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Home My WebLink About0336 WAKEBY ROAD ✓6� .'e,(. `:v... :.c+u1i^J T �.;.r-:,,• � `s'� �'C;.ri.r5�. 6�+�'-Ku ., a°�.>�'J.sq�.��ay ��yy;n,�' "S':i��:�a _. -c �' .. � .. `•h<�-. _ _. ..o ea Assessor's office (1st floor):: Y TNE Assessor's map and lot number .....�� ."...� �-00.5� C-el— TO` Board of Health (3rd floor):/ ' q / j fO�Q ♦� Sewage Permit number +' � ...../J � l. �/ � Z Bisa9TsnLE J Engineering Department .(3rd floor): 3 (o OAK r" �o Mb 9 Housenumber .........................................................:.............. W. Definitive Plan Approved by Planning Board ________________________________19________ . APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ................ ......................................................................................... TYPEOF CONSTRUCTION .........(.A.)Q77!�d.....lt✓`V................................................................................................. 1�1 Cu ...... .�............19 TO THE INSPECTOR OF BUILDINGS: The undersigned --hereby ��applies for a permit according to the following information: Location ........ ..............Wri�l�,.:. .. .......��4xG� � .. .....� ..... r ProposedUse ........:.................................................................................................................................................................... y � Zoning District ................... ......................................Fire District ............ .... Name of Owner .........,G� .. - ............Address ..................................... ' ......... . ........................ . h Name of Builder W �� .....Address Q'✓�� Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ................:/.............................................Foundation V.-(.'...... Exterior .. 1 (f. v.........................................................Roofing .......� ........ y , ..........................................................................Interior l ' Floors :j✓ Heating ........ ......................................................Plumbing . Fireplace yVd VL `�. 0 p ... ............................................................Approximate Cost .....�. .... Area .......... .�........ ...... 00 Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ........ ........................................................ j Construction Supervisor's License ...!!��!!//C ... i WEST, JAMES G. III - A'=028-014-004 N No ...31944 Permit for ...Build Barn AccessorX to Dwelling . ............... Location ....336 Wakeby. Road Marstons Mills ............................................................................... Owner ....James G WEst . . .........III........................ Type of Construction ....Frame ............................................................................... Plot ............................ Lot ..:............................. Permit Granted ...M`.......31......................19 88 Date of Inspection ....................................1:9 Date Completed ......................................19 l - Assessor tNE s offioe Ost floor): Qo7a /y— v 0 A essor's ma and lot number ..... Fr ss� Board of Health (3rd floor): Sewage Permit number ........... ............" i BaH39TGDLE, J Engineering Department (3rd floor): moo NAM House number ... �o .. MO 6• APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING 11SPECTOR ^� APPLICATION FOR PERMIT TO ........... iL. ..l. ....._. .......................................................................... TYPE OF CONSTRUCTION / ..1.�!../f rp/%� ........., ........................................................ ...............:..... ......:... ... :.....�.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: / 33l LVa IP �1� ��, �rn.��................................................. ?.. .........................::........ Location ...-....... ................................................_................�...; ProposedUse G .c. Z.... 4t .................................................................................................................................... Zoning District 1< ................................Fire District ........C—....0. ". -Name of Owner ..: ..:.W1. .5.....G.. ,5 ..-T--�r�........Address Name of Builder ...\Gt IM•P .. ...11 Q.S ......L ...........Address .......S �?:!.. ...........................:.......................... Nameof Architect ...............................:... Address ....................... . . ....................................................... _ Z.......Number of Rooms ..................................... Foundation ............. -F`)(�u2— 1-1 1 / Exterior ........... �.. .. ...................,�r. ....................Roofing ..........�!..S.�? .�:..!. ....................