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HomeMy WebLinkAbout0436 TURTLEBACK ROAD mow Town of Barnstable Building Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept DAMNSMOLM 1� Posted Until Final Inspection Has Been Made. Permit ' Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-20-1108 Applicant Name: kyle bray Approvals Date Issued: 04/29/2020 Current Use: Structure Permit Type: Building-Deck Expiration Date: 10/29/2020 Foundation: Location: 436 TURTLEBACK ROAD, MARSTONS MILLS Map/Lot: 062-002 Zoning District: RF Sheathing: Owner on Record: WILLIAMS WENDY F TR Contractor Name: KYLE R BRAY Framing: 1 Address: 8200 BEECHTREE ROAD Contractor License: CS-112340 2 BETHESDA, MD 20817 Est. Project Cost: $7,400.00 Chimney: Description: A tree fell on the deck.The home owner request that I rebuild the Permit Fee: $ 110.00 decks railings and pergola above the deck to match a closet as Insulation: Fee Paid: $ 110.00 possible as to what was there before.The deck itself has not damage but some of the railings and the complete pergola`was Date: 4/29/2020 Final: destroyed. Plumbing/Gas Project Review Req: Rough Plumbing: \Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. I Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: S.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Per cting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). � Fire Department Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Providing Insurance and Financial Services : StateFarmo Home Office, Bloomington, IL February 17, 2020 BUILDING OAP' FEB 2 4 2020 Town Of Barnstable Building Commissioner State Farm Claims 200 Main St PO Box 106169 �OVviv yr ++r+•+ g�� Hyannis MA 02601-4002 Atlanta GA 30348-6169 CERTIFIED MAIL: RETURN RECEIPT REQUESTED RE: Claim Number: 21-04M1-27D Our Insured: Wendy F Williams Date of Loss: February 7, 2020 Loss Location: 436 Turtleback Rd, Marstons Mills, MA 02648-1124 Tax Block: **TAX BLOCK** Tax Lot: **TAX LOT** To Whom'lt May Concern---- State Farm Fire & Casualty Insurance Company writes to provide notice as required by Massachusetts law in connection with the matter referenced above. State Farm®received notice of loss or damage in excess of$1,000 at 436 Turtleback Rd. Marstons Mills MA. 02648. We hereby notify your office pursuant to General Laws c. 139, §313 that State Farm intends to make a payment of$1,000 or more in connection with the above referenced insurance claim. Further, the applicable amendatory Policy Endorsement informs the insured of the Massachusetts requirement by stating the following: "We are required by Massachusetts law that we must notify the local inspector of buildings or Board of Health at least 10 days before we make a payment of$1,000 or more for loss to a building or structure. We must also give notice if there is damage which makes a building a health or safety hazard or dangerous or unsafe for occupancy regardless of the amount of our payment. If, prior to payment, we receive official notice of a pending or existing lien against your premises, we must delay payment until the matter is settled. If we are required to pay all or part of the amount of the lien, we will not be obligated to pay that amount to you. If you have questions or need assistance, call us at (844) 458-4300 Ext. 9725416486. 21-04M 1-27D Page 2 February 17, 2020 Sincerely, Eric Maina External Claim Resource -Worley (844) 458-4300 Ext. 9725416486 State Farm Fire and Casualty Company I Y~•�� y,+�-T'�"riF':.j%•2�s^^'i�'Al:hrY'ti.;.+"�r^?isi.a.bs.sib`�tfrt+j+�liF.s,'wry'.i..+"�RYA`lirtr`' �v��C+r+q. �^-e+.K�•_'.'s".