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Building Permit #507-2011 - 649 FOREST STREET 11/28/2010
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO' --v Date Issued: LWORTANT: Date Received must complete all items on this Print L, -i = - ..."-- Print MAP NO: 1vSA3 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes (M>\ l A&ij,z ";�'D '. 'L1 a `i c�.� I •I TYPE OF IMPROVEMENT New Building ❑ Addition ❑ Alteration ❑ Repair, replacement ❑ Demolition PROPOSED USE Res! ential One family ❑ Two or more family No. of units: ❑ Assessory Bldg ❑ Other DESCRIPTION OF WORK TO BE PERFORMED: Please Type or Print Clearly) OWNER: Name: • w o Address1"Jol -t �%Iil . �3Ds3 Non- Residential ❑ Industrial ❑ Commercial ❑ Others: CONTRACTOR Name: r �.c2�tt< fit.. T Phone: Address: 3U oNL_ doh ®� � S Ex Date: ll 1 Zca I lot 3 ' Construction License: P• Supervisor's Co Home Improvement License: {�� +{t, Exp. Date: 312.1,1LO ARCHITECT/ENGINEER Qlus Aw (tOstT tn(�.acG���1�_ Phone: ©�-GZZ Address: maihck,sf(r Nq Reg. No. FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925,00 PER S F. Total Project Cost: $ e * al1sS00 FEE: $ �� Check No.:It Receipt No.:_ 2 -1j;7 NOTE: persons contracting with nye 4 teres contractors do not have} access M the guaranty fund Location �; y9 06-5-7- S�— No. S-07—.2011 Date F Check # / �,—U TOWN OF NORTH ANDOVER Certificate of Occupancy $ /00-- Building/Frame revBuilding/Frame Permit Fee $ Z 4'k — Foundation Permit Fee Other Permit Fee TOTAL 23821 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well Private (septic tank, etc. Tanning/MassageBody Art ❑ Tobacco Sales ❑ Permanent Dumpster on Site ❑ Swimming Pools ❑ Food Packaging/Sales ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMME CONSERVATION Reviewed 10 COMMENTS "r—� r1K-7-v-N<,o l i , er,�%As-, k X\.i 1 ob, A HEALTH o COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Sianature & Date DPW Town Engineer: Signature: FIRE DEPARTMENT..- Temp:D.umpster on site yes_ Located at 124 Man- Street Fire Department signature/ COMMENTS Located 384 Osgood Street no '-� /01/0 Dimension Number of Stories* = Total square feet of floor area, based on Exterior dimensions.21 Total land area, sq. ft.: 2.L$ ac%s 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 Doc:.Building Permit Revised 2008 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 I i ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. AndlOr C.S.L. Licenses ❑ Copy of Contract i ❑ 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 Perm 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 140TE: All dumpster permits require sign off from Fire Department prior to Issuance of Bldg Permit Ideal 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 I®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit,, f. 1 -'all cases if a variance or special permit was required the Town CIerks office must stamp the decision from the Board of Appeals is t the appeal period is over. The applicant must then u sf be submitted with the building application get this recorded at the Registry of Deeds. 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RISERS x If 14 EQ. RISERS x [7 D N c� -i :I;L _1 to U) 1 N I SOC ug) i N - r,: 1 _ rle 710 1 1 D z o�� �x I ; ' J O N0 l 'I _--- p, n 7u� n re0[ z N awe Cln XI- ox �� X o r �Z �� dD >X cn �v �� Lo U) C) N� Z'3 N x 70 -0 m 3 x �2 r, x o - N X N rn l n r LO N z�< D a U T� o x rD- r- D N r0--i m[l Z N U r, (-) L Z Q N rel 6. ISI rj IJ _ x lU z n X I 79 `1 - 7'-10' Z N o N c D. WALL NGT. i AF - 01 0 1 tt A�}wjV C.4 F.F. 41-4 1-0 PLATE F.F. TO PLATE w n m Z� �' 5EGTI ©I 5 p Forest St. , :t O .. - It I 1J Z° O X -A n Z 3 ` [V1fllf I o � - <-4 J _ _ DA D < THE SUI" MERSET 2 66 GILCRE,\," I 1'l`': LONDONUEPP"t. 6' o orn U1 ;t WITH GARAGE UNDER Tel:(603) 425-2300 1 .; :a,.,," = 71 --i T.O. SLAB 70 T.O. FIJD. WALL 1 1'-0" CJ X N_ -i N " Z TJ �z� Forest St. �' s°;�. o 1 U7 N � zoo �z 3 ry " N m 3m0 z �Cp _ D A D < THE SUI' MERSET 2 �I r D - o i;um rD WITH GARAGE UNDER Tei:(603) 425-2300 1 ,. o 1Euj j n O_ 2t1N m N'w �p0 p 3 1 X Z U t �t1►, m� o n Z D 4l d m X/x _ w X rn /u U) O G) m� oa � nD 0 O D�n XZ Z O - rn o > T.O. SLAB 70 T.O. FIJD. WALL 1 1'-0" ITI D -i N " Z TJ /� �I 5EGT�®N5 Forest St. �' s°;�. o 1 -nO zoo �z 3 ry " z �Cp _ D A D < THE SUI' MERSET 2 66 GILCREA'a 1 I LUNDONDEP!";. 1'. i;um rD WITH GARAGE UNDER Tei:(603) 425-2300 1 ,. 3 r70 - n 2t1N �p0 O o O Z n> - \■ m� o n U) Fmw "� x > �0�p m� oa � D�n XZ O - rn o > fri rdz -wl oN 9 t �qul0 z - p rn 70 N r71N. 6 00- o0o O C z ��OZ - _ 77-1 r n l III=1 I -1=I 8n - of o ,70 nJ "-III-III= n m I,=1 MIN. m Voo nm On z07UZ I n�tP�Z 2u- AO nz LS O 0)p I+ Ozx�A_� z.) G) �� n �rn�� C7N 30 > -zm� G) _ mp -0 DDTD >rnrin — Orn70mm 7U U)N D iu > � M lmx< rn x c m z 7U pD I'-0" d wz _ 7u 0 8" 7'-10" ' " FULL CONC. WALL NGF. ITI w _ -i N " Z TJ /� �I 5EGT�®N5 Forest St. �' s°;�. o 1 zoo �z 3 ry " �' o in _I ) _ D A D < THE SUI' MERSET 2 66 GILCREA'a 1 I LUNDONDEP!";. 1'. J <� WITH GARAGE UNDER Tei:(603) 425-2300 1 ,. Forest St. Realty Trust PANZAVECCIIIA 66 GILCREAST ROAD LOT 1 7 > LONDONDERRY, N.H. 03053 0 FOREST ST. N A ND O VER Tel:(603) 425-2300 FAX:(603)425-7861 N/F JAMES HARTIGAN I u I .OJ JId. 17 34.,,w FOREST STREET NOTE x SITE IS SHOWN ON TOWN OF' NORTH ANDOVER ASSESSORS MAP #105 B LOT #171 AND E. N. D. R. D. BOOK #2929 PAGE #302 & PLAN # 11498 FOR SITE DEED. v 0 I 0) rn P PLAN OF LAND IN NORTH ANDOVER, MASSACHUSETTS DRAWN FOR GREENSCAPE PROPERTY & BUIMING 66 GILCREAST ROAD LONDONDERRY, NH SCALE: 1"=40' DATE: NOVEMBER 3, 2010 0 20 40 80 120 �p�� S?`•jam V/ MERRIMACK ENGINEERING SERVICES e6 PARK STRUT 11/3/10 AAFDOVER MAS'SACHVSls'7°!S 01810 STEPHEN S' PI 'KI, R.L.S. DATE PHOAM (978) 475-8555 FAX: (978) 475-1448 EMAIL JWBRENG®AOLCOM Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Registration' -'-,-4 65746 Expiration 3/2212012 Tr# 294924 Type 'Individual GEORGE HASELTfNE GEORGE HASELTINE-,; ...:" 32R OLD POINT RD NEWBURY, MA 01951` Undersecretary Massachusetts (' _ Board of g peP•trtment Re�:ulatil►nt of Public Safet, CmlistruCt'ion S Ind , i dar `, pervis Stan di °r License j -,License- GS 103765 � I Restticted,to .. . DD ( GEORGE , 32R Opp, 1VEWBlJRyO�AiT (unmusFioner: Ezpiratio n: 11/29/2013 Tr#: 103765 North Andover Health Department (ommunity Development Division December 15, 2010 Greenscape Property & Building Attn: George Haseltine 66 Gilcrest Road Londonderry, NH 03053 Re: Subsurface Sewage Disposal System Plan for Forest Street, May 105D, Lot 171, aka 649 Forest Street Dear Mr. Haseltine: The North Andover Board of Health has completed the review of the septic system design plans for the above referenced property. These plans dated October 26, 2010, final revision date of December 7, 2010, have been approved for a four (4) bedroom, maximum nine -room home. In accordance with 310 CMR 105.020(2) " Construction of all systems for which a Disposal System Construction Permit application has been approved by the local Approving Authority and/or the Department shall be completed, and the Certificate of Compliance (COC) obtained within three years of issuance of the final approval." During this time a licensed septic system installer must obtain a permit and complete this work. Other items to be submitted prior to a COC is issued by the Town of North Andover are; an as -built of the system and an installation certification form endorsed by the installer, designer. This approval is subject to the following conditions:. 1. Prior to receiving a building permit, the applicant must provide complete floor plans of the new home. Please include all living spaces. 2. Prior to receiving a Disposal Works Construction permit, the applicant must provide a foundation plan in 1" = 20' scale to overlay on the septic plan. 3. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Forest Street Map 105D Lot 171, aka, 649 Forest Street Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit (3 10 CMR 15.020(1)). 4. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincere Susan Sawyer;REHS/R Public Health Director cc: Vladimir Nemchenok, Merrimack Engineering, c/o: Bill Dufresne File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 ®Boise Cascade Double 1-314" x 9-1/4" VERSA -LAM® 2.0 3100 SP Floor Beam121301 BC CALC@ 3.0 Design Report - US 1 span I No cantilevers 10/12 slope Friday, October 29, 2010 Build 440 B0, 3-1/2" LL 2,243 lbs DL 1,099 lbs B1, 3-1/2" LL 4,128 lbs DL 2,109 lbs Total Horizontal Product Length = 11-06-00 Live Dead Snow Wind Roof Live Trib. (in.) Load Summary File Name: 1010285.BCC Job Name: 1010285 Description: over living/dining Address: Forest St Specifier: Jeff Sabia City, State, Zip: N. Andover, MA Designer: Bill Walker Customer: Greenscape Property and Build Company: National Lumber Co Code reports: ESR -1040 Misc: 65 Maple St., Mansfield, MA B0, 3-1/2" LL 2,243 lbs DL 1,099 lbs B1, 3-1/2" LL 4,128 lbs DL 2,109 lbs Total Horizontal Product Length = 11-06-00 Live Dead Snow Wind Roof Live Trib. (in.) Load Summary Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% 1 2nd fl Unf. Area (psf) L 00-00-00 11-06-00 30 14 13-00-00 2 3601 at bearing B1 Conc. Pt. (lbs) R 00-02-00 00-02-00 1,885 1,010 n/a' Controls Summary Value %Allowable Duration Case Span Disclosure Pos. Moment 8,856 ft -lbs 66.7% 100% 1 1 -Internal Completeness and accuracy of input must End Shear 2,724 lbs 44.3% 100% 1 1 - Left be verified by anyone who would rely on Total Load Defl. L/315 (0.421") 76.2% 1 1 output as evidence of suitability for Live Load Defl. L/469 (0.283") 76.8% 1 1 particular application. Output here based Max Defl. 0.421" 42.1 % 1 1 on building code -accepted design Span / Depth 14.3 n/a 1 properties and analysis methods. Installation of BOISE engineered wood products must be in accordance with % Allow % Allow current Installation Guide and applicable Bearing Supports Dim. (L x W) Value Support Member Material building codes. To obtain Installation Guide BO Post 3-1/2" x 3-1/2" 3,341 lbs 37.6% 36.4% Spruce ruce Pine Fir (8 ask questions, please call (800)232-0788 before installation. B1 Post 3-1/2" x 3-1/2" 6,236 lbs 70.2% 67.9% Spruce Pine Fir 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. User Notes 3-2x4 KD post at BO 4-2x6 KD post at B1 Connection Diagram a a minimum = 2" c = 5-1/4" b minimum = 3" d = 12" Calculated Side Load = 286.0 plf Connection design assumes point load is 'top -loaded'. For connection design of 'side -loaded' point loads, please consult a technical representative or professional of Record. Concentrated loads are not considered in side load analysis. Pgy@eFV1 are: 16d Sinker Nails BC CALC@, BC FRAMER@ , AJS-, ALLJOISTO , BC RIM BOARD-, BCIO , BOISE GLULAMTm, SIMPLE FRAMING SYSTEM@ , VERSA -LAM@, VERSA -RIM PLUS@, VERSA -RIM@, VERSA -STRAND@, VERSA -STUD@ are trademarks of Boise Cascade, L.L.C. ®Boise Cascade Triple 1-3/4" x 9-1/4" VERSA -LAM® 2.0 3100 SP BC CALC® 3.0 Design Report - US 1 span I No cantilevers 10/12 slope Build 440 Job Name: 1010285 File Name: 1010285.BCC Description: over family room Floor Beam121302 Address: Forest St Specifier: Jeff Sabia City, State, Zip: N. Andover, MA Designer: Bill Walker Customer: Greenscape Property and Build Company: National Lumber Co Code reports: ESR -1040 Misc: 65 Maple St., Mansfield, MA Friday, October 29, 2010 4 3 2 B0, 5-1/2" LL 2,807 lbs DL 2,516 lbs SL 3,732 lbs 14-00-00 Total Horizontal Product Length = 14-00-00 B1, 5-1/2" LL 4,021 lbs DL 5,214 lbs SL 10,130 lbs Controls Summary Value %Allowable Duration Live Dead Snow Wind Roof Live Trib. (in.) Load Summary 100% 1 1 - Internal End Shear 2,422 lbs 26.2% 100% Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% 1 1 2nd fl Unf. Area (psf) L 00-00-00 14-00-00 30 14 Max Defl. 06-06-00 2 front joist Unf. Area (psf) L 00-00-00 14-00-00 30 10 n/a 03-00-00 3 3802 at bearing B1 Conc. Pt. (Ibs) R 00-02-00 00-02-00 2,026 4,271 10,130 n/a 4 3B02 at bearing BO Conc. Pt. (Ibs) L 00-02-00 00-02-00 812 1,573 3,732 n/a Controls Summary Value %Allowable Duration Case Span Pos. Moment 9,152 ft-Ibs 46.0% 100% 1 1 - Internal End Shear 2,422 lbs 26.2% 100% 1 1 -Left Total Load Defl. L/382 (0.415') 62.8% 1 1 Live Load Defl. L/562 (0.282") 64.0% 1 1 Max Defl. 0.415' 41.5% 1 1 Span / Depth 17.1 n/a 1 % Allow % Allow Bearing Supports Dim. (L x W) Value Support Member Material BO Post 5-1/2" x 5-1/4" 9,055 lbs 43.3% 41.8% Spruce Pine Fir B1 Post 5-1/2" x 5-1/4" 19,365 lbs 92.5% 89.4% Spruce Pine Fir 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. User Notes 4-2x6 KD post at BO 5 1/4 x 5 1/4 v -lam post at BO Page 1 of 2 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 CALC®, BC FRAMER®, AJS-, ALLJOIST®, BC RIM BOARDTTM, BCI®, BOISE GLULAMTm, SIMPLE FRAMING SYSTEM®, VERSA -LAM®, VERSA -RIM PLUS®, VERSA -RIM®, VERSA -STRAND®, VERSA -STUD® are trademarks of Boise Cascade, L.L.C. ®Boise Cascade Triple 1-3/4" x 9-1/4" VERSA -LAM® 2.0 3100 SP Floor Beam121302 BC CALCO 3.0 Design Report - US 1 span I No cantilevers 10/12 slope Friday, October 29, 2010 Build 440 b minimum = 3" d = 12" e minimum = 3" Calculated Side Load = 203.0 plf Connection design assumes point load is `top -loaded'. For connection design of 'side -loaded' point loads, please consult a technical representative or professional of Record. Nailing schedule applies to both sides of the member. Concentrated loads are not considered in side load analysis. Connectors are: 16d Sinker Nails Page 2 of 2 BC CALCO, BC FRAMER@ , AJSTm, ALLJOISTO , BC RIM BOARDTTM, BCI@ , BOISE GLULAMTm, SIMPLE FRAMING SYSTEM@ , VERSA -LAW, VERSA -RIM PLUS@ , VERSA -RIM@, VERSA -STRAND@, VERSA -STUD@ are trademarks of Boise Cascade, L.L.C. File Name: 1010285.BCC Job Name: 1010285 Description: over family room Address: Forest St Specifier: Jeff Sabia City, State, Zip: N. Andover, MA Designer: Bill Walker Customer: Greenscape Property and Build Company: National Lumber Cc Code reports: ESR -1040 Misc: 65 Maple St., Mansfield, MA Connection Diagram Disclosure b d � I r Completeness and accuracy of input must be verified by anyone who would rely on a 04 0 output as evidence of suitability for particular application. Output here based c on building code -accepted design properties and analysis methods. • • Installation of BOISE engineered wood e 0 0 0 products must be in accordance with current Installation Guide and applicable building codes. To obtain Installation Guide or ask questions, please call a minimum = 2" c = 4-1/4" (800)232-0788 before installation. b minimum = 3" d = 12" e minimum = 3" Calculated Side Load = 203.0 plf Connection design assumes point load is `top -loaded'. For connection design of 'side -loaded' point loads, please consult a technical representative or professional of Record. Nailing schedule applies to both sides of the member. Concentrated loads are not considered in side load analysis. Connectors are: 16d Sinker Nails Page 2 of 2 BC CALCO, BC FRAMER@ , AJSTm, ALLJOISTO , BC RIM BOARDTTM, BCI@ , BOISE GLULAMTm, SIMPLE FRAMING SYSTEM@ , VERSA -LAW, VERSA -RIM PLUS@ , VERSA -RIM@, VERSA -STRAND@, VERSA -STUD@ are trademarks of Boise Cascade, L.L.C. ®Boise Cascade Double 1-3/4" x 9-1/2" VERSA -LAM® 2.0 3100 SP Floor Beam131301 BC CALCO 3.0 Design Report - US 1 span I No cantilevers 10/12 slope Friday, October 29, 2010 Build 440 B0, 3-1/2" LL 1,885 lbs DL 1,010 lbs B1, 3-1/2" LL 1,885 lbs DL 1,010 lbs Total Horizontal Product Length = 14-06-00 Live Dead Snow Wind Roof Live Trib. (in.) Load Summary File Name: 1010285.BCC Job Name: 1010285 Description: attic beam over master bdrm Address: Forest St Specifier: Jeff Sabia City, State, Zip: N. Andover, MA Designer: Bill Walker Customer: Greenscape Property and Build Company: National Lumber Co Code reports: ESR -1040 Misc: 65 Maple St., Mansfield, MA B0, 3-1/2" LL 1,885 lbs DL 1,010 lbs B1, 3-1/2" LL 1,885 lbs DL 1,010 lbs Total Horizontal Product Length = 14-06-00 Live Dead Snow Wind Roof Live Trib. (in.) Load Summary Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% 1 attic Unf. Area (psf) L 00-00-00 14-06-00 20 10 13-00-00 Controls Summary Value %Allowable Duration Case Span Disclosure Pos. Moment 9,843 ft -lbs 70.5% 100% 1 1 -Internal Completeness and accuracy of input must End Shear 2,463 lbs 39.0% 100% 1 1 - Left be verified by anyone who would rely on Total Load Defl. L/241 (0.698") 99.5% 1 1 output as evidence of suitability for Live Load Defl. L/371 (0.455") 97.2% 1 1 particular application. Output here based Max Defl. 0.698" 69.8% 1 1 on building code -accepted design Span / Depth 17.7 n/a 1 properties and analysis methods. Installation of BOISE engineered wood products must be in accordance with %Allow %Allow current Installation Guide and applicable Bearing Supports Dim. (L x W) Value Support Member Material building codes. To obtain Installation Guide BO Post 3-1/2 x 3-1/2 2,895 lbs ° 32.6% ° 31.5% Spruce Pine Fir or ask questions, please call (800)232-0788 before installation. B1 Post 3-1/2" x 3-1/2" 2,895 lbs 32.6% 31.5% Spruce Pine Fir 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. User Notes 3-2x4 KD post at BO 3-2x6 KD post at B1 Connection Diagram a minimum = 2" c = 5-1/2" b minimum = 3" d = 12" Calculated Side Load = 195.0 plf Connectors are: 16d Sinker Nails Page 1 of 1 BC CALCO, BC FRAMER@ , AJSTm, ALLJOISTO , BC RIM BOARDTTM, BCI@ , BOISE GLULAM-, SIMPLE FRAMING SYSTEM@ , VERSA -LAM@, VERSA -RIM PLUS@ , VERSA -RIM@, VERSA -STRAND@, VERSA -STUD@ are trademarks of Boise Cascade, L.L.C. ®BolseCascade Triple 1-3/4" x 9-1/2" VERSA -LAM® 2.0 3100 SP Floor Beam131302 BC CALCO 3.0 Design Report - US 2 spans I No cantilevers 10/12 slope Friday, October 29, 2010 Build 440 Duration Case Span Pos. Moment 15,532 ft -lbs File Name: 1010285.13CC Job Name: 1010285 Description: beam over front bdrm Address: Forest St Specifier: Jeff Sabia City, State, Zip: N. Andover, MA Designer: Bill Walker Customer: Greenscape Property and Build Company: National Lumber Co Code reports: ESR -1040 Misc: 65 Maple St., Mansfield, MA 14-00-00 B0, 5-1/4" LL 812 lbs DL 1,573 lbs SL 3,732 lbs z B1, 5-1/4" LL 2,026 lbs DL 4,271 lbs SL 10,131 lbs Total Horizontal Product Length = 25-06-00 B2, 5-1/2" LL 692 lbs DL 1,144 lbs SL 2,713 lbs Live Dead Snow Wind Roof Live Trib. (in.) Load Summary Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% 1 attic Unf. Area (psf) L 00-00-00 25-06-00 20 10 06-06-00 2 roof Unf. Area (psf) L 00-00-00 25-06-00 15 50 13-00-00 Controls Summary Value %Allowable Duration Case Span Pos. Moment 15,532 ft -lbs 64.5% 115% 13 1 - Internal Neg. Moment -20,771 ft -lbs 86.3% 115% 2 2 - Left End Shear 4,822 lbs 44.2% 115% 13 1 - Left Cont. Shear 7,640 lbs 70.1% 115% 2 1 - Right Total Load Defl. L/288 (0.568") 83.4% 13 1 Live Load Defl. L/383 (0.426") 93.9% 13 1 Total Neg. Defl. L/4,544 (-0.029") 5.3% 13 2 Max Defl. 0.568" 56.8% 13 1 Span / Depth 17.2 n/a 1 % Allow % Allow Bearing Supports Dim. (L x W) Value Support Member Material BO Post 5-1/4" x 5-1/4" 6,117 lbs 30.6% 29.6% Spruce Pine Fir 131 Post 5-1/4" x 5-1/4" 16,428 lbs 19.9% 79.5% Versa -Lam 1.7 B2 Post 5-1/2" x 5-1/4" 4,548 lbs 21.7% 21.0% Spruce Pine Fir 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. User Notes 3-2x6 KD post at BO 3 1/2 x 7 v -lam post at B1 3-2x6 KD post at B2 Page 1 of 2 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@ , AJS-, ALLJOISTO , BC RIM BOARDT BCI@ , BOISE GLULAM1m, SIMPLE FRAMING SYSTEMO , VERSA -LAM@, VERSA -RIM PLUS@, VERSA -RIM@, VERSA -STRAND@, VERSA -STUD@ are trademarks of Boise Cascade, L.L.C. ®Boise Cascade Triple 1-3/4" x 9-1/2" VERSA -LAM® 2.0 3100 SP BC CALCO 3.0 Design Report - US 2 spans I No cantilevers 10/12 slope Build 440 Floor Beam131302 Friday, October 29, 2010 File Name: 1010285.BCC Job Name: 1010285 Description: beam over front bdrm Address: Forest St Specifier: Jeff Sabia City, State, Zip: N. Andover, MA Designer: Bill Walker Customer: Greenscape Property and Build Company: National Lumber Co Code reports: ESR -1040 Misc: 65 Maple St., Mansfield, MA Connection Diagram Disclosure L b` d Completeness and accuracy fmust be verified by anyone who would rely on a o output as evidence of suitability for c particular application. Output here based on building code -accepted design properties and analysis methods. L• Installation of BOISE engineered wood e products must be in accordance with current Installation Guide and applicable building codes. To obtain Installation Guide a minimum — 2" c = 2-1 /4" or ask questions, please call (800)232-0788 before installation. b minimum = 3" d = 12" e minimum = 3" Calculated Side Load = 520.0 plf Nailing schedule applies to both sides of the member. Connectors are: 16d Sinker Nails Page 2 of 2 BC CALCO, BC FRAMER@ , AJS-, ALLJOISTO , BC RIM BOARDTm, BCI@ , BOISE GLULAMTm, SIMPLE FRAMING SYSTEM@ , VERSA -LAM@, VERSA -RIM PLUS@ , VERSA -RIM@, VERSA -STRAND@, VERSA -STUD@ are trademarks of Boise Cascade, L.L.C. REScheck Software Version 4.4.0 Compliance Certificate Project Title: The Summerset 2 Energy Code: 2009 IECC 49.0 0.0 Location: North Andover, Massachusetts Wall 1: Wood Frame, 16" o.c. Construction Type: Single Family 0.0 Building Orientation: Bldg. orientation unspecified Glazing Area Percentage: 12% Heating Degree Days: 6322 21.0 0.0 Climate Zone: 5 Orientation: Left Side Construction Site: Owner/Agent: Designer/Contractor: 0 Forest Street 210 Forest Street Really Trust Forest Street Realty Trust North Andover, MA 12 66 Gilcreast Road 66 Gilcreast Road Londonderry, NH 03053 Londonderry, NH 03053 Wall 4: Wood Frame, 16" o.c. 210 (603) 425-2300 (603) 425-2300 12 Orientation: Right Side Compliance: 5.2% Better Than Code Maximum UA: 289 Your UA: 274 The % Better or Worse Than Code index reflects how close to compliance the house is based on code trade-off rules It DOES NOT provide an estimate of energy use or cost relative to a minimum-oode home. Ceiling 1: Flat Ceiling or Scissor Truss 1097 49.0 0.0 29 Wall 1: Wood Frame, 16" o.c. 259 21.0 0.0 15 Orientation: Left Side Wall 2: Wood Frame, 16" o.c. 259 21.0 0.0 15 Orientation: Left Side Wall 3: Wood Frame, 16" o.c. 210 21.0 0.0 12 Orientation: Right Side Wall 4: Wood Frame, 16" o.c. 210 21.0 0.0 12 Orientation: Right Side Wall 5: Wood Frame, 16" o.c. 307 21.0 0.0 15 Orientation: Back Window: 2-2828: Vinyl Frame:Double Pane with Low -E 31 0.350 11 SHGC: 0.31 Orientation: Back Window: 2416: Vinyl Frame, Double Pane with Low -E 17 0.350 6 SHGC: 0.31 Orientation: Back Wall 6: Wood Frame, 16" o.c. 307 21.0 0.0 13 Orientation: Back Window: 2-2828: Vinyl Frame:Double Pane with Low -E 31 0.350 11 SHGC: 0.31 Orientation: Back Window: 3036: Vinyl Frame, Double Pane with Low -E 11 0.350 4 SHGC: 0.31 Orientation: Back Door: 6068: Glass 40 0.310 12 SHGC: 0.35 Orientation: Back Wall 7: Wood Frame, 16" o.c. 113 21.0 0.0 5 Orientation: Front Window: 2828:.Vinyl Frame:Double Pane with Low -E 31 0.350 11 SHGC: 0.31 Orientation: Front Wall 8: Wood Frame, 16" o.c. 113 21.0 0.0 5 Project Title: The Summerset 2 Report date: 11/14/10 Data filename: F:\REScheck\The Summerset 2.rck Page 1 of 6 REScheck Software Version 4.4.0 Inspection Checklist Ceilings: ❑ Ceiling 1: Flat Ceiling or Scissor Truss, R-49.0 cavity insulation Comments: Second Floor Above -Grade Walls: ❑ Wall 1: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 2: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 3: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 4: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 5: Wood Frame, 16" o.c., R-21:0 cavity insulation Comments: ❑ Wall 6: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 7: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 8: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 9: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 10: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 11: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 12: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: ❑ Wall 13: Wood Frame, l6" o.c., R-21.0 cavity insulation Comments: ❑ Wall 14: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: Windows: ❑. Window: 2-2828: Vinyl Frame:Double Pane with Low -E, U -factor: 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Thermopane TilUln ❑ Window: 2416: Vinyl Frame, Double Pane with Low -E, U -factor. 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Thermopane Tilt/In Project Title: The Summerset 2 Report date: 11/14/10 Data filename: F:\REScheck\The Summerset 2.rck Page 3 of 6 Orientation: Front Window: 2828: Vinyl Frame:Double Pane with Low -E 31 0.350 11 SHGC: 0.31 Orientation: Front Wall 9: Wood Frame, 16" o.c. 101 21.0 0.0 4 Orientation: Front Window`: 2-2828: Vinyl Frame:Double Pane with Low -E 31 0.350 11 SHGC: 0.31 Orientation: Front Wall 10: Wood Frame, 16" o.c. 194 21.0 0.0 7 Orientation: Front Window: 2-2828: Vinyl Frame:Double Pane with Low -E 31 0.350 11 SHGC: 0.31 Orientation: Front Door: 3068: Solid 36 0.120 4 Orientation: Front Wall 11: Wood Frame, 16" o.c. 93 21.0 0.0 4 Orientation: Front Window: 2828: Vinyl Frame:Double Pane with Low -E 15 0.350 5 SHGC: 0.31 Orientation: Front Wall 12: Wood Frame, 16" o.c. 32 21.0 0.0 2 Orientation: Front Wall 13: Wood Frame, 16" o.c. 49 21.0 0.0 3 Orientation: Front Wall 14: Wood Frame, 16" o.c. 16 21.0 0.0 1 Orientation: Front Floor 1: All -Wood Joist/Truss, Over Unconditioned Space 1074 30.0 0.0 35 Compliance Statement: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the 2009 IECC requirements in REScheck Version 4.4.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. Name - Title Project Notes: with Garage under Signature Date Project Title: The Summerset 2 Report date: 11/14/10 Data filename: F:\REScheck\The Summerset 2.rck Page 2 of 6 ❑ Window: 2-2828: Vinyl Frame:Double Pane with Low -E, U -factor. 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Thermopane Tiltlin ❑ Window: 3036: Vinyl Frame, Double Pane with Low -E, U -factor. 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Sliding Window ❑ Window: 2828: Vinyl Frame:Double Pane with Low -E, U factor: 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Thermopane TilUln ❑ Window: 2828: Vinyl Frame:Double Pane with Low -E, U -factor. 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Thermopane Tilttln ❑ Window: 2-2828: Vinyl Frame:Double Pane with Low -E, U -factor. 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Thermopane Tiltlin ❑ Window: 2-2828: Vinyl Frame:Double Pane with Low -E, U -factor: 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Thermopane Tilt/In ❑ Window: 2828: Vinyl Frame:Double Pane with Low -E, U -factor. 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Thermopane Tilt/In Doors: ❑ Door: 6068: Glass, U -factor: 0.310 Comments: Slider ❑ Door: 3068: Solid, U -factor: 0.120 Comments: Fiberglas Exterior Doors Floors: ❑ Floor 1: All -Wood Joist/Truss, Over Unconditioned Space, R-30.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: ❑ Joints (including rim joist junctions), attic access openings, penetrations, and all other such openings in the building envelope that are sources of air leakage are sealed with caulk, gasketed, weatherstripped or otherwise sealed with an air barrier material, suitable film or solid material. ❑ Air barrier and sealing exists on common walls between dwelling units, on exterior walls behind tubs/showers, and in openings between window/door jambs and framing. F1 Recessed lights in the building thermal envelope are 1) type IC rated and ASTM E283 labeled and 2) sealed with a gasket or caulk between the housing and the interior wall or ceiling covering. ❑ Access doors separating conditioned from unconditioned space are weather-stripped and insulated (without insulation compression or damage) to at least the level of insulation on the surrounding surfaces. Where loose fill insulation exists, a baffle or retainer is installed to maintain insulation application. ❑ Wood -burning fireplaces have gasketed doors and outdoor combustion air. Air Sealing and Insulation: ❑ Building envelope air tightness and insulation installation complies by either 1) a post rough -in blower door test result of less than 7 ACH at 33.5 psf OR 2) the following items have been satisfied: Project Title: The Summerset 2 Report date: 11/14/10 Data filename: F:\REScheck\The Summerset 2.rck Page 4 of 6 (a) Air barriers and thermal barrier: Installed on outside of air -permeable insulation and breaks or joints in the air barrier are filled or repaired. (b) Ceiling/attic: Air barrier in any dropped ceiling/soffit is substantially aligned with insulation and any gaps are sealed. (c) Above -grade walls: Insulation is installed in substantial contact and continuous alignment with the building envelope air barrier. (d) Floors: Air barrier is installed at any exposed edge of insulation. (e) Plumbing and wiring: Insulation is placed between outside and pipes. Batt insulation is cut to fit around wiring and plumbing, or sprayediblown insulation extends behind piping and wiring. (0 Comers, headers, narrow framing cavities, and rim joists are insulated. (9) Shower/tub on exterior wall: Insulation exists between showers/tubs and exterior wall. Sunrooms: 0 Sunrooms that are thermally isolated from the building envelope have a maximum fenestration LI -factor of 0.50 and the maximum skylight U -factor of 0.75. New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Materials Identification and Installation: L] Materials and equipment are installed in accordance with the manufacturer's installation instructions. F1 Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R -value. Materials and equipment are identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. Insulation R -values and glazing U -factors are dearly marked on the building plans or specifications. Duct Insulation: Supply ducts in attics are insulated to a minimum of R-8. All other ducts in unconditioned spaces or outside the building envelope are insulated to at least R-6. Duct Construction and Testing: Building framing cavities are not used as supply ducts. F1 All joints and seams of air ducts, air handlers, filter boxes, and building cavities used as return ducts are substantially airtight by means of tapes, mastics, liquid sealants, gasketing or other approved closure systems. Tapes, mastics, and fasteners are rated UL 181 A or UL 181 B and are labeled according to the duct construction. Metal duct connections with equipment and/or fittings are mechanically fastened. Crimp joints for round metal ducts have a contact lap of at least 1 1/2 inches and are fastened with a minimum of three equally spaced sheet -metal screws. Exceptions: Joint and seams covered with spray polyurethane foam. Where a partially inaccessible duct connection exists, mechanical fasteners can be equally spaced on the exposed portion of the joint so as to prevent a hinge effect. Continuously welded and locking -type longitudinal joints and seams on duds operating at less than 2 in. w.g. (500 Pa). C] Duct tightness test has been performed and meets one of the following test criteria: (1) Postconstruction leakage to outdoors test: Less than or equal to 173.4 cfm (8 cfm per 100 ft2 of conditioned floor area). (2) Postconstrudion total leakage test (including air handier enclosure): Less than or equal to 260.0 cfm (12 cfm per 100 ft2 of conditioned floor area) pressure differential of 0.1 inches w.g. (3) Rough -in total leakage test with air handler installed: Less than or equal to 130.0 cfm (6 cfm per 100 ft2 of conditioned floor area) when tested at a pressure differential of 0.1 inches w.g. (4) Rough -in total leakage test without air handler installed: Less than or equal to 86.7 cfm (4 cfm per 100 ft2 of conditioned floor area). Temperature Controls: Cj At least one programmable thermostat is installed to control the primary heating system and has set -points initialized at 70 degree F for the heating cycle and 78 degree F for the cooling cycle. Heating and Cooling Equipment Sizing: L] Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code. For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2009 IECC Commercial Building Mechanical and/or Service Water Heating (Sections 503 and 504). Circulating Service Hot Water Systems: EI Circulating service hot water pipes are insulated to R-2. Ej Circulating service hot water systems include an automatic or accessible manual switch to tum off the circulating pump when the system is not in use. Project Title: The Summerset 2 Report date: 11/14/10 Data filename: F:1RESchecklThe Summerset 2.rck Page 5 of 6 Heating and Cooling Piping Insulation: HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-3. Swimming Pools: Lj Heated swimming pools have an on/off heater switch. Pool heaters operating on natural gas or LPG have an electronic pilot light. Timer switches on pool heaters and pumps are present. Exceptions: Where public health standards require continuous pump operation. Where pumps operate within solar- and/or waste -heat -recovery systems. 0 Heated swimming pools have a cover on or at the water surface. For pools heated over 90 degrees F (32 degrees C) the cover has a minimum insulation value of R-12. Exceptions: Covers are not required when 60% of the heating energy is from site -recovered energy or solar energy source. Lighting Requirements: F1 A minimum of 50 percent of the lamps in permanently installed lighting fixtures can be categorized as one of the following: (a) Compact fluorescent (b) T-8 or smaller diameter linear fluorescent (c) 40 lumens per watt for lamp wattage — 15 (d) 50 lumens per watt for lamp wattage > 15 and — 40 (e) 60 lumens per watt for lamp wattage > 40 Other Requirements: Snow- and ice -melting systems with energy supplied from the service to a building shall include automatic controls capable of shutting off the system when a) the pavement temperature is above 50 degrees F, b) no precipitation is falling, and c) the outdoor temperature is above 40 degrees F (a manual shutoff control is also permitted to satisfy requirement's'). Certificate: L] A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R -values; window U -factors; type and efficiency of space -conditioning and water heating equipment. The certificate does not cover or obstruct the visibility . of the circuit directory label, service disconnect label or other required labels. NOTES TO FIELD: (Building Department Use Only) Project Title: The Summerset 2 Report date: 11/14/10 Data filename: F:\REScheck\The Summerset 2.rck Page 6 of 6 IECC Energy C2009. �(j Efficiency Certificate Fw—wamQM@ MUM Ceiling / Roof 49.00 Wail 21.00 Floor / Foundation 30.00 Ductwork (unconditioned spaces): k�lmvwaoft Window 0.35 0.31 Door 0.31 0.35 pi�iza &Eft . Heating System: Cooling System: Water Heater: Name: Date: Comments: m m X m X m y v m v, y C •C 'v O CD n Z CO) CL r C CZ C y a� -v v CD CDo CL r .c d Cts CCD O CCD C CD y. Qv y to CD S- CO) CO O .0 Z CD O CD O CCD �� 1* 0 - M _. SO ® "o CO) OaCD CO m n O N® CL 2 �, M Z �� N 0 mag, ® O T O 5m CD im CAO) m n > > m '� !N7 90 ?� O O N CJ C S N \ Q CL cn1 c )M 1 \�+ m c C O 0ca N CL z N, e' r N CD C 1 eC V I' m > CO) N �CD CD cap: m CD Z �o zca -CD 0 =r . cn oma: cnCD oCD r'• a CL 0 O C �. O ". m � o m� 0. w ac C)tz 'n cn pd o Cil 7d 'n e. 7d o oda � � � `v �' n a' 7d o 'p 0 d co c o a 0 omi 0 9 0 c 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 onon 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 cant' 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 pen -nit 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 pen-nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple.-pen-nit/license applications inany 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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit 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 Tnvestiptions 600 Washington Street Boston, MA 02,111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Legib1Y Name (Business/Organization/Individual): Address: ` ` 66 6i1eve00 0 City/State/Zip: Ld"`clo�" 0k- � Phone ##: � ' Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts 4. ❑ I am a general contractor and I Department of Industrial Accidents have hired the sub -contractors Office of Investigations ,r��-. ; 600 Washington Street ti I'eu j`�/ R Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Legib1Y Name (Business/Organization/Individual): Address: ` ` 66 6i1eve00 0 City/State/Zip: Ld"`clo�" 0k- � Phone ##: � ' Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I nployees (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 me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I 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.] employees. [No workers' comp. insurance required.] Type of project (required): 6. '°New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12. E] Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors afid 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 �Asd-ra'nce*coverage verification. I do hereby certify and t,iepains and penalties ofpeijuiy that the information provided aboXX ' a and correct. Date. G�►!t7 Phone #: bol ^ __7V,!9 ` 01- �6 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 #• www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,r- i Please Print'Leaibiy Name(Business/Organization/Individual): 1�t'�E%-c%ft"`� Address: V (A" 61lCiRC10 f e4 City/State/Zip: `��.cto"dk �3G�3 Phone #: ��3 - 1� 0 Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts ' Department of Industrial Accidents have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. Office of Investigations • i iir e• � ". 600 Washington Street workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its Boston, YM 02111 CG 3. ❑ I am a homeowner doing all work www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,r- i Please Print'Leaibiy Name(Business/Organization/Individual): 1�t'�E%-c%ft"`� Address: V (A" 61lCiRC10 f e4 City/State/Zip: `��.cto"dk �3G�3 Phone #: ��3 - 1� 0 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (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 me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I 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.] 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.❑ Plumbing repairs or additions 12. F] Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the 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. Lie. #: Job Site Address: Expiration Date:. 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 irystirance coverage verification. I do hereby certify and t pains and penalties ofpeijurytl:at the information provided above' tr a and correct.' Date - Phone 9: ate: Phone#: baS^9- f)W 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 #: