HomeMy WebLinkAbout0204 WASHINGTON AVENUE W `Ala
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Town of Barnstable
_ .� -- Building
{Posh This Card So That it is Visible From the Street-Approved Plans-Must be Retained an Job and this Card Must be Kept-
i�M [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 1r
Permit No. B-19-1634 Applicant Name: ALAN CURTIS Approvals
Date Issued: 05/22/2019 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/22/2019 Foundation:
Location: 204 A WASHINGTON AVENUE,OSTERVILLE _ ._ _Map/Lot: 139-083 Zoning District: RF-1 Sheathing:
Owner on Record: CURTIS,ALAN B&EAGAN,GAIL Contractor Name:` Framing: 1
Address: 32 UNION PARK#1 Contractor License: 2
Est. Project Cost: $ 1 00,800.
BOSTON, MA 02118 � Chimney:
Description: Replace 6 windows with no header changes Permit Fee: $35.00
Insulation:
Fee Paid: $35.00
Project Review Req: SAME SIZE REPLACEMENT.
Date: ;' 5/22/2019 Final:
•� �nr- .... Plumbing/Gas
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.
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:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Rough:
7.Final Inspection before Occupancy
Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Health
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT pw L__T�yj C Final:
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�a,s< Town of Barnstable. *Permit#
} � Regulatory Services X.PR�Expires 6 months from issue date
-�
r;naxernara.
suss. Thomas F.Geiler,Director
Building Division AUG 3 0 2012
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
TOWN OF BARNSTABLE
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-190-6230
EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY
2 Not Valid without Red X-Press Imprint
Map/parcel Number �3 Doi 7
Property Address
,Residential Value of Work 3SbD II Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address 'wr l uyl 'tl\5
Q U P f �
Contractor's Name Telephone Numbe 6 t 1 we _113 3
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany 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 roof)
><Re-side
#of doors 6
Replacement Windows/doors/sliders.U-Value 10 (maximum.35)#of windows _
*Where required Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
r quired.
SIGNATURE:
C:\Users\decollik\AppData\Local\Microsofl\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc
Revised 072110
y
The Contnionweakh of Massachusetts
Department of lndustrzal Accidents
Office of Investigations
vi 600 Washington Suet
Boston,MA 02111
rvww.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 'Q Please Print Leeibly
Name(BasinesVOgpnizatiion& ivid=0:
Address: -b h ^^
City/State/Zip: Phone
Are you an employer?Check the appropriate boz. Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time),
s have.hired the sub-contractors 6. []New construction
2.El am a sole proprietor or partner- listed on the attached sheet. 7- ❑Remodeling
ship and have no employees 'These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance l 9. [:]Budding addition
required-) 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
officers have exercised their
3.�I am a homeowner doing all work 11.❑Plumbing repairs or additions
/ myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required]l c.152,§1(4X and we have no
employees.[No workers' 13.0 Other
comp.insurance required]
'Any applicant that checks boa#1 roue also fill out the section below showing thendt woers'compensation policy information.
1 Homeowners wbo submit this affidavit indicating they are doing all wank and then hire catside contractors�a submit a new affidavit indicating wch
fConuacmrs that check ibis box must attached an additional sheet showing the name of the subtomtrKtors and state wbethu or not those entities have
employees. If the subcontractors We employees,they most provide their workers'camp.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.Uc.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains and�n�'es of perjury that the information provided bove is true and correct
Si tune: N �.J&_ Date: ' D I Z
Phone#: S 2 'S?l
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.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
6
i
� > Town of Barnstable `
�^ Regulatory Services
AJ" Thomas F.Geiler,Director
sh Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:_ 1 Z e
JOB LOCATION: 7 4 1.1 2S t�'1 S�Oh `l QS V ti I e
number -� street village
"HOMEOWNER': ' V alh CV 's ��) 4-24 7733 C t7 8-7 Z-S7 1
name k
f h me phone# Work phone#
CURRENT MAILING ADDRESS: U h 1 0`1 Pow -41
6S-he tj OIL tt
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-
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 for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
pros ores and requiremtrandubat he/she will comply with said procedures and requirements.
Signature ofHomeo er
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section
109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as
supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for
Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons.
In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately
responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner
certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and
adopt such a form/certification for use in your community.