*._-Ws-�eYrts`n..ti„`.;j-• ^..�+��• i The Town of Barnstable RM Department of Health Safety and Environmental Services g °rFo;p�•'° Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice �►.� 1 Type of Inspection n t-i�� _ Location +36 -rualg .Z Permit Number 43 { ( T Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: 7� c- m . Please call: 508-862r4038 for re-inspection. Inspected by V Date .t a. r � { i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION L717- 6 Parcel Permit# 3((`( r. Health Division Date Issued Conservation Division Z q Fee ��S> !9-D Tax Collector Treasurerl"� eta I t rir• oIRT� —.Qrmm�iatinn Hv�� Project Street Address �+S(e Village I, " AZ l6„15 1IWS Owner _at F. \1111,DAYY15 Address 8 e-t1.�Fs r%-gD. 8�"1 Telephone C30) 36 5- 2-3 n Permit Request STP-4lr' 3CQfi OF !~jL( )J4 Syki1�L. 5 4!�� Square feet: 1 st floor: existing 1 proposed 2nd floor:existing � proposed Total new Estimated Project Costt 5� Zoning District Flood Plain Groundwater Overlay Construction Type ZS IgPff� ASPRNL1�-( -Rwe 51frr_� -c= Lot Size 3 z D a 41 6r Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 2(o 'fObZ'5 Historic House: ❑Yes ,@ No On Old King's Highway: ❑Yes DgNo Basement Type: ❑Full ❑Crawl Walkout ❑Other WkLK-W-r—AlZeA Srkow� Basement Finished Area(sq.ft.) iN Figb-c Reye- /t Basement Unfinished Area(sq.ft) Number of Baths: Full: existing -CWO new Half:existing new Number of Bedrooms: existing new A Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas O-Oil ❑ Electric ❑Other Central Air: ❑Yes VNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes 4 No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 3,No If yes, site plan review# Current Use "Si1SQ G FA*"t-( qAr-Alto-0 Proposed Use 54Mt; BUILDER INFORMATION Name �F G� ?APC3M M9S. T,. c Telephone Number -000 f Address T0--. ?0K 133 License# SAS r►,`�� 1-IrRSL 51. Home Improvement Contractor# 1 0O 131 Worker's Compensation# Lkb-q 55K911 - ALL CONSTRUCTION7RESUL ROM THIS PROJECT WILL BETAKEN TO IF1 _Du_-k 457u SIGNATURE a DATE i • FOR OFFICIAL USE ONLY .E MIT,NO: i DATE ISSUED 1pe� MAP/PARCEL NO. ' `-• ' ADDRESS � � - - VILLAGE OWNER DATE OF INSPECTION:- ' FOUNDATION ' FRAME L INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL? FINAL BUILDING i r - DATE CLOSED OUT t ASSOCIATION PLAN NO. :::::............................:.;i:<is ::i::::i::::i:::::::::::::: }iiii::::::i::::i::::iii:::!:::ii}i:::::::::::iiiiii::.i:;:isfiii::iiiii::ii::::::i::::i::ii::i::i::::i�::i:::i:::::................�; :: :'> :i' ': :::i::i::ii:ii::i::::i::isi:!':iiii:.::.ii:.iiiiii:.i:.ii.......... i:.:is is..ii:i.iii?iiiii:.i:.i?: .: • C.i:• ii:::. :: ii: .i: :::: •i: •ii:• iii: •i:.i :• .. :. :.: :ii:.i .•'i:iiiiiiii:.:':::::::::::....X•:C•iiiiiiii:iii:�:;v:!�:iiiiiiiy : :..... ::.::::::>:.;:.;;;:.::.>:.;;:.::.;:.; DATE(MM\DD\YY) :C:::::::::::::::::::: .::1:t�.S. :R�►N: .E:. ::.::::::::.:::::::::::::: ....................................................................... ................................................... 6— — O 14 99 PRODUCER FALTER IS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION LY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MYCOCK INS AGCY LDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR P 0 BOX 437 THE COVERAGE AFFORDED BY THE POLICIES BELOW. COTUIT MA 02635 COMPANIES AFFORDING COVERAGE COMPANY 297SB A RELIANCE INSURANCE COMPANY INSURED COMPANY PADGETT BUILDERS, INC. B P.O. BOX 133 COMPANY COTUIT MA 02635 C COMPANY D THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR OMITS DATE(MM=\YY) DATE(MM\DD\YV) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE E7 OCCUR. PERSONAL&ADV.INJURY $ OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE UABIUTY ANY AUTO COMBINED SINGLE $ LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per Accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY•EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: .................................... EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM A WORKER'S COMPENSATION AND EMPLOYER'SLIABILITY (UB-955K917-7-99) 06-01-99 06-01-00 STATUTORY LIMITS THE PROPRIETOR/ EACH ACCIDENT $ 100.000 PARTNERS/EXECUTIVE X INCL DISEASE—POLICY LIMIT $ 500,000 OFFICERS ARE: EXCL OTHER DISEASE—EACH EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS i THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. ICATE.HOLDER...::::::::.:::::.:......................::..::::::::::::::..........................:::::::::::.: ..... . ION :::....................:.::::::::::::::.:......................:...:::::::::::::::.: ............... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL TOWN OF MASHP E E 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE BUILDING DEPARTMENT 16 GREAT NECK ROAD NORTH LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR MA SHP E E MA 02649 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE RD;GQ.RPQRA'i'ION':1'9 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Workers' Compensation Insurance Affidavit Applicant Information: . :.. PLEASE PRINT NAME O — L (�t7 t✓_?T tt �s LOCATION =IdOOiL, CITY C��la-� STATE ZIP CODE ©U-5 5 PHONE# 501 `k2,b -cam l O I am a homeowner performing all work myself. O I am a sole proprietor and have no one working in any capacity. I am an employer providing workers' compensation for my employees working on this job. Company Name kme AS A30Q Address Ciry State Zip Code Phone# Insurance Co. - C Lr h-rJ cE Policy#UL q5-5 -7--7-23 Expiration Date (,0 t 0 0 O I am a sole proprietor, general contractor,or homeowner.(circle one)and have hired the contractors listed below who have the following workers' compensation policies: Company Name Address C'h' State Zip Code Phone# Insurance Co. Policy # Expiration Date Company Name Address City State Zip Code Phone # Insurance Co. Policy# Expiration Date Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. certifu r p/do hereby y d na ties' per' ry that the information provided above is nue and correct. Signature Date lW �5/�� Print name > I 1/I(Y, �;,p� . a� phone# C � .� -wo) Official use only—do not write in this area—to be completed by city.or town official Ciry or town Permit license# ! O Building Department j S O Licensing Board O Selectmen's Office O check if immediate response is required O Health Department O Other Contact person Phone# • NAM g Department of Health Safety and Environmental Services Ea '' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Cressen Fax: 508-790-6230 Building'Commissione. Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. c t) Type of Work: S 19AP a,.ro �e�LAet��1-1�1�LG� _Estimated Cost�s,3 7 s AddressofWork: ' 36 luR`i'LF-back DNP-S-0,6 11iU5 dZ(o�B Owner's Name: Date of Application: D ELerr,(6F-(z- 15, (r 19 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law oJob Under S1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MUROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the pvmqp cz(15 -� -b" T .�� vUr3 Date ontractor Name Registration No. OR Date Owner's Name q:forms:Affidav i✓/lP T0�24^tz4(/¢O�L 6�i%I�GQQQ�LLLQeG(4.t DEPARTMENT OFjUBIICSAFET;Y CONSTR T OBI SUPERVISOR LICENSE t N Expires: y t -- . . 16: M � B Dk�TT:; € drr.4r of !'