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HomeMy WebLinkAbout0362 WIANNO AVENUE ��a ��� �� �� �� .. , . � � ,, �� � � �� �� ., �� �� „ � << o �� � ,, �� �� � �, ,� �� � ., �� � � � o 'a, .. .$ r �, ,. a ,; �...e.+.—� _ -+.r.wry _ n. _ y-.�1._— ._r`t.+�,#'1. C;;, _ ,.a..f.�. _ f� Town of Barnstable *Permit# Zb Expires 6 months from issue date a7 Regulatory Services Fee�s inRtvsr►e>.e, MASS. Thomas F.Geiler,Director d1SN 9 Building Division Tom Perry,CBO, Building Commissioner g t Nn f 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 ��� Fax: 508-790-6230 RMT APPLICATION - RESIDENTIAL ONLY A Not Valid without Red X-Press Imprint Map/p v Number f n Property Address 3(A Y 4t A#4!'1 c A` C 0 5'�i�M1�LCN.E , V N t t• 03,y SS 5�Zesidential Value of Work$ C4 o+ — Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address A44 f Ro 1.61 Cdti��wt4�•lc�"lg 3 C-1 wSAW*je Anti. o���.v.Cu-E, MN. o f,t SS C e Aa'f I"c- moo► Pei Se-c-, .a!f Telephone Number IT I— 3S5_ S(. I Q Home Improvement Contractor License#(if applicable) Email: (', Str7�rtinn a.� ,;s®ma's r oe#(if applicable) C, r ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ft I have Worker's Compensation Insurance Insurance Company Name hm-f_t,4C P-0 —blrR!gC 6 M1^I Co Workman's Comp.Policy# V-I C- - se q S$91 —oo C44. (el t ' 13 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 ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#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: Prol2c Owner must sign Property O ng Letter of Permission. A copy of Home Improveme ractors License&Construction Supervisors License is required. SIGNA C C:\Users\decollik\AppData\LocalVvlicroso indows\Te orary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 �-Y �ti J � DARNBTABI.E. � 6 Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO 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 n4 Etf��ttcS>� M 1'I, IgrA-C'-r4X (�0YAd4tJ 0g4C' ,as Owner of the subject property �- hereby authorize AADf JLA-c, ap,,p, nnr r SEGwA.fa(i to act on my behalf, in all matters relative to work authorized by this building permit application for: YUPP-t-"o 1gv,E. • (Address of Job) Signature of Ow er Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollikWppDataU.ocal\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 L J ne Cammomweafth of Massachusefft Depaphnait of Industrial Accidents C ice of Inwsfigwdons 600 Washington Stmet _ .Boston,MA 02111 nwmwass.gov/dia N.Vorkers' Campemsatian Insurance Affidavit Budder-JC4ntractorsfFIertricians(Plu nbers Applicant Information Please Print Uwhly Name Address: giwstateJ _ W �1 woo, t�A• d-o o Phone# ^1 I 3 S 1 Are you an'employer?Olueckthe appropriate box: T mf project r 4. I am a cxsntzat;tor and i Yl� l? 3 ( ��d}- 1-,2 I ama employer with a�� ❑ i�� 6- ❑/dew construction employees(fall Mworpart-time)* have lured the sub-contractors 2-❑ I am a sole pn4detor or partner- ii on the attached sheet. 7- ❑Remodeling ship and have no employees 'ham sab-oontractms have g_ ❑Demolition w.eding for me in any capacity. employees and have workers' 9 ❑Building addition [No workers'Comp_insurance Coop:insurance 1 14❑ require�� 5. ❑ We are a corporation.and its Electrical repairs car adcTitioms 3-❑ I area homemmer doing ailwork officers have exrMsed iheh 11_0 Plumbing repairs or additions my [No worlmre gip- right of exemption per MGL 12-❑Roof repairs. insurmm r i r-152, J.1(4),and we have no -, employees.[No workers' 13 Other �l i;a Y�i ilw comer insurance required-] "'Amy appHcuxt fiW cheats troy-1 nma also i U oet ttce secfirm below sbouingth&value m fi=P0aY mfnM=6oa $H wwnm who submit this zTxlzw&indicating they are doing all srmk sad thm lag outside coutnumrs mast sd=a new af5davR indicating sarll ,Czn=ctois that ctn3cic tins twos must attarhm ffi additional ahem g the nmme of the sub-raaaacmcs.and stem whethm ornot fhnse ea ities have emphayees-Ifthe snb-amt amm haw emplofees,they==pmvide their worker'camp.policy number., I am an employer that is providing workers'compe nsation inmiranw for arty eaq7toyem Hdow is the policy and jab site information Insurance CompanyName: 1M p4(,P rl �+.,yL (��{ Se,.'i. a C C.v►�P r,i-i Policy#or Self ins.lic.# VJ " 5 0 9 5 g 9 0,0 Expiration Date: dT 1 2 1 3 .Job Site_A.ddrf.=: 3 WSr4,41-40 A"E - City/State/Zrp: Aitt2ch a copy of the workers!compensationp cy decLaration page(snowinge pro q=m er 3—na Uxpna on ZTW. 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 tD$1,500.00 and/or onB-yearimprisonaneuk is well as civil penalties is the form of a STOP WORK ORDER and,a fine of up to MUG a clay againg the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for msura ce coverage verification I aio hers A,under tkcr aides o.fpediar}:that the iR,formadan ptvt itlad above is iris anal carrect Da Sim te: 1,61 Phone#: Official use only. Do not trrite in this area,to be cornpTew by cil�y or town offidA City or Tower.: PermitlLit:ense# Isvdmg.Authority(circle One): 1.Bawd of Health 2.BmMng.Departmenf 3.CftylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/01/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Marsh USA,Inc. NAME E FAX 1166 Avenue of the Americas PHC N No, A/C No): New York,NY 10036 E-MAIL ADDRESS: INSURE S AFFORDING COVERAGE NAIC# 58880-ADT-MAIN-12-13 INSURER A:Zurich American Insurance Company 16535 INSURED ADT LLC INSURER B:American Zurich Insurance Company 40142 410 University Avenue INSURER c: Westwood,MA 02090 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE.NUMBER: NYC-00648037D-06 REVISION NUMBER:3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE IADDL SUBR POLICY EFF POLICY EXP LIMITS LTR II POLICY NUMBER MMIDD MM/DD A GENERAL LIABILITY GLO 5095899-00 09/2812012 10/012013 EACH OCCURRENCE $ 2,000,000 DAMAGE TX COMMERCIAL GENERAL LIABILITY PREM SESOEa occunence I$ 1,000,000 ' CLAIMS-MADE OCCUR IVIED EXP Any one person $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,D00,0D0 GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 4,0D0,000 X POLICY PRO- n LOC $ A AUTOMOBILE LIABILITY AL 5095900-00 0928/2012 10/012013 COMBINED SINGLE LIMIT 1,ODO,D00 Ea accident $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PROP AGE $ HIREDAUTOS AUTOS S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I RETENTIONS I I S B WORKERS COMPENSATION WC 5095897-00(Deductible) 09/282012 10/012013 X WC A TORYSTALIMTU- OTH- AND EMPLOYERS'LIABILITY YIN N WC 5095898-00( )Retro 09292D12 10/012013 FR 2,000,000 AND PROPRIEfOR/PARTNERlECECUTIVE E.L.EACH ACGDENT $ OFFICERIMEMBER EXCLUDED? FYI N I A (Myandatory in NH) EL DISEASE-EA EMPLOYE S Z000,000 ,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ Z000,0DO DESCRIPTION OF OPERATIONS I LOCATONS I ICLES Attach ACORD t0 dditiona a arfcs S edule are s ace's ui d ' CERTIFICATE HOLDER CANCELLATION ADT LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:TOM LEE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 410 UNIVERSITY AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. WESTWOOD,MA 02090 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Cynthia Y.IGm ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ' 1 �T_-�. .��:I�1+ri��:�v�='�-:- _ . •t.�;�"vim . `; CC lVtt N%VFALT'H OF.MASS Ct 1SET S_ =r; :..-ArftE .18 'ERED;SY-81 M COW. _ - =-- �I�SUES:�;ES�QYEi.:ICEhSE7fY"- -- _ - '1.-: - • a fRSl-TY.-A-VE;" W. T.