-0........................... Floors .:........k'...�CIC '� D� D� t:'0�✓��a.�i./•.. '-".:.'::...Interior .............. .. f�... ... .................................... .......... HeatingPlumbing .................................................................................. s Fireplace ..................................................................................Approximate Cost ...✓.......... ........... ................... J.. � ......... Definitive Plan Approved by Planning Board __________________________ ------�9-------- . Area ............................................ Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH f P , r OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .....�/�.C�!/�X; / /1�............................. Construction Supervisor's License .................................... ."/WEST, JAMES G. III A=028-014—Y No ... Permit for h4ild..Gq.r.a.ge........ g................... Location .....................Y...........................:.............336 Wqeb s Marstons Mills Owner ...Jme .as..G. .....We.s.t...I.I.I.......................... .. ........ Type of Construction "...Frame............................ ............................................................................... Plot ............................ Lot .................................. Permit Granted ......Augus.t 6, .......19 86 .......... :.............. Date of Inspection ....................................19 Date Completed ......................................19 *7 Assessor's map and lot .number........... ............... ........ . FT NE T P Sewage Permit, number _............................!L1v........".... d�'y �y°► BASB9Ta LE, i House. number :.....................:..............................................:..•. v AG 4p i6,39. aYAYA\e TOWN OF.. BARNSTABLE BUILDING INSPECTOR 'APPLICATION FOR PERMIT TO /........!v' TYPE OF CONSTRUCTION ................... ..................................................................................................... 9. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permi according to to following information: ............... Location /..... %./.;:.j ................................. ProposedUse ......... .. ..%I.........`................................................................................................................................................. l� �/ . ZoningDistrict ..............................P................/..............................,Fire District ........... .. -..................................../.,............ Name of Owner .( ...: !. �if, ...1�..�U.-.....Address :..0....... 6.........l t�. ?'��!�!. Name of Builder G 1 h ..h �C?5. ................Address 5-� .kt.!j 5� .......I .y- �l/••1�>.l.1•!{7;•li(�-- Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ..................................................................Foundation .................. I e .. . . .U... .t..................�. ! ...'.............�... 1A Exterior ....%�/CS..kr+!�..u. U.......................................................Roofing ;� ��L� -- � ...11........... �. :.Floors :.....Interior .............:7 l G � � :....................................... Heating ..0..'.., .. /Y�/ � �� a l�(�...................Plumbing .......... I? ............... +. ..... :....:...... i p Approximate i� U f• Fireplace .......... ..�..............................................................A roximate Cost ................ .................a.�........... ... A L/ Definitive Plan Approved by Planning Board -----------_______-----------19_______ . Area ..,��v'I'.................... Diagram of Lot and Building with Dimensions Fee ...... ....... SUBJECT TO APPROVAL OF BOARD OF HEALTH � I J � ' �o OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules'and Regulations of the Town of Barnstable regarding the above construction. o Name ..! ..............�/...... �J ... ................... .... Construction Supervisor's License ...... A=28-14 ►a ST, JAMES G. III No .26'.3.11.... Permit for .............. .....Single Family...V.w ..Pg................ .eLj.]ZU........................ Location .);Pt..7.......3-36--WakebY..Road........... ................ ................................ Owner ...J. S.. III....................... Type of Construction Fxame............................. ............................... ................................................ Plot ............................ Lot ................................ Permit Granted ....AIR4.1...1? ...........19 84 Date of Inspection ...................................19 Date Completed ......................................19 Asspsor's office (1st floor): p / ?ME' Assessor's map and lot nRr ..... �Board,of Health (3rd floor) /9/SewagePermit number .�l.d.fr!