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HomeMy WebLinkAbout0036 WOODCREST ROAD �,� ,,nn Qa �'d 1 0 . .. _ . .. .. . FZHETp`_ � Town of Barnstable 200 Main Street Tel. 508 862-4038 s�►xxsrwe�. � ( ) �A 16 . 'fOMA<IN INSPECTION REPORT Permit: Building - Insulation - Residential Use: Date: 12/26/2017 4:04 PM Inspector: sheas Permit Number: TB-17-4405 Name: ESTABROOKS, TODD L & SHELLEY A TRS Address: 36 WOODCREST ROAD, MARSTONS MILLS Unit No. Inspection Type Inspection Item Status Comment Building Admin - BA- Property Owner NIC Contract not with Superior but with Rise and Mass Save. Solar& Insulation . Authorization, if Builder Property owner must approve contractor seeking permit. is Applicant Building Admin - BA-Workman's Comp PASS Solar& Insulation Affidavit Building Admin - BA-Workman's Comp PASS Solar& Insulation Certificate of Insurance Inspection Overall Comment: Overall Inspection Status: FAILED Re-Inspection Date: i Inspector Signature Owner Signature Total Score: 100 avi��� � �oFrru>oy Town of Barnstable *Permit# ti o Regulatory SeI'vlces LFeces6n,o,rlhsJ. ,,r is-sue dnle 22 rnAnvsr&BLE, 7 S bjq Thomas F. Geiler, Director Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 fig www.town.barnstable,ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Nol VON Ivilhoul Red X-Press Imprint Map/parcel Number Prop Address 5(p Ujoub Residential Value of Work Millitnurn fee of$35.00 for-work under$6000.00 Owner's Nam e Address l✓ //!! Contractor's Name Telephone Number �'�r� Home Improvement Contractor License #(if applicable) IT& 9)2 Cons uction Supervisor's License#(if applicable) 7yo2;1 Workman's Compensation Insurance -PRESS PERMIT Check one: VI m a sole proprietor �QV ' 9 )0 10 m the Homeowner ve Worker's Compensation Insurance 1 -)VVN OF BARNSTABLE Insurance Company Name Workman's Comp. Policy# ?V Copy of Insurance Cornpliance Certificattrrd'sVa`ec'omp,1rry each permit. Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed) (not stripping. Going over existing layers of toot) ❑ Re- Ide #of doors Replacement Windows/doors/sliders. U-Value � 3 (maximum .35) #of window *Where required: Issuance orthis permit does not exempt compliance will other town department regulations,i.e. Historic,Conservation,ctc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors,License & Construction Supervisors License is required. 3IGNATURF: s� )AWPru.psIFORMSIbuildine ocrmit fhrins\GXP P r.CC rtnr s The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations (F'l bad Flash. Street MA02111 Boston, www.ra iss.gou/dia Workers' Compensation Insurance Aff'tda iit: Builders/Contractors/EI Tease ns/ - b.,rs Applicant Information Name(Business/Organizatiott/lndividual): � Address: jj kT City/State%Zip: tl Phone#:Are you an employer?Check t eropriate bo Type of pro'�ct(required): 4. 1 am a general contractor and 1 6 N construction 1 c�l am a employer with have hired the sub-contractors ❑ employees(full and/or part-time).' listed on the attached sheet. 7. Remodeling 2.❑ I am a sole proprietor or partner-;hest sub-r c,ntractors have - g. ❑'Demolition ship and have no employees employees and have workers' 9. Building addition working for me in any capacity. comp. insurance.t ❑ [No workers'.comp.insurance ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 5. officers have exercised their 1 I.[]Plumbing repairs or additions 3.❑ I am a homeowner doing all work -myself.[No workers' comp. right officers g exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑Other employees. [No workers' comp.insurance required.] 'Any applicant that checks box 91 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 subcontractors 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.#: �pira Expiration Date: Job Site Address: City/State/Zip: •Attach a copy of th orkers' compensation policy declaration page(showing the policy number and on date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine 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 tine of up to$250.00 a day against the violator. Be advised that a copy of this statement may.be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u the pains and pe I ' rmation provided above is true and correct es of perjury that the info Signature: Date: ool Phone# l+ Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/I,icense# 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#: f The Commome'eallh of'A.fassadittsells r -- Deparlinerrl of Indusirial_Accidews _ 4jjice ofInvestignlions 600 W,ashh..igloii S'lreel Bos/ozv AL4 02111 I Mass.goIldia Workers' Compeusati.on Insurance Mfi.dx6t: Builder•s/Conti:.lctor•s/El:ectiiciius/Pliunbei•s Applicant Information _ Please hint Le 'b]N, Na:me..