C:\Users\dewllik\AppDataV-ocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc
Revised 072110
i
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ( �JIL'rf1 j L
E +
Map Parcel. 0 Application # 6
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee 4, a-L
Date Definitive Plan Approved by Planning Board (c—
Historic - OKH Preservation/ Hyannis
Project Street Address 1 QL� 1.i a(Zh 1 v)dE"� >�dG�1v'2.
Village :5'k1( v l e Owner 'qv\ e-4, 'I—) t (�4� ' 4� Address I VvgV_\ P,'yV ( � d-ovl N6 o211 i
Telephone S_�
'15
ox
Permit Request Ck
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 3 C U0 Construction Type
Lot Size Grandfathered: ❑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: ❑ Full . ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)
CD
® —a
Number of Baths: Full: existing new Half: existing N new
Number of Bedrooms: existing _new C:3
. , -r,
Total Room Count (not including baths): existing new First Floor .Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal s,t4ve:'a Yes ❑ 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 ❑ No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
�( \\ � I
Nome 1��4� Cus�'��s fi (41 I Eaxav\ Telephone Number( t l ��2 S 1 1
Address `7�) �^ r Q� 4 License # f
d�- Home Improvement Contractor# N
Worker's Compensation #
ALL CONSTRUCTION
`f DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
ArV.i ,J I e Jv w�D A iA
SIGNATURE C04" I ,. DATE y Z
i
Y .
FOR OFFICIAL USE-ONLY �
APPLICATION# ;
2
DATE ISSUED
MAP/PARCEL N0.
ADDRESS VILLAGE
OWNER r
t • 1 e^ ,
,f DATE OF INSPECTION:
FOUNDATION
FRAME
u
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
. GAS: ROUGH FINAL
FINAL BUILDING SG 62.
DATE CLOSED OUT
ASSOCIATION PLAN NO.
,_ � L
- The Commonwealth ofMassachuserts
• Department oflndustiWAcciden
Office of Investigations
600 Washington Street
Boston, ML4 02III
Workers'
www mass.govldia
Compensation Insurance Affidavit: Builders/Contractors/Electrician.s/plumbers
A licant Information
Please Print Le 'bl
Name (Business/organizahon/lndividnaI): I
D 1
Address:
City/State/Zip: a ti 0111 Phone#:
Are you an employer? Check the appropriate box:
1,❑ I am a employer with 4. I am a Type of project(required):�P Y ❑ general contractor and I p ) ( q �:
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner_ listed on the attached sheet 7. Remodeling e
ship and have no employees These sub-contractors have L p F
working for me in any capacity, employees and have workers' 8, ❑Demolition
[No workers' comp.insurance comp.insurance,# 9• ❑Building addition .
3Xrequired.] 5, ❑ We are a corporation and its 10.❑Electrical repairs or additions
I am a homeowner doing all work officers have exercised their
myself. [No workers' comp, right of exemption per MGL 11.❑Plumbing repay or additions
insurance regilired.] t c, 152, §1(4),and we have no 12•❑Roof repairs
employees. [No workers' 13.❑Other
comp•insurance required,]
*Amy applicant that checks box#I must also fM out the section below showing their workers'compensation policy information.
t Homeowners who submit this aif3davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating
ZContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities h.
employees If the sub-contractors have employees,they must provide their workers'co Policy mP•P ey mrmber.
I am an employer that is providing workers,compensation insurance for my e 1 information mp oyees Below is the policy and job site
Inmzance 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 policl
quired under Sec
number and expiration date).
Failure to secure coverage as re tion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1;500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties o
fPerjw7'that the information provided above is true and correct,
SI atum..
rrQ
.
oil
se only. Do not write in this area,to be completed by city or town official
wn: Permit/License#
thority(circle one):f Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbna Ins ector g prson:
Phone#:
i
I
r .
'Town of Barnstable
��. Reg-aratury Semces
MA.R, R-56 I Thomas F. Genes,Director
BniTding Division
Tom Perry,Building Commisgioner
200 Main-St-�--c _Hyannis,MA 02601 _
www.town_harastable_ma_us
Dffice: 509-952-403 8 Fax: 508-790-6230
sol�o�ll�x I.Ic$its��I�-rox •
Plrare Print .
