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0068 WIANNO AVENUE
�� � �, � R; ,, ,� r, �� a ., �� Q,,: �� i ��I� � ��r �� �—,ter ,-.,—� „' —r - _ _ a — __ _ �_..____ — '.e..�....u�e.,.-�.,m�__:�._�.r�. IKE Town of Barnstable *Permit ) V I- ' "� Regulatory Services Fee 6monthsjrom issue date SAHNSPABIA ArKAM. Richard V.Scali,Dire a5 ®� i639• ♦0 Building Division Paul Roma,Building CommissiMAG" 202018 200 Main Street,Hyan�s`}}�� 02601 www.town.batnsta if f�, � � Office: 508-862-4038 ARNSTAB �ax. 508-790-6230 EXPRESS PERNHT APPLICATION - RE&EDFA4UL ONLY J Not Valid without Red X-Press Imprint -- —Map/parcel Number Property Address [/ (,� 7t D��' r]�a P /l�P PL, A ❑ Residential Value of Work$ . 6 6 c Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ;,o�;,, (.� �, �G� 1 J •� P P �i Z.C JET' Contractor's Name ��h S S�� ��� Telephone Number- —,,� F- 737 Home Improvement Contractor License#(if applicable) ? d Email: .` Vt (-'G U( i"n 1 0 CS Construction Supervisor's License#(if applicable) 0 G 3 3- ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance /— Insurance Company Name (n S G v cl a c " L` v `� / o 11/ Workman's Comp.Policy#IP-1 C ( - Copy of Insurance Compliance Certificate must accompany each permit. Permit Reg est(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to_4-X cc- ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 required. SIGNATURE: o��2. �° � � Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 4 .T7ie Commornrealth of Massachusetts Departrrfent af1mfustrid Accide7ds �► - -ry O ire of Lmaestigatiom. 600 Ff ashizigion Street -- Boston,41A 02111 *vita,nrassgospldia Wcwkers' Campensat on Insurance Affidavit:BEildeisfCuntractursMectricianslPhunbers Applicant Infw-matign Please Print 1iv Name(B.0 gaIIaslaon/€nd�dnal}'- 1 v 1 - 5 (7 f v f l o�O W e c-,-f _ � a r �7 _ Address: a r; r (9 4 4 _ in 9-r �c/ Citgf fiatel — 6 7 o? Are you an employer?.fheckthe appropriate box: Type of project(required): I am a general contractor and I ❑ I employees(fanandfor part-time)-* ❑bave hired the sub-contractors 6_ New construction 2.El I am a sole proprietor orgartaer- listed ou the attached sheet ?- ❑Remodeling. skip and have no employees . These stab-contractors have g_ ❑Demolition worlano Q for me in any capacity. employees and lm a workers' 9. .❑B.nil [Na Wodmrs' camp.incur-Mce Comp.inSnrance.$ - �addition regnired] 5. ❑ We are a corporation and its M❑Electrical repairs or ad4sons 3.❑ I am homeouner doing all work officers have exercised their 1L❑Plumbingrepaiss or additions tom€[No workers'camp- might of esempfion per MGL 132 Roofrepairs immnance required_]i c.152, §lM andwe have no employees.[No wmkers' -3- Other comp-iusorance required-j '$ay apphunt6ut chetksboa F1 mast also Moutthe sectionbelowslrn -g theawodsee compevaatkupercyin z6on- I llam mmers wbo submit dm affidaviu;r trxtmg dry Rm daiag all walk and then hie outside cautm=rs mast submit anew affrdxzft iadicsaan=dr. ICon=ctoa that cbeckihis boot mast attsched=additi®sl sheet showing thenzmeof the sub camdrrcto-ss•and state whether or not those enfftieshap employees.If the sub-tontm t„mhare employees,they=rstpandde their wadzss'ramp.policy number. I am air euipLa1,vr fliat is prai ddng warke s'compatsir an inmirance for my employees $elow is ffie po cy and joh site information I � / Insurance Company'NTame:� 6 c.f %�T s �'� e w, Policy A,or Self-inns.Lic. tz., 6 0 _6 6 -Fxpir do Date: �� Z/ Job Site Address �> Lev �.a. a 0Z o ti City/Statel2.ap: O�4 c.r kpl(P G ca- C2 C)1 Attach a-copy of fhe workers'compensationpolicy declaration page(showing the poPicy number and expiration date). Fair to secure coverage as req*edunder Section 25A o€MGL c.1572 can lead to the imposition of criminal penalties of a fine up to S1,SOUG andlar wie-yearimpFisonment,as w611 asrivil penalties in Vie:form of a STOP WORK ORDER and a fine of up to$250-00 a day against the violator. Be adiased that a copy of this statement maybe fxwarded to the Office of Investigations.of the DIA for insurance coverage verification_ Ida lterslry cwWf}r wtdcr tha pains and periatfies afgerfrrry fllatfJte informafioitptmirledabmv is true and correct Sismature• Date- 6 " ' -2 3 OSZ of use apily. Dv not o-rrite in this area,to 5e campleted 5y cify arfanm ghat City or Town: PermitUcense# Issuing Authority(tide one): L Board of Health 2.RuMing Department 3.City/Town Clerk 4.Electrical Insperttor S.PIumbmg Inspector 6.Other Contact Person: Phone#: -- --- -- -- - 6 . Y Information and Instructions a MassaZimsatts Crenexal Laws cbapta 152 regnaes all=3pIoycas Yo provioie worker'compensation far their employees. pm:mm-mtio this sty,an errp&5me is defined as-¢_evezy person in fe seavi.ce of another under any contract ofhire, express or hnplied,oral or n An eznpkyer is defined as"an individaA partnership,association;corporation or other legal entity, or arty two or more of the foregoing engaged is a joint uprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individUal,partnership,association or other legal entity,employing eurpinyexs_ However the owner of a.dweIling how having not more tban th=apart m.m s and who resides therein,or the oocogant of the - dweIIing hone of another who empIoys pessaos to do maLteijance,cons ruction or repair work.on such dwelling house or on the grounds or buiIdmg appwtrua�thereto shall not because of snrJi employmentbe deemed to be an employer." MQ,cbaptrs 152.§25C(6)also Stems that"every state or local licensing agency shall withhold$e issuance or renewaal of a Iiceuse or permit to operate a busnaess or to construct buildings in the comet Gawealth for any applicantw•ho has not produced acceptable uddence of cdmpsan—with tit$insurance coverage required_" Additionally,M*GL chapter 152,§25C(7)states'Feither the coi n„rtrrtuealtii nor may ofifs political subdivisions shall enter min any contract for the pmf mlaace of public work untI acceptable evidence of compliance veith the insuranc6. req=r-mi e afs of this chapter have been presented to the co*fra ctiag anthoi5ty." APPIicanis PImse fill Dirt the workers' compensation affidavit completely,by checlang ffie boxes tha±apply to your sitnation and,if necessary,s oppIy sub-contract or(s)name(s), addresses)and phone number(s) along with their certcdcate(s) of ins ce- Limited Liability Companies(LLC)or Limited Liability Partnembips(LIP)widino employees other than the members or par(neas,are not regtm-ed to cry workers' compensation insurance If an LLC or LLP does have empIoyees, a.policy is required. Be advised that this afiEda.Vrt may be sure to the Depa-tlnent of Industrial Accidents for conformation ofinsi rz coverage- Also besure to sign and date the affidavit-The affidavit should be rstumed to ffie city or town that the application for the permit or license is being requested,not the Department of Tn�t ial-A r-ddm-ts. Should you have any gnestions regardmg the law or if you are required to obtain a workers' compensation policy,please call the Department at rite number lL-ted below: Self-ins<z<ed companies should ent-z their s e1f-fi sorance license n=ber on tine appropriate line. Cityor Town Officials Please be sore that the affidavit is complete and prix i legibly. The Department leas provided a space at the bottom of the affidavit for you to fill out in the event the Office ofdnvestigationc has to contact you regarding the applicant. Please be sire to fill in the pen iOicease number which will be used as a reference mmmber. In-addition, an applicant I that must:submit multiple pe=3tllicense appli-cations in any given year,need only submit one affidavit indicating=ent policy information(if necessazy)and under`'Job Site Address"the applicant should write"all locations in (may or. town) "A copy of the-affidavit that has beta officially stamped or m v$ed by the city or town may be provided to rite ' applicant as l'Iroofthat a valid affidavit is on Ele for futmre permits or licenses Anew affidavit must be filled oirt each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commea-cial vantlre (ie. a dog license orpen rt� itto bum leaves eta_)said person is MOTedt:o complete this affidavit The Office of Ines would Ilse to thank you is a.dv-ance for your cooperation and sbovld you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number_' -1h.L-C_aMMawe�attbE of Massaahnseft', Dement of lad i Aociden1�, ��of�esfig`ktio� EQ�� n Slz�t BQston,MA 0�111 Tc,-L 4 617 -4900 cmt 406 or 1-V7 MA SS F Fax 617` 27 7749 Kevised 4-24--07 W .maz�-7Idia �IHE Town of Barnstable Regulatory Services ` MAE& ` Richard V. Scab,Director 1 Building Division. Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us —Office: 508-862-4038— _ - "---- .._... Fax: 508-790-6230 - — Property Owner Must Complete and Sign This Section If Using A Builder I / , as Owner of the subject property hereby authorize ��� ( to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final ins ctions are performed and accepted. -of er ignatare of Applicant Print Name Print Name /Q0 Dat Q YORMS:OW NERPERMISSIONPOOLS Town of Barnstable Regulatory Services °FTC racy Richard V.Scali,Director ti Building Division t sAxxsr"Lr. ' Paul Roma,Building Commissioner ��� 200 Main Street, Hyannis,MA 02601 Argo www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 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.responsbility 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 procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner 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,Ru-les &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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms EXPRESS.doc 06/20/16 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards I Constr#ctfbii` bpgrvisor CS-065898 4pires:07/10/2019 �SCOTT S SHiELOS '-�a. ;� C 72 BRIAR pAT'RH RD �;'.,: 06TERVILLE fOrW.02666 �` Commissioner V"^� Office of Consumer Affairs Regulation HOME IYPROVEMEIIIT CONfM&OR 8981811 C�rporatinn istration valid Mr Individual use onlyi1'`qInotion before theeWIrattpn date: it bond retttm to: :. .::.10/0312019 1�P�k C��Affairs and Business Regulation TRI-SDEVELOP Plaza-Suite 5170 Mti p Ct?RP_.' 