(Busines,`Orgauizabon/individual): Address: J City/State/zip:t/l/ • Phone #: S-,8 J�a '�?� �• Are y ou .rl emp.loyer?-Check t e approprintr.box.: T}pt° ofpt o' ct(reqId L❑ a employer ix th 4• ❑ I am a general contractor and I oyees(fv1'I andlorpart-tinse).* have hu,2d.tlie sub-contractors 6- ❑.N constnic.t 2 I sole proprietor orpariner- list-Ed on.the attached sheet- 7. eartotieling ship and have no employees These sub-contractors have g. .Demolition working :for,me in any capacity. employees and have workers' TNo xvorkers' comp.insurance comp-in im—auce..1 9. .Building additi required] 5. ❑ We are.a corporation.and its 10.❑Electrical repai3.❑ :I am a.homemimer doing.all work affcers have eaeirised their I LE]Plumbing repair .myself. (No workers'comp. right of e-cemptiou per NMI, l2 ❑Roof repairs insurance:require,d.]T c- I J2, §1{4), and.v-ve have no euip.loyees. [No workers' 13..❑ O:ther coup.insurance required.] 'Any appticaur that chec9:s box#l.nu-st also filloutxhe section betow charring iheirworlers'compeusetion policy infornr.rtiarL t Homeowners wbo submit this.affidavit indicating they are doing all'av:org and then hire autside contractors must submit.a ueu,affidavit indicating such- "Cantractnrs that check this boa must attached sit sddilional sheet shoring the oame of the sab-covtrac.tws sod state rrheth�er or not those entities-have employees. Ifthe sub-contractors:have employees,ihey.must provide their workers'comp.policy,number. Ialit mr eJuploysr thatisprOJIMing workees':* rrpealsrrhan iJ:csarm.rr.ce for my e.+rrployees. Belory is filepvli. aJr:rl job site ilffOJ'JJ+2ti0J4 Insurance Company Name: Policy#or Self-ins. L:ic.#: �P Expiration Date: Job Site Address: c u(, 'J City/StatrJZip: , 0 �� Attach a copy of.the.workers' camp erYsntionpolicy d-e.claration page(s l.oiiing the policy numbe.t•and ezpb ion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminaI 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 WORD ORDER and a fine ofup-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 D.IA for insurance coverage verifcahon. .I'do hereby certify ruder fhe p is aJrrt peatath: prarjetry f.)rat f�'+e iJ.forJrrrctiaJt prot�irled: ove is true and correct. Si ature: Date: f l/ Phone#: FOther only. Do not lrrite ill this area,to be cosipieted 6} cih or torl�Jt ociaL n: Permit/License# wity(circle one): Health 2.Building Department 3. _ y/rown Clerk 4. Electrical Inspector S.Plumbing Inspector on: Phone#: 7 ® DA7E WMIDDnYYY) ACOR17 CERTIFICATE OF LIABILITY INSURANCE 02/19/10 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED.AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICA.C_ DOES NOT Alb!;=NQ, EXTEND 0P homedePot.ceztrequestgtnarsh.com _!_TER THE COVERAGE AF=CRDEC BY THE FOLiCiES 3__V,/. Two Alliance Center, 3550 Lenox Road, Sure 2400 j Cif 30326 Fax 12) 943_09_)2— -- -------NSURErSAFFORDING O`!_=?"•-J~-- --- - `1 ` _ . INSURED ' 1• ,tea f- ...JSu?.ER.a:� d_a.st =*ts Co 26337 The Home Duct, Inc. -- - - Home Depot U.S.A., in=. IiNSURER3:Zurich American Ina Co 15535 2455 Paces Ferry Road NW INSURERC:New Hampshire Ins Co_ _— 23841_—___—_ Building C-20 INSURER D:NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER E: Union Ins Ca I27960 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS TWqRr POLICY NUMBER I T I IYY Y _ A GENERAL LIABILITY GL04 88 7 714-0 0 03/01/10 031/01/11 EACH OCCURRENCE $ 4_000_,000 DAMAGE P::: M -PREMISES MERCIAL GENERAL LIABILITY TO RENTED PREMISES Ea occurrence 1,000,000$ CLAIMS MADE �OCCUR MED EXP(Any one person) - $EXCLUDED__—._ PERSONAL&ADV INJURY $4,000,600 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 X POLICY PRO- LOC B AUTOMOBILE LIABILITY BAP 2938863-07 03/01/10 03/01/11 COMBINED SINGLE LIMIT - (Ea accident) $ 1,000,000 X 'ANY