•..... � �1 �� o, � INSTALLED IN C CSC Engineering Department (3rd floor): 3 3(o ..' WITH M t6 °- �e House number .......... 3 A p. Definitive Plan Approved by Planning Board _______________________________19________ . �! `` APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00.2:00 P.M. only TOWIN' REGIOUTIONS- TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ............ ................................................................................................................ TYPE OF CONSTRUCTION ........(„e��lY�..:... . .................. 1n/, /....... �............19 TO THE INSPECTOR OF BUILDINGS: L The undersigned hereby applies for a permit, according to the following information: Location ......... ..�......ul/.!.!1..... .. ...... 4/ te-1 .��' ... ProposedUse .............................................................................................................................................................................. Zoning District ..........:....... .. .......................................Fire District . ..�.�. ................................. 3 3 Name of Owner ............Address .............................. .......................... Name of Builder CJ......V..... ...... ...Address Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .............../.............................................Foundation ....................................... Exlerior . . ........................................................Roofing ...... . .... .. . .. ........................................................... Floors .... Vh.........................................................................Interior ...... Heating .............tlD.h .....................................................Plumbing ............. 0 >7 `�� Fireplace �/0 VL `ems .......................Approximate Cost ...... .. !7 Q�c/ .......... Area ....:.....'Td�.�................ i Diagram of Lot and Building with Dimensions Fee ........... 5........................ OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name G� ' • Construction Supervisor's License ...� .... WEST, JAMES G. III .o No :..319.4A. Permit for ...AU:Ll.d...D.drn....... Acc.ess.ary...�a...D.w.1.1,i n.g............ w; Location .....3.3FWakeby...Road a ..................:. x. ons„Mi11s Owner. .......James...G.-...West. ...I.IL......... . Type of,Construction ..FV.,A e............................ Plot ...................... Lot V................... Per .Granted ......bia ...31...:...............19 88 Date'df-Inspection ....................................1.9 ` Date 'Completed .............. ..........19 it J wri U A IVA G M A 19, V'j C-s 336 VNJAKc, Y-2,y ROAD U. MARS-foNS MILLS "A 0261+9 0) (D 0 r.3 w 4- (.n 0) ,1 00 (n -I-' _ Ti- 7- -7 -1-1 _F --i - J+7 +H _F -F N I--- _..�_. y I i-{ l I I`-I j { I'-I - !-I_ _ f^I- I ,1 -i I--Irr r, Aj- I it ; ! it , ; a I 71 L 1 J i .7. LLL_d=_ 4, 77— J- + --H I E i H-11 J-d -Tj F 7_1 i 17- F -1 71 7_ 7 T F r _FF _F it A- i F�T it L -F-F77-4-77 7 -1:TPLP _±LE __EE L F-1-Tt- 44-11 7_1 2- 1144 T 77-TiT FFF 7-F CO -T1 I i ! 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( I I - ---! -f_--` (-- --- I�_..'_F-� ? i 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 t twn to �� 5 tiyuares to the Centimeter , l 1 . TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB. LOCATION'. um er tre t a ress. ection o town "HOMEOWNER" ame ome p one worK phone PRESENT MAILING ADDRESS X to / s it town tate ip co e :The curren dw t exemption for "homeowners" was extended to include owner-occupied eIIi-ngs. of six units or ess •an to allow such homeowners to engage. an in- ivi ua for hire. who does not possess a license; provided that the owner acts as supervisor. (State Building Code Section . :DEFINITION OF HOMEOWNER: . Person(s) who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be,' a one to six family dwelling, 'attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one. home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official , on,a. form' acceptable to the Building Official ,, that he/she shall be responsible 1 for all such work performed under the building permit. kbection . :The undersigned "homeowner" assumes responsibility for compliance with the State Buil.ding Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of .Barnstable Building Department.'Minimum inspection procedures and requirements !and that he/she will comply with said procedures and requirements: HOMEOWNER'S SIGNATURE � r APPROVAL OF BUILDING OFFICIAL S Note: Three family dwellings 35,000 cubic feet,' or larger, will be require to comply with State Building Code Section 127.0, Construction Control . d --. • HOME OWNER 'S EXEMPTION The Code state that : "Any Home Owner Permit Is required shall be exempt from for which a building . (Section 109. 1 . 