3 Boskm%MA 02116 A SCOTT SHIELDS 11 72 BRIAR PATCH Ro% OSTERVILLE,MA ' Undersemewy Not valid without signature I -- WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE \1 Associated Employers Insurance Company } 54 Third Avenue, Burlington, Massachusetts 01803-0970 ({ (800) 876-2765 NCCI NO 40959 POLICY NO. I WCC-500-5007148-2018A PRIOR NO. WCC-500-5007148-2017A ITEM 1. The Insured: TRI-S Development Corp DBA: Mailing address: 72 Briar Patch Road FEIN:"*"8313 Osterville, MA 02655 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 05/01/2018 to 05/01/2019 12:01 a.m..standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,006 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 404881 INTER SEE CLASS CODE SCHEDU E Minimum Premium $324 Total Estimated Annual Premium $557 Deposit Premium $566 [S"TATIECUSS' State Assessments/Surcharges $204.00 x 4.5600% $9 This policy, including all endorsements, is hereby countersigned by ��'� —~� 04/05/2018 Authorized Signature Date Service Office: Dowling&O'Neil Ins Agcy 54 Third Avenue 973 lyannough Road Burlington MA 01803 Hyannis, MA 02601 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION O Map Parcel Z 0��CI `0 Application # Health Division ®� ®, S�PO�� Date Issued Conservation Division �P Application F . Planning Dept. Permit Fee Nw Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address G 4 erg � k G Ut Village f(l Owner I.e�� /wl�,�i 1���� Address Telephone Permit Request 10 4 44C Square feet: 1 st floor: existing proposed 2nd floor: existing 'proposed Total new Zoning District` A ° Flood Plain A)ez Groundwater Overlay _ Project Valuation EGG 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) 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: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No. Fireplaces: Existing New Existing wood/coal stove: ❑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) Name Telephone Numbers Address %3 y / i eA License# a h F S G (Act, v("//P -L 14 e Z e- r j— Home Improvement Contractor# 4 ') Q- Z ) 6 Email_GJ e q4�v U ee O e `h Worker's Compensation # (v Cl 5-661 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 4:�i�lea SIGNATUR� �� DATE ��2 er FOR OFFICIAL USE ONLY APPLICATION # `DATE ISSUED MAP/ PARCEL NO. F` ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME t� f INSULATION FIREPLACE ( ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL- FINAL BUILDING 4. . DATE CLOSED OUT r : ASSOCIATION PLAN NO. ' r fit Massachusetts-Department of Public Safety Board of Building Regulations and Standards Sti1�e1 v'1111� 1.t1�1{�U�.UUII yy F. License: CS-065898 AN SCOTT S SHIELD 72 BRIAR PATC11t RRMIF 0STERVIIa.E 1V11�► r Expiration commissioner 07110/2017 3ari4sus!s;nog1jM p!le ;ou C�ela�aasaapan r 959Z0 WV'3111n2i31S0 `6108 HO1Vd NVINS ZL S(3131HS 1100S ,C "__. d210 -1N3Wd013A30 S-lal 'ao so ==- OLiS aT!nS' Id Maud Oi uogeiodioO L4UZ/ti/OLD=uoge�ldx3 uopuln;laB ssau!sng pue sjiul d jacansuoZ);o aa!Tl0 adA1 OLZOLL;;':uogegsl6ab :o;ainpi puno;;I -aiup uogui!daa aq;aao;aq H013VH1NO3 1N3W3A0MdWl0WOH - kluo asn lnp!A!pW jo;pguA uoguajs!2W Jo asuaa!j aogeinBag ssau!sng v sj!epV numsuoO;o 33UJ0 - - � vnaenvavecm�n�o airmamuouvuea0► a�/n WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 0180340970 (800)876-2765 NCCI NO 40959 POLICY NO. I WCC-500-5007148-201 PRIOR NO. WCC-500-5007148-2015A ITEM 1. The Insured: TRI-S Development Corp DBA: Mailing address: 72 Briar Patch Road FEIN: *"Wl3 Ostennlle,MA.02655 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 05/01/2016 to 05/01/2017 12:01 a.m.standard time at the insureds mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability insurance:Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audiL Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTEA 404881 INTER SEE CLASS CODE SCHEDU LE Minimum Premium $317 Total Estimated Annual Premium $526 GOV GOV Deposit Premium $536 STATE CLASS MA 5606 State Assessments/Surcharges $173.00 x 5.7500% $10 This policy,including all endorsements,is hereby oountersigned by 03/11/2016 Auttai¢ed Signature Date Senr0e Office: Miller McCartin dba Dowling&O'Neil Ins Agcy 54 Third Avenue 973 tyannough Road Burlington MA 01803 Hyannis,MA 02601 WC 00 00 01 A(7-11) Inclucift COW it omaterlat of the tit council an Compensation dreunume, TMKET y Town of Barnstable Regulatory Services MAM g RichardP.Scan,Dimdor Btu1dmg Division TTOMrerrp,BMIdmg Co=AsdOner 200 Ma a Sweet Hpaads,MA 02601 WWW tDwnl rnstablenta_us Office: 508-8624.038 Fay 508-790-6230 PropeAy Owner Must Complete and Sign This Section if•CTsing A Builder as Qwner of the subject property be33ebYauthoaze to act on mpbehaX . in all maibs relative to work autho&-ed bythis bmldiag permit application for. , (Address of Job) Toolfences and alarms are the responsib�7rtyof the applicant Pools are not to be filled or utilized before fence is installed and all final ' inspections.are pedo=med and acceptei ignatute of Signature 6f A�plira rrt Pffif ame Print Name 6�3-7 L6jd Date QIMMs:o oors ' Town of Barnstable Regulatory Services ray Richard V.Scar,Director , Tom Perry,DMI mg Commissioner ICASM1a 200 Maier Street; Symms,MA 02601 M W yr tayvn.barn�m-us Office. 508-862-4-038 Fay 508-790-6230 13:01MWNMltac =NX130ITOM . •P[ezcePrmt DATE: . JOB LOCA C)K- mamma• � h=.pho=# wo3cpHc=# m2= CURRENT mAff-WG ADDRESS- _ - state Zip Coda The eusent cxcmption for homeowners' was extndcdto mclpde owns-ocx�ied dweIImes of six mifs orIcss and fn allow hiomeovrners to.enga.ge an mcasri ual for hirewho dots notpossess a liccnsq pfvyided thatfba awns acts as=crvison DSFMdMX OFHOMEOWNM P ason(s)wbo owns a parcel of land on which helshe resides or intends to reside,der which ffi=is,or is intended to ba,a one or two- family dwelling,. welling,aid or detarbed sftmzb=accessory to snriz use and/or fame sftuc: nes. A person who constructs mare than one home in a two-yet p=iod shaU notbe emLddrred Ahmncownm- Such '.shaJl Ito the Bm-Idmg Of cia1 on a fmu acceptable to the Bm1�Of add#wthdshe shall bo MMonmblc fvr aIl=c:hwcakpe �drrthtbmldinJ-r p it (Section 109.L1) The undyed`hammwner"also=respoasbsZd'y for=33ph aca w&thc Sian Buffi mg Code and otfia applicablo codes, bylaws,tales and rcg ktia= - Thu aulmgmed`-homwwace caiifics fiiatbdsbe mA=sbmds fE=Town ofBamstabJe BmIdmg Depazimcntm=3mm mspecbon proved==andsand.thathdsho will complywithsaidprocednxrsandr eofs- - Side ofHnmw�nrr - ApptvPal ofBm7irmgOf&aal • Note. Tbreo-gm3Ty dWcUja s cnnfmfn% 35,000 tabu$et or la Mm wMbo rimedtD coniply wiflltho Slam Bmld'mg Coda Section f27.0 Canstra 31 Cantml - HDMMWNEX S ESEMPTIDN The Code sus that 'Any homeowner performing work for which a bur73iag Permit is reclnsed steal[be e�oempt from the provisions of this secfinn(Section 10911-Isr—yTm of cons nc ion SkpervbDrs);provided that if the homeowner =gzges a persons)for hire to do such wD&,that Bach RomeOwner shaft act as supervisor.' Many homeowners who rise fhfs exemp5on are mmWare,fkat finey are z=uamg f e respons-ITTI its of a supervisor (=e gppendbc Q,Rubs Bc Regulations for 11=nsing Co strmcf1on Sipc=visors,Section 2I5) This lack of awareness ofF= rwalts in serious problems,parficnlarip when f'he homeowner hors xorcensed persons. In this case,our Board cannot proceed agzb st the maiTiceased person as it wadd with a licensed Supervisor_ The homeowner acting as SIIperv=is atelp responsible. ons��,m,a np cow requite,as part of am To eas-trte Brat the homeowner is homeownerfaIIy aware of hislher resp permit applirafian,tbzt the homeowner certify fliat hdsh.e un erstinds the responsffi iff of a Supervisor. On fha Last page of thin issue is a form mrreafiy,used by.several towns. Yon may can t amend and adept sack a fbrm[=rffffczffDn for use in your w=IMEmity. Rv&cd 061313 s Ile Commoniveahh of 1Vassachusetts D,epartimuit of Industrial Accidents pffl-ce of Imwstigations 600 Washiugton Street :.z Boston,JIM D2111 wnnv mas&gov1dia 'ttorkers' Campensatiou Insurance Affidavit- Btdlders/Contractars/EIectr ians/Plu nbers Applicant Infarmatfan Please Frint LembIy Name(BrlsmessADFgflnffiCian/Indvidnal�'S� city/ > / _ Are you an employer?Check the appropriate bom Type of project(required): 1.&1 am a employer with 4. ❑I am a general contractor and I 6_ New construction employees(full and/or Part-time)-* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7- ❑Remodeling ship and have no employees These sub-contractors have g- ❑Demolition working for me in any capacity_ employees and have workers' c 1 9. El Building addition [No�vorioecs' Comp.insurance comp.msurant� required-] 5. ❑ We are a corporation and its 10_❑Electrical repairs or additions 3.❑ I am homeowner doing all work officers have exercised their 11-❑Piumbingrepaks or additions mysef [No workers'comp- rim of exemption per MGL 12.❑Roofrepairs insurance required_]T C.152, §1(4h and we have no employees.[No wogs' 13.�]Other comp.insurance required_] •Aay apptic=t&at cheds box ff1 mast also fal cW the sectionbeIow showing their wwkess'compensate np0&T iafbrms[ion_ Homeawnen who submit this afiidatdt ia&catmZ they are doing all wa&aaji then hire outside contractors mast submit a new affidavit indicant-.suds TCaatractors that cher]r this bat must attached an addinnnal sheet shommg the name:of the sub-contrsctm and state whether or not those entities hwP employees.Ifthemff-contmctorshave employees,they mrstprovide their workers'comp.policy number. I am an errrploywr that is prauidbW it,arkers'eougmisadarr insurance forms,enrploy'ees Be£oav is the ptrficy dud job site information. Iasurance Company Name:1lj c� F��s o>s r � Fik e�t /A 5QCA h/C Policy#or Self--ins.Lic_# L.b [[ S'h 5 Fkpir-atioa Date: Job Site Address /�, ��.f�, h N� �n F�e City/Stawzl p: 6 Attach a copy of the workers'compensationpolicy declaration page(showing the policy number and expiration date). Failure to serum coverage as required.under Section 25A of MGL c. 1527 can lead to the imposition of criminal penalties of a fine up to$1,50a 00 and/or one-year imprisonment as well as civil penalties.in i e 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 ofthe DIA for insurance coverage verification- I do heraby c Or under tha pairs and penDa£ties ofperjuty that the information-proti&d abm a is true wed correct Sitmatme: /t Date Z61 SC Phone i- r-ii G — 7 7 -,D F 4,;? Official use only. Do not write in this area,to be contp£etesd by cdy ortown oficiaL City or To-nu: PermitUcense# 1 Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.Ciiyfrown Clerk d.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#- information and listructions Massachusetts Gfenmzl Laws chapter 152 requires all employers to provide woikeas'compensation for their employee§- Pursuantto this statute,an.emplay�e is defined as."_-every Person inthe service of another under any contract of hire, express or finplied,oral or wrh�m" i An etnploy�is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged is a joint enterprise,and inclndmg the legal representatives of a deceased employes,or the receiver or trustee of an individual,partnership,association or other Iegal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occapant of the . dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the groimds or Molding appurbm, therein shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(t7 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 amry applicant who has not produced acceptable evidence of complianm With the insmrance.coverage requse(L Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor ray of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the ins ran ce. refui ements of this chapter have been presented to the contracting a±.odtY-" Applicants Please fill out the workers'compensation affidavit completely,by chec1dag the boxes that apply to your situation and,if necessary,supply sub--contractor(s)name(s), address(es)and phone numbers)along with their certificates) of insL=ce. 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, apolicy is regnired. Be advised that this affdayitmaybe submitted to the Department of Industrial Accidents for confu nation of in saran ce coverage. Also be sure to sign and date+he afsrdavi t The affidavit should be returned to me city or town that the application for the permit or license is being requcsteiL not the Department:of Exh,.ctrial Accidents. Shouldyou have any questions regarding the law or ifyou are required to obtain a workers' compensation policy,please call the Department at the number listed below, Self-msmired companies should enter their self-;nsur-ace license number an the appropriate line. City or Town Officials . t - Please be scie that the affidavit is complete and pied legibly. The Departmenthas provided a space at the bottom of the affidavit for you tD fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure t a fill in the peamit/licmise number which will be used as a reference number. In addition, an applicant that must submit multiple pennitllicense.applications in any given year,need only submit one affidavit indicating current p olicy infro»nation(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 th6 city or town may be provided to the ' applicant as proof that a valid affidavit is on file for fi>fore permits or licenses A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le. a dog license or permit to bum leaves etc.)said person is NOT required to complete t3iis affidavit The Office of Tnvestigations would like to thank you is 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. Tie CanM:kaaWatth of Massachust-,tts ' Depa tment of hidulrial AocZents 0�ffi=ofjvesfdntio= 6Q4�asl�ingtQn Stt Boston,MA G2111 Tf,-L#617 727-4g00 Qxt 406 or 1477 SAFF, Fax#617-727-7M Revised 4-24-07 w mash gQ-vf dia. i YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. • it does not give you permission to operate.) You must first obtain the necessary signatureti on this foma at 200 Main St.., Hyannis. Take the completed form to the Town Clerk's Office, 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is rt�quired by lay,v. Y DATE Fill in please: fi 1iZVI �;;��+ n�_ APPLICANT'S YOUR NAME/S: C?A B SINESS YOUR HOME ADDRESS: I6 /� -/. CG -' ="a�i' TELEPHONE # Home Telephone Number NAME OF CORPORATION: i NAME OFF BUSINESS 14 V TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES �. ADDRESS OF BUSINESS .A) AP/PARCEL NUMBER (Assessing):. When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to crake sure you have the appropriate permits and licenses required to legally operate yo-ur business in this.town. 1. BUILDING CO M R'S OFF CE This individ 1 ha b infor a an per it requirements that pertain to this type of business. Aut ri d Sign COMMENTS: 2. BOARD OF HEALTH This individual h een infor e f t 43 perm irequiregitnts that pertain to this type of business. r: Authorized gnature**COMMENTS: MUST�-,OMPLYWITM ALL MATERIALS REGIjLATInnrS 3. CONSUMER AFFAIRS C NSING AU ORITY) This individual h bee informed e lice sing requirements that pertain to this type of business. ,A thorized Sig ature.* COMMENTS: I i i YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates [cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: APPLICANT'S YOUR NAME/S: A�1AC�LP-� + I INESS YOUR HOME ADDRESS: 7 f 'TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS S TYPE OF BUSINESS y��- S21rV I C IS THIS A HOME OCCUPATI9N? YES NO�_ ADDRESS OF BUSINESS 9 W�- N � j .�26i AP/PARCEL NUMBER y (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual haspeien informed of permit requirements that pertain to this type of business. Authorized Signa ure* COMMENTS: �^ -)on ( 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has be for t e licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: �•z i i � is ��`4 �� dy � � y �^ � y �� • ��� c � � o_d Yp ! -- o• 71 1 '� O � � y .- '�,�� t�y . o � � ♦f s \� �.r y y .'� , , 'e ��� ?+ jam �r,rt1Tj�L ��� 1 ��. .� � y o, � � �- �- .� � � � � . t � � � �I � `k. ' ��' I' �►y �O4 . �' . . �� I&A n y �, •.�, .$• 7 . YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4:years). A business certificate ONLY REGISTERS YOUR NAME in,town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1s` FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) / DATEft : I.. W Wp n Fill i lease: APPLICANT'S YOUR NAME: 3 BUSINESS YOUR HOME DRESS: BUS 1/2? TELEPHONE # Home Telephone Number O!— NAME OF NEW BUSINESS TYPE OF BUSINESS Q IS THIS A HOME OCCUPATION? YES N.O: Have you been given approval from the building division? YES NO l ADDRESS OF BUSINESS (4-0 Vje © 2WgV'4u�MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town.of Barnstable. This form is intended to assist you in obtaining the information'you may need. You MUST GO TO 200 Main St.—(corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and.licenses required to legally operate your business in this town. 1. BUILDING COM ER'S OFFICE This individu I hats e o fany permit requirements that pertain to this type of business. . Au orized Si at re'* U COMMENTS: 2. BOARD OF-HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature"" COMMENTS: ' 3. "CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain'to this type of business. Authorized Signature" COMMENTS: tl Assessor's map and lot number ... ...... ... ....... ......1.... FT NET �_ Sewage Permit number ...�............!,?........f.............. Z BAHB9TAELE, i Housenumber ............................. 2639......... ...................................... 90o i67q 00� - TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .... yl . ................................................................ ............................................:.......... TYPEOF CONSTRUCTION ..........................`" n................................................................................................. .................. ........19,�. TO l'-FiE;1N5PEC-TOR=0F=H1JiL"Oit>16S:r-� - �.- The undersigned hereby applies for a permit according to the following information: Location �V �v�,rl a ,. '" O5�p• VIA 4 G' ............................................ Proposed Use ,........... ..... .......... .... !,A ---.........................................................................................................:..... a ZoningDistrict .....................�..................................................Fire District .................. 01....................................................... Name of Owner ........ ..�........................................................Address .... ......`.. h Nameof Builder N r+ ��Q...... . ........................ ................................Address .................................................................................... Nameof Architect ....:.............................................................Address ........................................................:........................... Numberof Rooms ..................................................................Foundation .......................................:................n..................... Exierior G + �S - /'�� yd? �....�. ........................Roofing .........1/"7< R, .............................................. Floors . .........................................................Interior .................. �� ......::. �� ...... .... ..... Heating ..........................................................................:.......Plumbing .... ~................................................ Fireplace ............. ..................................................................Approximate Cost ...................................................l ............... Definitive Plan Approved by Planning Board f __ l ------t 9------- . Area ..�.. ...�.............................. r Diagram of Lot and Building with Dimensions Fee ' SUBJECT TO APPROVAL OF BOARD OF HEALTH 3 • -1r I hereby agree- to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .............................. �~ ^^^l"s ,°"^^ a 1*1_lZ5 . . . . . . . ` � ' No ---.--. ,=."". .= office---.. .'`,^~ � '......................................................... ................ i 68 �iauoo � iocohon -------------���!��.---.. OoterviIlm ` ._------------------------.. . i John Shields Ovvner ---------.------------ i Type ofConstruction --. -------.. ) P| Lot / ^ - movmm ti.19 Date of Inspection ` . . Date PEI REFUSED � - ^ | / .^� | '��—'' ............. ! , .................. --' .-----.. .. --... \ -------------..q�. —. --.--.. � � Approved ................................................ lg ' � ' --------.------~~..----.~.--. ' -------------------~—.---~.— - � . � � L� * - q-,2,2 - ? . ,Assessor's map and lot nu ``..�..'1.,..... .��.a-Q� C�THE TO Swage Permit number .. .�.............. SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE. House number � . . : B9BB9TODLE, i WITH ARTICLE II'. STATE, :....... . ....... . .............................................. o SANITA .Y�CODCAN6 TOWN` o 0NO*`0m TOWN OF BAR1��Tlb`LE RUI-LDING% INSPECTOR APPLICATION FOR PERMIT TO ..... ....... ......................................... ........ TYPE OF CONSTRUCTION .........................`�� .. ..... .................:.......................................................... .............. ....�/.......19't1... TO=TH NS E-IPEe7oR=oP�BUit��rac3s:..�..,..� The undersigned hereby�ap fpl'ies for a permit according to the following information: Location .............................4N.� ...:.....�� -...�... STL.... ....:................................. ProposedUse .................... ... . ....... ........ . ... ................................................................................................................... ZoningDistrict ........................................................................Fire District .............0 .................................................. Name of Owner ...... /.4?!.5....................Address ....V.1..a!?P.q...... ............ Nameof Builder 2. D..X1.1.7...... . .J. ..//..V..................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exterior . .. .... ........................Roofng ......... ... .... ha cr.............................................. Floors ...... .......... .... ............:............................................Interior .................. . .` .. ....................................... Heating ..................................................................................Plumbing ....C7�... / .5,................................................ Fireplace ..................................Approximate Cost � ._ �s Q 0 a p -....................... `............. Definitive Plan Approved by Planning Board ------------___---_-_ / 19 ----. Area (?&. . ..................... Diagram of Lot and Building with Dimensions Fee :'..aJ ..... .... ............................ SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. _ Name / ....... ... (.... .... ' 'elds, John Osterville Date Date Completed ... 19 . PERMIT REFUSED � -----.-----.--------.`—.� lV � � , � � . � ~ .............................................................................. � —~---.--.—~------~..------.— , � ' ...................,.�---.----------...--., � � ' ----------------.~.~...----'. � . ` � Approved ................................................ lg - . � ._---------------~.--.—.—.-- � ..................—....... .................................................. � ` f 1 36, t m pp q u�l 4*4-w(t> AVE RtcHmno A, OAXTUR 1' LEV-TIFtE.I.) Pi..OT PL./11,1 � C64ZTIt=Y i1-1AT TNt= C�UWba'j"6bI.,� SN�U P•�.�.�1 Q�F'i=`2'ENGE NEt?Eot,3 GcsNlt'L�(S WIT" THE- 51DI= LI"C- �� Plr� � •FO(�,. A1.ia SETS�GIC tiZE4ui1ZCNic�Ts ot= T+-I� . -zo w Q of T3A 1JyT.4(SL 6: ;...�-,. _, _ � ....- ..,. _ .� __.:-.._- - � ...._- -----cZEG t�S_rUZE�:��:..A►.t'� Sty e ucYo trS_ '� 1-115 l7�At-t (S UUT 13ASC� U�1 A164 US'�EtZ�/1LLC IlrtS('iZcJ�KENT SUGZ�/E�{ Tl�l= Gi=�S�rS S�{o�� ' ::AI?PLI GAtiIT /' ►—rr Ar-- USEp To l7CTCzMt+.IC I DT l_Il,li_S Complaint Number: 1715 Taken bv: UJLL.D�1G Sl RYL S Date: 4 6 00 Map/parcel: Referred to: UJLDJN—G SUBJECT OF COMPLAINT Business/Occupant Name: JI,M/MY CROCKER Number Street: Village: Lo-syx,RVILLE COMPLAINT INFORMATION Complainant's Name: NEIGHBORS IN OS T. Address: Telephone Number: Complaint Description: SAND BLOWING FROM LARGE PILE. r r + Actions Taken/Results: CALLED WIANNO REALTY--THEY WILL RELAY MESSAGE. Date Closed: 4/6/00 I TOWN OF BARNSTABLE�BUILDING PERMIT APPLICATION ,Map `T Parcel /�11 Permit# 3 yoro Health Division �� Date Issued 1 Conservation Division ` Fee Tax Collector //s'��� Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board f Historic-OKH Preservation/Hyannis , Project Street Address I ail y s()O vie- Village ��eyi�� 424-- _ A Owner��� 24 C�� I K, Address � � l '�C ' Telephone �a�'� woo Permit Request Square feet: 1 st floor: ex' ing proposed 2nd floor:existing proposed Total new 'Estimated Project Cost �� Zonin District Flood Plain Groundwater Overlay 1 9 Y 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) 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: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No . Fireplaces: Existing New Existing wood/coal stove: ❑Yes O 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 " BUILDER INFORMATION Name t/)' �v, ZZ4zJ Telephone Number , Egg Address 6i- " kr Ix License# Home Improvement Contractor# 112300 Worker's Compensation# a05TESoo ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Qr'f7 4 SIGNATURE DATE �� FOR OFFICIAL USE ONLY - PERMIT NO. - DATE ISSOED ' 1' ' MAP'/PARCEL NO. - ADDRESS. VILLAGE - OWNER' . 117 - / DATE OF INSPECTION 9 / FOUNDATION i• } i FRAME INSULATION FIREPLACE :• • `. _ .. - �+ .r ELECTRICAL: ROUGH FINAL + PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL = , FINAL BUILDING ' f 7 DATE CLOSED OUT ASSOCIATION PLAN NO. ' Department of Health Safety and Environmental Services Eon Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen 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. , Type of Work: r& 6 -/�f n Estimated Cost aj5-6 O Address of Work: 4o 1A// et,h h a Owner's Name: Date of Application: TT I hereby certify that: Registration is not required for the following reason(s): Work excluded by law C]1ob Under S 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 UNDER PENALTIES OF PERJURY I hereby ap ly for a permit as ent of the owne . o 0 Date OntracoeName Registration No. OR Date Owner's Name q:forms:AfTdav "i --j Department of Industrial Accidents Office oflayestfgalloas -Q_: -— � 600 Washington Street Boston,Mass. 02111 //� Workers' Compensation Insuranc(�e davit �r/r������ �������1111MIN 71 .. name: D N C, v location: city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any ma acity U 1 am an employer providing workers' compensation for my employees working on this job. comnnnv name: ZJ, ✓; . address: t vh city: C-Itk�ti phone:. . . insurance Co. ❑ 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: comoanv name• address: ::�::•.<,.;:..: edty: phone#- .. ..... ........... .::: ........:" .:' .. ...:.'r lV•:M YtY'i nw000A v''ivw^iY:::. insurance co. oitcv#• .. comnanv name: :. :.. Y..;t....... address• cit%7 ... phone ...... irtsurancc co. i;iure to secure coverage ss required under Section ZSA of MCL I52 can lead to the imposition of criminal penalties of a one up to s1.500.o0 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a nne of 3100.o0 a day against me. I understand that a copy of this statement may be forwarded to the Ounce of Investigations of the DIA for coverage veriflntion. I do hereby c if under the p ' and pen ies of perjssry that the informadon provided above is&uP d eorre sienature Date Print nameAJ 4-6 Phone official use only do not write in this area to be completed by city or town otOdal city or town: •:p��e q C3Building Department ❑Licensing Board ❑check if ittayediate mponse is required ❑Selectmen's Ounce ❑Health Department contact person: phone 1t; ❑other�� ([enam 9,95 PJA) Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensationFfor the:.: employees. As quoted from the "law", an employee is defined as every person in the service of another under any;,cam- 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 the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the rece:s•e: 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 as the grounds c: 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 renew of a license or permit to operate a business or to construct bindings 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 eater into any contract for the performance of public work until acceptable evidence of compliance with the ins=ince of this chapter have been presented to the contract= authority. - w 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 confimation 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 Deparmnent 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 camtact you regarding the applicant. Please be surc to fill is the permitlliccnse number which will be used as a reference number. The affidavits may be rc=ned io the Department by marl 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 DeparQaent's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of fmlUMB90132 600 Washington Stream Boston;Ma. 02111 fax#: (617) 727--7749 phone#: (617) 7274900 ext 406, 409 or 375 ,ME -INRRaVEREAI Registxation 119300.: TyW.- -_DOA 'Ex-PiTatign 06./19799 .: - _.;;R9Nl E`L.-_TAYLOR- :. ANNI CIRCLE