`184 $G OOC��F P08.133 1' -�COTUIT,R'NA e2635 41 ftj, rCM,A�.3y •io 3't �., �!1 q' St �,�'" '("�'.}' >`t'• 5�i s Too�rmanaiaa�i c� d�tidellLia "'` `} `k�NOME'IMPROVEMENT�CONTRA TUR1 pRegistrationh00131 t o Type X PRIVATE-CORPORATION� 46, Ezpiration06J09/00��_ " %k�` PADGETJ`BUILDERS;'INC ` 4°; ,• >,�� ,OberttR; PQett ,;syc�,ti ; ozr133/18CSchool1St� • �tivwsr�roR,, t�CotuitJMA;026354I ��r� 1 h'"E�`'i;rt s`, �'.t°.kv..J t � �, r•+,,f' .f,.: �, lid f , - -------155732 � Restricted To: 16 a a Oe - 35;866 cf enclosed space I (M6L C.112 SAL) 1p - Masonry only 16 - 1 i 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license'. `, y,. e:, s -' ,f4 'tM Yd License or registcagon valid'for�;indiv'du al� `A fuse onlyrybefoie`�expiraton'date If'founds jeturn to:Ocie Ashburton Place Rm 1301t; $osto .02108 J r f ? TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ,r� Parcel - 02- Permit# t� Health Division /Z--% 7.9 t� Date Issued Conservation Division I 40,0 C_ Fee ffar ector q Tct 0 tL' '�" Treasurer SEPTIC'� SEPTIC SYSTEM h5UST BE INSTALLED IN COMPLIANCE "nin WITH TITLE 5 Date-Definitive-Plan Approved by Planning Board ENVIRONMENTAL CODE AND TOWN REGULATICINS .Historic—OKH_ Preservation/Hyannis Project Street Address 4'SG TuR?I eL ( ZU . Village To►si S MILLS 2c�o '3L=ech `CPeE RID. Owner WeLw F. \,1A-L4)TMs Address 6r_-- RESDA - mt) Soovi Telephone (-So' ) 3 C 5 — 2 S I Permit Request &► D "9aPJL4).-D E=CEZ?R 'DECK IQ TVAE SWI^ �i Pi����C �S ry j Cep Tl. i STS Square feet: 1st floor: existing 18 proposed 2nd floor: existing 8`� proposed Total new c0 Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type PT WO D ' Lot Size -32 i 0-0 Q — 5 F Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family)4 Two Family ❑ Multi-Family(#units) Age of Existing Structure ZS `t 2S , Historic House: ❑Yes �Ao On Old King's Highway: ❑Yes /-6mo Basement Type: ❑Full ❑Crawl )P(Walkout ❑Other Basement Finished Area(sq.ft.) IOU,-MT- WeA 5N0,00 ��Basement ( q ) Basement Unfinished Area s ft (- - Number of Baths: Full: existing _T'*-AI0 new (YHalf: existing new Number of Bedrooms: existing 3 new (— Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas '0Oil ❑ Electric ❑Other Central Air: ❑Yes p]No Fireplaces: Existing — (I _ New Existing wood/coal stove: ❑Yes CONo etached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size °S1k ttached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ANO If yes, site plan review# Current Use Proposed Use c� j� BUILDER INFORMATION Name _ I Telephone Number �Z$--y v 0/ C� Address rLC� Z _ f 3 3 License# L- S (• Home Improvement Contractor# 10o is/ 2(z,35 Worker's Compensation# 6R:10u3—?5SKJI T-1-9$ ALL CONSTRUCTION DEB RESULTING FROM THIS PROJECT WILL BE TAKEN TO (J1- SIGNATURE - / DATE j z, -'4 FOR OFFICIAL USE ONLY M PERMIT NO, DATE ISSUED MAP/PARCEL NO. ADDRESS, VILLAGE " OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION I ' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH :=? FINAL FINAL BUILDING44 Q , �. d -' u DATE CLOSED OUT ASSOCIATION PLAN NO. (. The Commonwealth of Massachusetts tn_1-= ae Department of Industrial Accidents Office of/nl•✓eslfgal%ans 600 Washington Street Boston,Mass. 02111 Workers' Comiensation Insu�rraance Affidavit ;Tli��tarri;lull ri r NNW'. /iioir name: location: city phone>y ❑ I am a homeowner performing all work myself. ❑ I am a sole ro rietor and have no one workin in any ca acity I am an employer providing workers' compensation for my employees working on this job. ►►//�/commynnv name: GC� Y.l�1 t-V -S � t�l�� R Qa; address: 26X city phone#: insurance co. �--;w C-E poiicv# RI OUB SK111 -1-1 S ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name- address: city phone#- .. ...... insurance ca. ...... .:...:.:.:. O11N#.. ..:: ::;::.:'�.::::;: . . // comnanv name: address: city phone#: insurance co. :.;;:::;:;::: >:.»:;.:: ..:. olicv# . :;:::::<::>:•»><>:::«::<>:::,;>::.. ;;>::>;>:;»>::z:i>:.:::?: <:.>:.>:.;::.:.. . Failure to secure coverage required under Section 25A oCMGL 152 can lead to the imposition of criminal penaltln of a fine up to SI,S00.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a copy of this statement be forwarded to the OfflAe of Investigations of the DIA for coverage verification. I do hereby certify n the p 'ns pen es jp u e information provided above is true and correct tu Signare ' Date i z'1 i i 'T e _ Print name 0'J _ 2 . Phone!t (SOV) �FZ£3 . C)00 official use only do not write in this area to be completed by city or town official city or town: petmitAlcense# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other .. ::.:......,.. :::..:., . (tevaea 9195 P)A1 i Information and Instructions 1 Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any corm-c. . 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 c= 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 section 25 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,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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the'law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns 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. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number. ' The Commonwealth Of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext 406, 409 or 375 OF THE Tq� . 'Y The Town of Barnstable • RARMAJ ram.%65 • MAM Department of Health Safety and Environmental Services 10TEDM � Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements.Type of Work:�E1Y oqe Jufu c o C�1 S—(,N GT Ptcy Estimated Cost Z oC) Address of Work: 4U _r[XR-q_C t�3AC.K'_�17, T7)AV5 Co0S 'TVIS,. TIN 02448 Owner's Name: 'q_, 1Jol F. \1M%1U,1rM5 Date of Application: -DEXem_6M 1111118 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDVIT_ S ERJURY 1 hereby apply for a permit as the agent of theIdt%lis q: � /oo 131 Date C ntractor Name Registration No. OR Date Owner's Name q:fortns:Affidav �e{oomrnanuieal!/a o�./�amac/umelYa" �F . HOME IMPROVEMENT CONTRACTOR DEPARTMENT OF PUB'lIC SAFETY f !Registration 100131 r ', CONSTRUCTI.ON SUPERVISOR LICENSE Type - PRIVATE CORPORATION Number Expires; I h 'Restr<icte'd To; 1G i PADGETT BUILDERS, INC. E Robert R. Padgett ` f.�Boz 133/184 School St ROBERT.R".PHDGETi ADMINISTRATOR Cotult MA 02635 � a► 184"SGHOOI`ST. POB 133 COTUIT, MA 02635 155732 Restricted To: 1G LI l : 00 - 35,000 cf enclosed space License or registration valid for individual (MGL C.112 S.60L) ' use only before expiration date. If found 1N Masonry only return to: One Ashburton Place Rm 1301 ; 1G 1 & 2 Family Homes Bosto 02108 failure to possess a current edition of the I / Massachusetts State Building Code ' v is cause for revocation of this license. r' I (HoQ i o,s-(A L Li►'Yll�(LSz� In11L1.S — � � u ULi 2-")(2 �3ALUS-t e res R IL l - No-( -(u Sc-A L L /7APe(2rr) Cr-P 1�3 4 ny PO51 co,.r;i;���u7 To `JuNo Tub O ZO ALI,I FLI-,lH iNG ZK y N/ti'LE� 0 �5PnoE(C5 --�j I�c4 lh/1Hc�Ra \.� sc 3�y" LAO PJc�L s CZ'oc '5 LAB 1 ti�'�SP�EE Zx8 ors e ►6 oc TROUGH 3cxT To L AcH POST LJl Two 3N�� Dii)mC7dz 3a7s 2�c8uer)oez i1EfgL isT Hn�-GcR 4 N L-„,1t Of P�v.,10 roc E,�DS OF �Ac,l -Tuis-r. 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