AUTO ------ ALL OWNED AUTOS .r" BODILY INJURY $ SCHEDULED AUTOS (Per person) -- HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) ------- X SELF INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO- OTHER THAN.' EA ACC $ -- _ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE $ 5,000,000---- X OCCUR CLAIMS MADE AGGREGATE $ 5,000,000-- $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION WCO20342355 (AOS) 03/O1/10 03/O1/11 X WCSTATU• OTH- AND EMPLOYERS'LIABILITY YIN X D ANY PROPRIETOR/PARTNERIEXECUTIVEa WCO20342356 (CA) 03/01/10 03/91/11 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? E (Mandatory in NH) WCO20342357 (FL) 03/01/10 03/O1/11 E.L.DISEASE-EA EMPLOYE $ 1,000,000 — If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,006 OTHER E TX Employers Excess TNSC46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 30M/2M D Workers Compensation WC0910566 (QSI) 03/01/10 03/01/11 C Workers Compensation WCO20342358(RY,MO,NY,WI, ) 03/01/10 1. 03/01/11 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS . RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN THE HOME DEPOT, INC. HOME DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR 2455 PACES FERRY ROAD NW -BUILDING C-20 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ATLANTA, GA 30339 USA ACORD 25 1(4481889 2009/01)Jthornton_hd ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �., ✓ge 'Pom4nonaea&A 01'AK246arJu,,e& -� Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ! OME IMPROVEMENT CONTRACTOR i before the expiration date. If found return to: I Office of Consumer Affairs and Business Regulation Registration;:-AA893 Type:; 10 Park Plaza-Suite 5170 l' Expiratiorirr!%P;_20t2 Supplement Card Boston,MA 02116 The Home Depot;Pit;Home .Services II DARREN DEMERS`` ':~`�_��� 2690 CUMBERLAND RARKNVAX S -��/� F"'4i ° Not valid without signature I AYC�AN9'A,GA 30�39`''":`::,.=- Undersecretary 1 s License: CS 70077 Restricted to: 00 JOSEPH C DUARTE 15 FALL ST WAREHAM. MA 02571 Expiration: i2/30/2010 Tru: 7662 ;I/L r;Oom."000K e.AwmAmwffi valid fur indivaul u1i fely 6 data. jr found MjwnfAr- iw too 1p the elfilrsbM M" E tmpROVEMEW COMMACTOk ji'lArd of Vuihft flopt1tipnS ou4 Standards "St-miDn., 132349 • Nib" Elpigalwiv im;12011 114t VN PA"No.*tA.IWO C T i El J ReMIOUW9 jo$"h Duatle lio wil"O"S;grown FBI St va HOME D4PROVEMUfffr C0lWfkACT PLEASE READ TWS Name: Boston. Sold,Furnished and Installed by:ranch THD At-Home Services,Inc.. d/b/a The Home Depot At-Horne Services 345A Greenwood Street,Unit2,Worcester,.MA.01607 Branch Number 31 To1lFfee(800)657-5182.Fax(508).756-8823 Federal ID#75-269846Q;M6 Lic#C 02439;Ri Cont 1 ic#16427 CT Uc#WC.0565522;MA Home Improvement Contractor Reg.#126893 Irratlation Address: (�/cu,cll�� l�'r'I air oa 6 City State Zip Purchaser(s): Work Phone: Rome Phone: Cell Phone: I ] 1 [ ] Horne Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing cmaits from The Home Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, O and THD At-Home Services,Inc.("The home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of all.materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#:'�,,aern,�l hoducts: S Sheets))#: Pro' Amount Roofing Siding Windows insulation G � ❑G.rtM/Covers pEntry Doors ❑ Q 6 $ Roofing Siding ❑Windows Insulation ❑Guuers/Covers OEntry Doors © $ Roofing ❑Siding ❑Windows insulation ❑Gutters/Covers QEntry Doors n $ ❑Roofing Siding ❑Windows.❑Insulation ❑Gutters/Covers ❑Entry Door: n $ Mialunu 25%Deposit of Contract Amount due upon execution of thin eont MC1. Maine Purdue ery may not deposit more than orr¢third of fhe ContradAntourrt Total Contract Amount $ Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Comppletition Ccrt it!cate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The tloure Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Contract. y, Payment Summary: The Payment Summary #__ YY,S"Q!C/ included as pan of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). you are entitled to a completely filled-its Co NOTICE TO CUSTOMER there is one Completion C ertifcxte for each listed Product as defin he Contract at the�yyindividua Spec Sheets)before DO not sign a workon that tI roduct