1 - Licensing of this Supervisors)sl.o�hO°Idedis section Home Owner engages a Person(s) for hire to do such work , that such Home owner Shall act as supervisor . " Many Home Owners who use this exemption are unawares that they are the responsibilities of a supervisor (See-Appendix p, . assuming for. Licensing. Construct Ion Supervisors, Section 2,;15) .• . This lack, .:.. often results In serious s unlicensed problems, particularly ,�M en the Home Owner hires Persons. In" this- case our Board cannot proceed against the unlicensed person as It would with Ilcensed Supervi sor..ultimately The Home Owner acting as; supervlsor is imately responsible. To ensure that the Home Owner. is fully aware of his/ res communities require, as part of the ponslbilitfes, •many certify that he/she understands the responsibilitisscation that the Owner of ,a supervisor . On- the last page of this Issue IS a form current ) •care to amend and adopt such a form/certlficatelonb fore use aInsl' t Your You may your community. Assessor's.offioe (1st floor): � � �J y— �" y Assessor's map .,and lot number .... .................................. �� - :� J-T`-7 � 1 �� F 1 WQ�o`T ¢To` o M Board of Health Ord floor): 1 8 .1 _ I (I �� '..� III ��®� D1 oUp,n`U a. Sewage Permit number ........................................................ 1 B' STA MWLE S Engineering Department (3rd floor): a ' �7�7House number .......................... 6\0�° MAI APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR 7 APPLICATION FOR PERMIT TO ........ : ... ..... .......................................................................... TYPE OF, CONSTRUCTION ...............G!1/ .. ...../.�!� . ..... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 11 � ,M Location .... ...... a.. F.!?! .... ...............�..�1. S i?..........................t.......1. !.. .,............................. 36.........lM : Proposed Use l 7 (c '�— I, Zoning District .................. .....................................Fire District ......... .. ./.�. ...y ' ' I .................... .............................................. Name of Owner �............Address ' ........ p ...FA. �.1.1=...S........h..s.. � Name of Builder .. , i WI Ps...'.....V.P.. �... .............Address ......S.4.. ?.. -...................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ....................................777. ........................Foundation ...�....... f,� C. S ............................................................ - Exterior !�........... .......... ...........................Roofing .............�F..S �2. .. .I................................................ Floors ................. ......................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace .............................................Approximate Cost . ..........Ye.0.� ....... ................................ Definitive Plan Approved by Planning Board ________________________________19________ . Area f.> .... Diagram of Lot and Building with Dimensions Fee �) ...� Vv.v... .................... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. ................. .. Construction Supervisor's License ................................... WEST, JAMES G. III No 29756. .... Permit for ....Build Garage ................................ Accessory to Dwelling .......................................................................... Location ....33.6...Wakeb.y...Road ............................ .......... . ...... . Marstons Mills ..................................................................... ......... Owner ........James G. West III- Type of Construction ............................. .................... ....................................... ............. Plot ............................. Lot................................. Permit 'Granted ..........August....6, 19 86 ........ . . Date of Inspection ....................................19 Date Completed ... ....................19 ■■■ a ; l .��t■ ■�� . ® ■ , �, MEN �` !■■■■■■■■■-- Mom- 0 MENEM �. ■�■�■■■■ i ___ - ��11/■■t!�■■!I■■■1'1■!■ll�!!■1■■■■�■■■■� II■■fig■■■■ m■■■■ ■■■ ■■■■■ ■■■■■■ ■��BA��■I■�0�■i�0�■O��I■■lOr� ■ ■ F � 1 IT, E f- ON i A ---- — — I-- —�-- IMAiRSraN MI i11 1 1 11111 , T j + I I I I i � � j � � ► i I � � - I i ! F7 ►, I I i I ► -a I I T ON P.L A' N -- .--- __t —-�— _-� - - - j -' -�- _ ; �SAM85- G: -t-i MA RY L.-Wcsf egy MA RS NS M i u5 MA • � ,,.w^ '' y: ,ice- � .>J�� t<�+y�, �;; '. ��. 't ��'w ;t>r.� ,+ 3 - � •y a '•��'" ;,�: yy1A�; _ - l Via., 3 .a .• .`f s. "±: Y s_t , x�i►.. #k�.c 4.av x- .e<.� '� i 1 T I S CALL: --- -- I SAWS G 8 MAR y L. W95f NAME �* ?r . 'a:• rr : ;!C. 3�e WA�K�IBywRo�;17 97. T P ........ x:-20 ON E- LA m `Ls ILLs Evv. E:*L:. G- A R , I G-Q; 0 Q. eo ! 