DkTE L{ L f
cpB=lot ArtoN: `fi Vy z e
number sir>~t
Nllage
+G�,l 4,, l Il u-1�7�� I 8-7 L -S1 t
name (� hotnep e# wtnphonc$
4CURRRXT-U ILING--ADDFMS:
HI
aty/tavtn ter' zip code
Tl7c cmrent exemption for`homeowners"was cxtcndt:d to inc)nde owner-orcvnicd dweIlmes of snc>mits or loss and
to allow homeowners to engage an individual for hire who does not possesS a ficcnse,provided tba#the owner acts as
SUDM-yisoI.
DEFU n ON OF ROhMOWNT-R
Parson(s)who owns a parcel of land on which hehhe resides or intends to-mHdc, on which th=is, or is intr n d to-
bc, a one or two-family dwelling, atfachzd or detached strnctm cs access ory to such use and/or farm slrtutacs. A
person who canstr4cts more than Dne home in a two-year period shall not be considered a hame owner. Such
"homeowner"shall submit to the Building Official on.a.form acecptablc to the Building Official, that hc/shc shall be
rcSDonsible for all such wow ycr£urmed Tinder tho bmldina pe»t (Section I09.1.1)
Tl�c undciaigned"home:ownce-assumes remponsibility for compliance with the State Building Code and other
applicable codes, bylaws,roles and regulation.
The undersigned`homeowner"certifies that.he/she tmdersfands the Town pf Barnstable Building Department
�-TiT mym inspection proccdtzr= and n--qu .Tints and that he/she will comply with said procedures and
cgTiitcmcnt s.
ignaLure_of CrHomctrwn
pproval of Building Of5cial ,
Notc: Three-family dwellings containing 35,000 cubic feet or larger will be requin:d to comply with the
ate Building Code Section 127.0 Construction Control.
90AMO WNER's Exn=bx
.The Cade states that: "Aay bon —6—PM-R ring wort;for which a binlding pert is require sbaD be Ua=nipt fT=the provW mu
thin scction.(Sectian 1D9.1.1 -Licaui4g-ofcoasGveban Supervisors);provided that if the homooqMa mgagu a pcm=(s)fm him to do such
r$,that such Iiamcowncr shag ad as nipervisar."
Nw My homeowners who use this==Ipti®arc Unaware tbat tbey arc assrng the:respansrbtlities of a sUrpavisor(sec Appendix Q:n h Regulations for s unlic n Camstrncfion Supavisars,Section 2.15) This lank of awa==bf=rrsutts ID saiau;problems,particularly
�t the homcowna hires un)inmsed persons. In.this ease,our Board cannot prD=rd against the unlic==d pawn as it would with IU licaued
-aviu r. The homeowger acting as Supavisar is ultimately responsib)r
To Moore that the hamevwncr is fully¢wars of hir/hcr-spaanbilitia,many nommunitirs roquae,as part of the permit application,
the homeowner ncr*that hchhe underatmmds the r=pmnbilities of a Supervisor. On the last page of this issue is a farm eut=oy used by
ra]towns. You may care t ainmd and adopt rurb a fotmlcuti5r-a on for use in your coannuaity.
ras:homco:cmpt
• I
• o�TMF Town of Barnstable
Regulatory Services '
r r
MASS eg Thomas F. Geiler,Director
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must y
Complete and Sign This Section
If Using A Builder '
. e
as Owner of the subject property
hereby authorize to act on my behalf;
in all matters relative to work authorized by this building permit
(Address of Job)
*Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled before fence is installed and pools are not to be
utilized until all final inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q:FORMS:OWNERPERMISSIONPOOLS
Town of Barnstable Geographic Information System April 3,2012 �.
139085
139073 #176'.