is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,tabor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts Set forth in this Agreement or allowed under applicable taw. THE HOME DEPOT MAY WITHHOLD Ap4OUNTS OWED TO THE HOME DEPOT FROM THE DFPOSIT PAYMENT OR OTHER PAYME,NT,,q MADL. WITHOUT . T-TMITING THE HOMir DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acce t nce and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Horne Depot wit regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and lnstallation_This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot Customer acknowledges and agrees that Customer has read,understands voluntarily accepts the terms of and has received a copy of this Agreement. Accept S ubk'tted by: Custo X `ssignatme Date sultant's Signature Date ' Customers Signature Date Telephone No. C_AN(ET, AT10N: CUSTOMER MAY CANCEL THIS Sales Consultant License No, AGREEMENT WITHOUT PENALTY OR OBLIGATION <�epplicabk) BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE TH1QmD BUSINESS DAY' AFTER SIGNING THIS AGREEMENT. - TI STAn SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED . BY LAW IN CUSTOMER'S STATE, NOTICE:ADDITIONAL TERMS AND CONDITIONS ARF,STATED ON TA[: REVERSE SIDE AM ARE PART Op THIS CONTRACT 8�3t-10 GSC White=Branch R4 Yellow— C+>st6mer Tel WdS£:Z 400Z L FpW iLZZZ9£80S: 'ON XtJ_i pP6wpf: wau qj 7MET0�♦ TOWN W N OF BAR.NSTABLE BARNSTAMLt M�a BUILDING INSPECTOR _ 900 1639• \0� �'0 YPY Or• , APPLICATION FOR PERMIT TO ................< ............................................-�/......................... .....:...yam...!...... TYPE OF CONSTRUCTION . 1 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...:L..�. T- .......................:j. ....L.d.^': ....... .......F�.rirl.S.... �.� / L��1 ...................... �. Proposed Use .... ....... ................................................... r . .................................... Zoning District ................... . . .........................................Fire District �Q.Ttr�T ............. ..................................................... Name of Owner /)')!9:/'. -. /......:. /�� - �1.!!.�-:....:.:...:..L............Address l�.Q...T3..�.�...�.�l.G.....��f1:�.�a:c.�....../�..7.�-s..S..:.. Name of Builder /.......&✓.... ..............................Address .?4?349x... Name of Architect .........��..Q.�/.�._ e-......Address g Number of Rooms ..........1.........................................:.............Foundation ....8....D.C�.vi.�:.4-�.:...�...�0�1..�!.�!!.�...:....... Exterior .... �...... a2,v. ....(D x.)........Roofing ....„A:.S .�. ct . T.................................................. Floors � /`'�`y.............. ...................r.�...............................:............Interior .,..�............................................................................ Heating f�...�............... (U �Tl1'� ..................................Plumbing .................................................................................. d �� d a Fireplace ....Q.N..4-................................ Approximate Cost ,,••••• Definitive Plan Approved by Planning Board --------------- ---- 19 --• °7" ` " Diagram of Lot and Building with Dimensions �� SUBJECT TO APPROVAL OF BOARD OF HEALTH Ion, 3a N W U Z O F- ¢ FW- ~ 3t 20o go = W 0 (n J �,- irP ¢ g ac~¢n � zc�7 3% N - §E < W I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.. Name . ........................................................ March, Inc. No ..16133... Permit for ........two ..StOZ7........ sin ................gle family dwellin.4........i........ Location ........ ...........................Mkrstons Mills ............................................. Owner .............. ............................ • Type of Construction ..............fVIMP................. . .............................................................................. Plot ............................ Lot ................W3....... April 20 73 Permit Granted .................. ....... ...............19 Date of Inspection Date Completed ...... 7).-19 PERMIt,REFUSED ................................................................. 19 ............................................................................... ......................................... ........................................ ............................................................................... (-Z) ............................................................................... Approved ............................................. 19 ............................................................................... . ............................................................................... oI2_0)os c9 Town of Barnstable *Permit# s rl?`{3 Expires 6 months om issue date Regulatory Services Fee Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 '� �; www.town.barnstable.ma.us n� Office: 508-862-4038 Faxa,,08-790-80? EXPRESS PERMIT APPLICATION - RESIDENTIAL ftkY 18200,5 Not Valid without Red X-Press Imprint OF jy eARNsT,q vlap/pazcel Number. O 7 CP _ eLE ?roperty Address0 I2cK 00 residential Value of Work -J 500 `Minimum fee of$25.00 for work under$6000.00 Jwner's Name &Address ,r O&& CL S" ro O O o Ck- Cyrs'S Contractor's Name Telephone Number 5087 Ll2o (l:4( Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor [D'I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) NT"Re-roof(stripping old shingles) All construction debris will be taken to CAL ,Xle� ❑Re-goof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property O ust sign Property Owner Letter of Permission. Home rov ent Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 1 ne.t ommonweatrn of massacnusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lesribly Name (Business/organization/Individual) I f7ck&. a S1'\e_I(t_q- ES - �oILS Address: 4cx�Cv�s 12rQ City/State/Zip: ALrs2ns S, NSA- a26�t$ Phone#: S© g 1-f20 11-6/y Are you an employer? Check the-appropriate box:. Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time)-* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. - 9, ❑ Building addition [No workers' comp.insurance 5• ❑ We are a corporation and its Electrical , uired.J officers have exercised their 10.❑ repairs or.additions 3.lb I am a homeowner doing all work right of exemption per MGL 11 Q Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no insurance required.]t employees. 12.�'Ifoof repairs eq ] [No workers'. COMP.insurance required.] 13.❑ Other.'. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information �a t Homeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors that check ibis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information 1 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 penadties 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ;t a r s and penalties of perjury that the information provided above is true and correct Signature: Cl Date: Phone#: �d �� 111 Official use only. Do not write in this area,to be completed by city or town of ial. City or Town: Permit/License# Issuing Authority(circle.one): 1.Board of Health 2..Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as�A'an iu&i duaL.:Pa.rtDeq*�:association,Forporation 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 ociation or other legal entity,employing employees. Howcv.,er*e- receiver or trustee of an individual,partnership, ass -' 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 shall not because of such employment be deemed to be an employer." or on the grounds or building appurtenant thereto 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 ofthis chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es) and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners; are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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.. Self-insured companimshouldenter 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 permit(license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"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 affidavit is on file for:future permits or licenses..A new affidavit must be filled out.each applicant as proof that a valid year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and.fax number: The Commonwealth of Massachusetts . Department of Industrial.Accidents ..Office of Investigations ,. 600 Washington Street- . Boston,MA 02111. :;Tel. #617-727-4900 ext 406 or l-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia