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• • The Commonwealth of Massachusetts
Department of Industrial Accidents
C =I 1 Congress Street, Suite 100
-.2,74:111= Boston,MA 02114-2017
:..w., www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information 1, Please Print Legibly
Name(Business/Organization/Individual): S,4-M)WS t I-I t��7^G cogs _DA/z. </ti#r r a PEI' ttl-Sl
Address: 5 i .wn/z£.s b/A Y
City/State/Zip:'EMT Spiv writ!, 1t4 OZ537 Phone#: 50s1/4 .5 ?'t-f to O Z
Are yon an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with ._employees(full and/or part-time).' 7. 0 New construction
2,4'I am a sole proprietor or partnership and have no employees working for me in 8. RI Remodeling
'TT any capacity.[No workers'comp. insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet
These sub-contractors have employees and have workers'comp.insurance? 13.0 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pal and penalties of perjury that the information provided above is true and correct
Si. attire: r. . 4/ Date: // Z —/ 1
Phone#: .SO $ . 5 --z_°OZ
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#:
Og'Y'9R0Ca
TOWN OF YARMOUTH
' ' 0BUILDING DEPARTMENT
N1146 Route 28,South Yarmouth,MA 02664
• 508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at `D Si FRE£Bo A-R_ 1-A-4,
Work Address
72,wn of VA-st At.oc. r d Dsrposfl
Is to be disposed of at the following location: ,¢2,E4 hht C o. '5T4-'c.r. vti
PBMO f't.*-reicc,4-t) — Cl-AC
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
/` jSo---- !/ - Z - !8
Signature of Apiiiication Date
Permit No.
.
r
Commonwealth of Massachusetts
•kirDivision of Professional Licensure
Board of Building Regulations and Standards
Con strMCtkri lsltpervisor .Y
CS-082869 Eyires: 08/02/2020
KEITH WILLIAM PETIPASreft
5 WINNIES WAy A }..'
EAST SANDWICH MA 02537 "`
Commissioner
•
•
•
Ste Wpo wzonwcal o/Qf6acluoee
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
-1-
I Type: Corporation
SANDWICH KITCHENS,INC. \ 1 r ° 1,th Registration: 192436
5 WINNIES WAY I jt 11„ Expiration: 07109/2020
I,
EAST SANDWICH,MA 02537 (`1 �-
Yfr +��J,1
- -��
Update Address and Return Card.
eau O 2041-091t
91'W,nn,nawr/IA eye"ffa.undea G
Office of of Consumer Affairs i Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation before the expiration date. If found return to:
Jteaistration Fxniration Office of Consumer Affairs and Business Regulation
192436 f 07/09/2020 1000 Washington Street-Suite 710
SANDWICH KITCHENS,INC. Boston,MA 02118
•
KEITH W.Pvii'X
KIES WAY
ff�I
EAST SANDWICH,MA 02531 Undersecretary Not valid without al ature
No 7- 7-0 S .S j'D DcESS rJob Name
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'Boise Cascade `Triple 1-3/4" x 9-1/2" VERSA-LAM®2.0 3100 SP Floor Beam\FB01
rIg•
Dry I 1 span j No cantilevers 10/12 slope October 26, 2018 15:11:01
BC CALL®Design Report
Build 6536 File Name: BC CALC Project
Job Nam-• :" Description:2nd floor girder
Addre s: 108 Freeboard Ln Specifier:
City, " •te,Zip:Yarmouthport, MA Designer:
Custome . Company:
Code reports: ESR-1040 Misc:
LS___._.s._ .—t—L2_.t_L.. ._;_i_. 1 v LY I ' i i i 1 cJ
V 12-00-00 V
BO B1
Total Horizontal Product Length-12-00-00
Reaction Summary(Down/Uplift) (lbs)
Bearing Live Dead Snow Wind Roof Live
B0,3-1/2" 3,120/0 1,023/0
81,3-1/2" 3,120/0 1,023/0
Live Dead Snow Wind Roof Live Trib.
Load Summary
Tag Description Load Type Ref. Start End 100% 90% 115% 160% 125%
1 2nd floor Unf.Area(Ib/ft^2) L 00-00-00 12-00-00 40 12 13-00-00
Controls Summary Value %Allowable Duration Case Location
Pos.Moment 11,497 ft-lbs 54.9% 100% 1 06-00-00
End Shear 3,395 lbs 35.8% 100% 1 01-01-00
Total Load Defl. L/377 (0.367") 63.7% n/a 1 06-00-00
Live Load Dell. 11500 (0.277") 71.9% n/a 2 06-00-00
Max Defl. 0.367" 36.7% n/a 1 06-00-00
Span/Depth 14.6 n/a n/a 0 00-00-00
%Allow %Allow
Bearing Supports Dim.(L x W) Value Support Member Material
BO Post 3-1/2"x 5-1/4" '4,143 lbs n/a 30.1% Unspecified
B1 Post 3-1/2"x 5-1/4" 4,143 lbs n/a 30.1% Unspecified
Notes
Design meets Code minimum(U240)Total load deflection criteria.
Design meets Code minimum(11360)Live load deflection criteria.
Design meets arbitrary(1") Maximum Total load deflection criteria.
Calculations assume member is fully braced.
BC CALL®analysis is based on IBC 2009.
Design based on Dry Service Condition.
Page 1 of 2
i
®Boise
Cascade Triple 1-3/4" x 9-1/2" VERSA-LAM® 2.0 3100 SP Floor Beam\FB01
Els
Dry j 1 span j No cantilevers j 0/12 slope October 26,2018 15:11:01
BC CALL®Design Report
Build 6536 File Name: BC CALC Project
Job Name: Description:2nd floor girder
Address: 108 Freeboard Ln Specifier:
City,State, ' :Yarmouthport, MA Designer:
Customer: Company:
Code reports: ESR-1040 Misc:
Connection Diagram Disclosure
--I b d--•-i Completeness and accuracy of Input must
be verified by anyone who would rely on
a MEP output as evidence of suitability for
o T o • 0a particular application.Output here based
c on building code-accepted design
properties and analysis methods.
t • • d Installation of Boise Cascade engineered
a o o o EM® wood products must be In accordance with
4 current Installation Guide and applicable
building codes.To obtain Installation Guide
or ask questions,please call
a minimum=2" C=4-1/2" (800)232-0788 before installation.
b minimum=3" d=6"
e minimum=3" BC CALC®,BC FRAMER®,AJSTM
ALLJOIST®,BC RIM BOARDT",ECI® ,
BOISE GLULAMT'",SIMPLE FRAMING
Calculated Side Load=676.0 lb/ft SYSTEM®,VERSA-LAM®,VERSA-RIM
PLUS®,VERSA-RIM®,
Nailing schedule applies to both sides of the member. VERSA-STRAND®,VERSA-STUDS are
Connectors are: 16d Sinker Nails trademarks of Boise Cascade Wood
Products L.L.C.