#19
139079
#0 `
139078
#188
139084
#194
139080
#0
O � �
139083
At
139088
#192
O13908 •`
138014
-� 139081 #202
#226 \
SNtµG�o� 1 0g /
138612�
138007
�Z 21 F+e:e•� ,
DISCLAIMERS:This map is for planning purposes only. It Is not adequate for legal Map:139 Parcel:083 N
Selected Parcel
boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:CURTIS,ALAN B&EAGAN,GAIL Total Assessed Value:$837100
1'-100'may not meet established map accuracy standards.The parcel lines on this map Co Owner: Acreage:0.25 acres Abutters W E
are only graphic representations of Assessor's tax parcels.They are not true property
boundaries and do not represent accurate relationships to physical features on the map Location:204 WASHINGTON AVENUE
such as building locations. Buffer
i
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l.e�C.:r�sr^1•���� ��f�ix' I""k'� � \ Q�a'` � ��l �' � ....0
�C �� V / r�� TOWN OF RARNSTA�4_E
G-t P t/ .�+�W Fy..n.l ,F� lr•(Q�.� Y �T L d /e rr P`JJ� l� lus0 • bra � 6kAL`— 4,/ t/
2012 J1. 23 P1 8: 53
D IV IS
QSA
��. Z' Cy•C , 1 i.�"P� �;�:1�7�� ��6.:.L.-, ���'i�1t...Ckt��. '�t=�A.�.�'�,�1��� i ��`` ��J
-�'8 `'1
2.y0CE 16
AT
t� y
ssessor's office(Ist Floor):
8sessor's map and lot number 1.1 3 d 1M
Conservation(4th Floor): ! r r'
Board of Health(3rd floor):
Sewage Permit number
� rua
Engineering Department(3rd floor):. oo t639.
House number
Definitive Plan'Approved by Planning Board 19 -
APPLICATIONS PROCESSED 8:30-9:30 A.M!and 1:00-2:00 P.M.only
T0, WN . Of BARNSTABLE
,BUIL' DI'NG ' INSPECTOR
APPLICATION FOR PERMIT TO
TYPE OF CONSTRUCTION wr ' /tlG Gds eovow
19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies r a permit acco-rlding to a following information:
Location �v6�e►� G
Proposed Use
Zoning District Fire District
Name of Owner GL/ Address,�D6( /9r0-f✓6TPlit! D bSYl�uG�
Name of Builder 2 Address//y�/jJi�lrc/�
Name of Architect Address
Number of Rooms Foundation
Exterior Roofing �/L�a
v
Floors Interior
Heating Plumbing
r
Fireplace Approximate Cost �, d
Area
Diagram of Lot and Building with Dimensions Fee
I
I
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
Construction Siipervisor's License D4G/8�
,- HASKINS, WILLIAM
1
A=139 083
NO Permit For reroof & sidewall
r
Location 204 Washington Street
Osterville
Owner HASKINS, WILLIAM
Type of Construction = -
Plot Lot
Permit Granted + July 11; 19 94
Date of Inspection:
Frame 19
1
Insulation
Fireplace 19
Date Completed g y 191
COMMONWEALTH OF MASSACHUSETTS
Z a ' DEI'AIC TvUM OF LNDUSTRI L ACCIDFN'TS
600 WASHINGTON STREET
`wnes s Can:aer BOSTON MASSACHUSEM 02111
zornm-sslone• WORKERS, COMPENSATION DWRANCE AFFIDAVIT
(liccnset/pertai
with a principal place of usinadresidence at:
.(GrylSatca-p)
do hereby certify,under the pains and penalties of perjury,chat
[) 1 am an employer providing the following worker'compe=don coverage for my employers working on this
job.
Insurance Company Policy Number
[) I am a sole proprietor and have no one working forme.
[) I am a sole proprieror,general contractor or homeowner(cirde one)and have hired the contraars fisted b_ow
who have the rollowing workers'compensation insurance polices
Name of Concraaor Insurance Company/Policy Number
Name of Conmaor Inswanae Company/Policy Number
Name of Contmaor Insurance Company/Policy Number
I am a homeowner performing all the'work myself
NOTE Please be swage that while homeowners who employ persons to do maintenance.construction or repair work on a
dwe:ling of not more than three units in which the homeowner also resides or on the grounds j1ppurtenant thereto are not genew,y
considered to be employers under the Workers Compensation Aet•(GL C 152.am 10)),application bra homeowner for a lice
or permit may evidence the legal tutus of an employer under the Workc: Compensation AeL
1 understand that a copy of this statement will be forwarded to the Depar=r:of lndustrW Aecidcats'Office of Insurance for eovcae:
ve mcation and that failure to secure coverage as required under Section 25A of.MGL 152 an lead to the imposition of criminal per. :es
consisting of a fine of up to S1500.00 and/or imprisonment of up to one year acid civil penalties in the form of a Stop Vork Order W...a
fine of S k,;0.00 a(Icy again::me.
. signed this day of
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