiring for the TV
• New fireplace insert
Estimated Total of this proposal is $ 24,548.64
If this proposal is accepted please sign and return one copy with a deposit
check in the amount of $4500.00. Other payments will be scheduled as
milestonesr reached.
Signed Date _2�1__�t_J2010
** Federal Law provides you with the right to cancel this transaction, if you so
desire, without any penalty or obligation, at any time before midnight of the third
business day from the date you sign this contract. Any down payment or other
consideration you may have tendered on entering this transaction must be
refunded to you in the event you cancel. If you desire to cancel this transaction,
you may do so by filling out the following form and mailing it to Andover Equity
Builders, Inc., 89 North Main Street, Andover, MA 01810
Date:
01/29/2008 06:18 FAX 978+373+2885 DAMARK IM O03/003
110
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AIL4-02111
www.mass.gov.1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Naive (Business/Organization/Individual):
L
Address: fmlh c
City/State/Zip: -na� r- M<, 01&(2 Phone #:
Ar you an employer? Check the appropriate boa:
1. I am a employer with (
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. $
ship and have no employees
These sub -contractors have
working for in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5• ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.V
umbing repairs or additions
12.of repairs
13.her I,� ,,
.z... aPp. ...a. —" uUu �; .uuiL WNU Mi opt ute secrron oeiow snowing their workers' compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I aman employer that isproviding workers' compensation insurance for my employees Below is thepolicy andjob site
information.
/1 , I r
Insurance Company Name:
Policy # or Self -ins. Lic. #: W G G.-��J�,I j Cy eq Expiration Date: ') - Iq- )_0/ p
Job Site Address:_ 0 t,] L,Pk Lane 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 ce un er the pains a p alties ojperjury that the information provided above is true and correct
G
Sipanafore: Date: Z �i`— IO
Phone #:
Official use only. Do not write in this area, to be completed by city or town offwial
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 -contractors) 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 rete ned 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 tine.
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 "Sob 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 fnvesflgations
640 Washington Street
Beoston, MA 02111.
Tel. # 617-7274900 ext 4.06 or 1-877 MASSAFE
Revised 5-26-05
Fax # 617-72.7-7749
vm,w.mass.gov/dia
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780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS
THE MASSACHUSETTS STATE BUILDING CODE
780 CMR TABLE 55025(1) _1 i
GIRDER SPANS'AND HEADER SPANS' FOR EXTERIOR BEARING WALLS a9ra;a,T h
(MaA num spans for Douglas ftr-larch, hem -fir, southern pine and spruce -pine -fir'
_a
GIRDERS AND
HEADERS
SUPPORTING
GROUND SNOW LOAD sf)`
30 S0
SIZE Building width` feet
20 28 36 20 28 36
San NJ° San NJ° San I NJ° San I NJ° 5 aa' NJ° San I NJ'
2-2 x 4
3-6
1
3-21
2-:101
1
3-2
1
2-9
1
2- 6. 1
2-2 x 6
5-5
1
4- 8
1
4-2
1
4-8
1
4-0
1
3-8
2
2-2 x 8
6-10
1
5-11
2
5-4
2
5-111
2
5-2
2
4-7
2
2-2 x 10
8-5
2
7- 3
2
6-6
2
7- 3
2
6- 3
2
5-7
2
2-2 x 12 9-9 2 8- 5 2 7-6 2 8- 5 2 T- 3 2 6-6
2
Roof and ceiling
3-2 z 8
8-4
1
7--5
1
6-8
1
7-5
1 I
1 6-5
2
5-9
1 2
3-2 x 10
10-6
1
9-1
2
8-2
1 2
9-1
1 2
17-10
2
7-0
2
3-2 x 12
12-2
2
1-7
2
9-5
2
10-7
2
9- 2
2
8- 2
2
4--2 x 8
7- 0
1
6- 1
2
5-5
2
6-1
2
5-3
2
4-8
2
4-2 x 10
it 8
1
10- 6
1
9-5
2
10-61
1
9-1
2
8-2
2
4-2 x 12
1,
1
12- 2
2
10-11
2
1 12- 21
2
10- 7
2
9-5
2
2-2 x 4
3-1
1
2-9
1
2-5
I
2-9
1
2-5
1
2-2
1
2-2 x 6
4-6
1
4-0
1
3- 7
2
4-0
1
3-7
2
3-3
2
2-2 x 8
—5-9
2
5- 0.
2
4-61
2
5-2
2
4- 6
2
4-0
2
2-2 x 10
7-0
2
6- 2
2
5- 6
2
6-4
2
2
5-0
2
oof, ceiling and
2-2 x 12
8-1
2
7- 1
2
6- 5
2
7-4
2
'6- 5
2
5-9
3
ne center -bearing
3-2 x 8
7-2
1
6-3
1 2
1 5- 8
2
6 5
2
5- 8
2
5-1
2
Dor
3-2 x 10
8- 9
2
7- 8
2
6- 11
2
17-11
2
16-111
2
6-3
2
2 x 12 10- 2 2 8- 11 2 8- 1 2 9- 2 2 8- 1 2 7- 3
2
-2 x 8
r4-2
5-10
2
5-:
2
4-8
2
5= 3
2
4-7
2
4-2
2
x 10
10-1
1
8- 10
2
8-I
2
9-1
2
8-1
2
7-2
2
2 x 12
11-9
1 2
10-43—
2
9- 32
10- 7
2
9- 3
2
8-4
2
2-2 x 4
2-8
1
2- 4
I
2- 1
1
2- 7 1
1
1 2-3
1
2-1
1
2-2 x 6 1
3-1
1
3-5
2
3-1
2
3-10
2
3-4
2
3-1
1 2
2-2 x 8
5- 0
2
4 4
2
3- 10
2
4-10
2
4-2
2
3-9
2
10 6.12 5-3 2 4-8 2 5- t l 2 5- 1 2 4- 7
3
oof, ceiling and
2-2 x 12
7- I
2
6- 1
3
5-5
3
6-10
2
5-11
3
5-4
3
ne.clear span floor
3
2
5-5—
2
4- 10
2
6-1
2
5-3
2
4-8
2
3-2 x 10
7-72
6-7
2
15-11
2
7-5
2
6-5
2
3-2 x 12
8- 101
2
1 7-8
2
6- 10
2
8-7
2
7-5
2
6-8
2
4-2 z 8
5- 1
2
4- 5
2
13-11
2
4-11
2
4-3
2
3-10
2
4-2 x 10
8- 9
2
7- 7
2
16-10
2
8-7
2
7-5
2
6-7
2
4-2 x 12
10-2
2
9-1
2
17-11
2
9-11
2
8- 7
2
7- 8
2
2-2 x 4
2-7
1
2-3 1
1
12-1 1
1
1- 11
1
2-2 x 6 3-9 2 3-3 1 2 12-11 1 2 2-10
2
2-2x 8
4-9
2
4-2 j
2
1 3-9 11
2
3-8
2
oof, ceiling and
o center -bearing
2-2 x 10
2-2 x 12
5- 9
6-8
2
2 1
5- 1
5-10
2
3
4- 7 —3
5-3 3
-5= 8
6-6
2
2
4- 1
5-9
2
3
4 5
5-2
3
3
3-2 x 8 5-11 2 5-2 1 2 4-8 2 5-9 2 5-1 2 4- 7
2
Dors
3-2 x 10
7-3
2
6-4
2
5-8
2
7-1
2
6 2
2
5-7
2
3-2 x 12
8-5
2
7-4
2
6-7
2
8-2
2
7-2
2
6 5
3
4-2 x 8
4-1
2
4-3
2
3-10
2
4-9
2
4 2
2
4-2 x 10
8-4
2
7-4
2
6-7
2
8-2
2
4-2 x 12
9-8
2
8- 62
7-9
Roof, ceiling and 2-2
two clear span floor
3-2
3-2
4-2
4-2
Fnr RT- t i—h — 7f n —
2-2x4
2-2 x 6
2-2 x 8
2-2 x 10
x 12
3- 2 x 8
x 10
x 12
4-2 x 8
x 10
x 12
t ..-a
2-7
3-1
3-10
4-9
5-6
4-10
5-11
6-10
5-7
6-10
7- 11
_
1
Z
2
2
3
2
2
2
2
2
1-8
2- 8
3- 4
4-1
4-9
4-2
5-1
5-11
4-10
5- 11
1
2
3
3
3
2
2
3
2
2
t
1-6
2- 4
3-0
3-8
4-3
3-9
4-7
5-4
4-4
2
2
3
3
3'
2
3
3
2
2-0
3- 0
3-10
4-8
5-5
4-9
5-10
6-
5-6
11-8
2
2
2
3
2
2
2- 7
3- 4
4-0
4-8
4-1
4 9
1
2
2
3
3
2
2
1-5
2-3 1
2-11 1
3-7
4-2
3- 8
4 3
2
2
3
3
3
2
2
a. Spans are given in feet and inches.
b. Tabulated values assume #2 grade lumber.
c. Building width is measured perpendicular to the ridge. For widths between those shown, spans are permitted to be interpolated.
d. NJ - Number ofjack studs required to support each end. Where the number of requiredjack studs equals one, the headeris
permitted to be supported by an approved framing anchor attached to the full -height wall stud and to the header.
e. Use 30 psf ground snow load for cases in which ground snow load is less than 30 psf and the roof live load is equal to or less
than 20 psf.
600 780 CMR - Seventh Edition 3/23/07 (Effective 4/1/07)
BOISE- Double 1-3/4" x 9-1/4" VERSA -LAM® 2.0 3100 SP Floor Beam\F1302
BC CALCO 2.0 Design Report - US 1 span I No cantilevers 10/12 slope Tuesday, February 09, 2010 13:32
Build 287
File Name: BC CALC Project
Job Name: andover equ. Description: FB02
Address: lisa lane Specifier:
City, State, Zip: n andover, ma Designer: WALTER DION
Customer: Company: DOYLE LUMBER
Code reports: ESR -1040 Misc: PERLIMINARY ONLY
f
BO
LL 1,950 lbs
DL 823 lbs
Total of Horizontal Design Spans = 05-00-00
B1
LL 1,950 lbs
DL 823 lbs
Load Summary
Case Span
.. .... ..... .. . ....... .. .. WIMINN"M
1 1 - Internal
End Shear 1,837 lbs 29.9% 100%
Live
f
BO
LL 1,950 lbs
DL 823 lbs
Total of Horizontal Design Spans = 05-00-00
B1
LL 1,950 lbs
DL 823 lbs
Load Summary
Case Span
Pos. Moment 3,466 ft -lbs 26.1% 100%
1 1 - Internal
End Shear 1,837 lbs 29.9% 100%
Live
Dead
Snow Wind Roof Live
Tag Description
Load Type
Ref.
Start
End
100%
90%
115% 133% 125% Trib.
1 Standard Load
Unf. Area (psf)
Left
00-00-00
05-00-00
30
10
13-00-00
2
Unf. Lin. (plf)
Left
00-00-00
05-00-00
0
60
n/a
3
Unf. Area (psf)
Left
00-00-00
05-00-00
30
10
13-00-00
Controls Summary value % Allowable Duration
Case Span
Pos. Moment 3,466 ft -lbs 26.1% 100%
1 1 - Internal
End Shear 1,837 lbs 29.9% 100%
1 1 - Left
Total Load Defl. L/1,776 (0.034") 13.5%
1 1
Live Load Defl. L/2,525 (0.024") 14.3%
1 1
Max Defl. 0.034" 3.4%
1 1
Span / Depth 6.5 n/a
1
Notes
Design meets Code minimum (L/240) Total load deflection criteria.
Design meets Code minimum (L/360) Live load deflection criteria.
Design meets arbitrary (1") Maximum load deflection criteria.
Minimum bearing length for BO is 1-1/2".
Minimum bearing length for 131 is 1-1/2".
Entered/Displayed Horizontal Span Length(s) = Clear Span + 1/2 min. end bearing +
1/2 intermediate bearing
Connection Diagram
a minimum = 2" c = 5-1/4"
b minimum = 3" d = 12"
Member has no side loads.
Connectors are: 16d Common Nails
Page 1 of 1
Disclosure
Completeness and accuracy of input must
be verified by anyone who would rely on
output as evidence of suitability for
particular application. Output here based
on building code -accepted design
properties and analysis methods.
Installation of BOISE engineered wood
products must be in accordance with
current Installation Guide and applicable
building codes. To obtain Installation Guide
or ask questions, please call
(800)232-0788 before installation.
BC CALCO, BC FRAMER@ , AJSTM,
ALLJOISTO , BC RIM BOARDTM, BCI@ ,
BOISE GLULAMM, SIMPLE FRAMING
SYSTEM@) , VERSA -LAM@, VERSA -RIM
PLUS@ , VERSA -RIM@,
VERSA -STRAND@, VERSA -STUD@ are
trademarks of Boise Wood Products,
L.L.C.
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