4�s Al : r I i I 46 - _ rT --�- - - I , ' ! I-' ' I • --1 SCALE : Pr' Li�� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �_Parcel - �� [ Permit# Health Division Date Issued Conservation Division /S� Fee Tax Collector Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 33 W al l cI —F cC Village M6i lz SA6 ll s I'll S Owner:=G tM P 5 N- G 1?= We s Address P D f3 c Nfi gzsk,* Telephone Permit Request Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost 6—S';00 Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: Cl Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing" new Total Room Count(not including baths): existing new First Floor Room Count 'Heat Type and Fuel: 0 Gas 0OiI ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ElYes ElNo Detached garage:4existing/ ❑new size Pool:❑existing ❑new size Barn:Irexisting O new size Attached garage:0 existing 0 new size Shed:O existing ❑new size Other: -f— w Zoning Board of Appeals Authorization ❑ Appeal# 'Recorded 0 Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION r/ Name �G�/ Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJE TWILL BETAKEN TO, .tt � , C. SIGNATURE DATE t FOR OFFICIAL USE ONLY r PE4MIT NO. DATE ISSUED MAP/PARCEL NO. y ADDRESS VILLAGE OWNER . DATE OF INSPECTION: i FOUNDATION FRAME INSULATION ' FIREPLACE ` ELECTRICAL: ROUGH FINAL ` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING, DATE CLOSED OUT ! ASSOCIATION PLAN NO. The Commonwealth of Massachusetts • .,- ,Department of Industrial Accidents - -- OIllce oflasgsmgatigns 600 Washington Street Boston,Mass. 02111 ' •v14� Workers' Com ensation Insurance Affidavit / rrrrri r rir i� name: e � location 3 4 city hone# am a homeowner performing all work myself.. ❑ I am a sole mprietor and have no one working m aavczPacitY to rovidin workers' ensation for my employees working on this job..:;:>:.;»:.:•>:<•;:.;>::•;»:•>:-;>:.>::„;:<;:;:;:<;:;«;:»;::::;:;:: I am an em :.; :::::::.::::::::::::::.:::::::.;;;:..::::::::::::::: ;:.::.:.:;:.:::: . `.:.:.,;:.: com anv n ''`7dre s • a ......:.. .. ::;:�;:.::::.;:.;:.;;::::;r;:;;;::;:>:G;:>;>:<:>r:4:-;:::::•::�r::::;:.:;:>::a;:<•;>;::»:<>:<#�::::>:�::z8i::<?<:>'t::i:i:: ::i:<:ri::::f>;;:>::: X. x. " `on Xx h X. of ICI insuranc / ❑ I am a sole proprietor,general contractor,or homeowner(circle One)and have hired the contractors listed below who have orkers' co ensation olices: the following mP.................P....:._.:.:,..._:::::,.:_:.:.:......_:::::.;::;.::._:::::::::.:::::::._.;;:.:::::::::::.:._..::.:::. cbm aav nam es dr as »»»>:>: on X. .:.2> ,.: elicv# ............................................ cavn am e:::::..... ......................... ad iire s :.;:.::.;:. •..:.: ......:...:::..........:::.. .. . ;::.;:.;::.;:.::.::::::::..::.:.:;:;;;•::.;;:•;:.;;:.:.:;:.... ;:>>.::<»>:-;;:;;.;:.;:.:.;;;:::;.;:.;:.:;<;.;:.;;<>.<:::»<::::»:........:::::.>::-:;<::»::>:=:<:::>::>:>..<:;:.:.;:-::.:.:::::::::::::. hen cl tP Failare to secure coverage as required wider Seclioa 25A of MGL 1S2 can lead to the lmpositl°n of erlminal pensltia of a Sae to SI,S00.00 and/or ons years'imprisonmm!as weII as civfi pensitlea in the form ota STOP WORK ORDER and a Sae o[S 100.00 s day against ma.I�mderstsnd that a copy of this statement may be forwarded to the Ocoee 0f Irtvestigati0ns of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si Date � Print name 1 e S Phone# official use only do not write in this area to be completed by city or town ofri"' city or town permit/license# ❑Building Department Qlicensing Board ❑Selectmen's Office ❑check if immediate response is required ❑Health Department contact person• phone#; ❑Other (revised 9195 P)A) Information and Instructions 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 contract of hire, express or implied, oral or written. An employer is defined as an individual,pa rtnership, 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 occupam of the dwelling house of grounds or another who.employs persons to do maintenance, construction or repair Rork on such dwelling house or on the 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 the not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither commonwealth nor any of its political subdivisions shall eater into any contract for the performance of public work until acceptable evidence of compliance with the irm=ce 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 fie. 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 off davit 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 peimit/license number which well be used as a referenc turn e number. The affidavits may be reed to the Department by man 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 member. The Commonwealth Of Massachusetts Department of Industrial Accidents 8MC0 of Invesduatlons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375