-W D 0-b 'Pl k.', 0 21r9 0.-233 :,' 3 07/31t13 :._ 193�+.'<; Fold.Tho Duch v 1 Common•.�ealth of Massachusetts Department of Public Safety • License:SS-001779 Thomas J Lee = ' 4110UniversitvjLve' 3 Westwood M�02090Ry Gtl ` Expiration: Conirrissioner 05/1612014 4 • J 36 Z w l/>rn►►..� / � • OSiZcz.r I-o- 0 r Fcl - Gj1 - \� • f C L (A bT [�qui��� SMOKE DETECTORS REVIEWED BARNSTABLE BUILDING DEPT. DATE FIRE DEPARTMENT DATE BOTH SIGNATURES ARE REQUIRED FOR PERMITTING h /7 r3 (' ( Sccur �� 5 ' GC, ;'`` Cl. e-rvA Q me\ CC7 t ` Town of Barnstable *Permit# ' Fxpires monthsfrom issue date 00, Regulatory Services FeeD as, Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building CommissioneXPRES s � Q 200 Main Street,Hyannis,MA 02601 ild www.townbamstable.ma.us " �OC T 12 20niz Office: 508-862-4038 Fax: 08-790-6230 rows aF B,gR�sr���� EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY" a Not Valid without Red X-Press Imprint dap/parcel Number ' go I S3 ?roperty Address A (�f, MA— residential Value of Work Minimum fee of$25.00 for work under$6000.00 Dwner's Name&Address i ava tin Contractor's Name Telephone Number Rome Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) orkman's Compensation Insurance p 5#e one: am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance � Insurance Company Names-f, "S Workman's Comp.Policy# C�tL( MAY ` 4—n ---`1 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) to ❑ 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 Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. SIGNATURE: QTorms:expmtrg .Revise071405 k7`J/1!/�bb5 t1 :1 L SrJrJ4'Ltil� 4 i r'Hur_ V1 t - David'Saw"r Coastrueduo 318 MeIgm Backus head S*udwiek, MA 02863 P� .i Sal�let ld To: � �- -� Woft ftc*: Psi-- sr, r Py e, and f1sttl Away ell oid ermf and or, waghingleL -�F SUPPLY&MMLL.- COLOR: � 1�pk��c �, � �.¢,r�e. �i r►f �ors a 6 � CMANARKMOVE ALL DEBRIS FROM WORK PLACE AFTER JOB IS COMPLE TLU ALL DEBRIS TO LANDFUA. TOTAL MWnMY4T PO R MAU RIAL&LABOAsY 3 All eta4e W It sd to be as ap If ack w4 tto tbove work to be poed is asco WO1,wide the snbmyftted tot d*sboe'e otk c I in a mbenmt*l wo F to be be made sa Atc%" l Q f �'i- i d t l-A�e,�ir my altl oce or drviwoo ftm dw wads w"I lcadorr kvervl"eats to will be exaevdid"bf ug M mime w*r,sod%ill become m expos dwp over sod above tlw eadM=. All AVMWM caatinettt opm sagow aeoldemto or de*s beyond oar control.Plow rauaove and/or somm any 641•hwahoW he=. No req mslble lt:r brokra or dxo wp houalwid hems. 10YUR LABOR WAFIKANT'Y/MVS MAIWFAC°PUM 9IGLE WAIRRAItITY. Thk t*ul my be wltbdaws by as if and eea�adwlt�ib days. satyaeledA.._. ", _,_- dez�,o, ACCEPTANCE O P1aOPOSAL f The sbvve prkis,tpedikedow ud condidoals an•ethhetetry and are hereby emptsL You are setberbed to do Me ark parified.Psymeeb wM be made a utm�arl DateE;T us 9i�etnrti 91te AG� i Board of Building Regulations and Standards One Ashburton Place Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 134313. Type: DBA Expiration: 10/24/2007 DAVID SAWYER CONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. SANDWICH, MA 02563 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card ;-CAI v 50M-0005-PC8698 ✓lie 'C�anv�na�zuie� o�✓�aaaaclzueetta Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: .j Board of Building Regulations and Standards - Registration: 134313 One Ashburton Place Rm 1301 Expiration: 10/24/2007 Boston,Ma.02108 Type: DBA DAVID SAWYER CONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. SANDWICH,MA 02563 Administrator Not valid without signature ' tr C t!� S SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE A ��� /�� VJI'W ARTICLE II STA`�L SANITARY CODE AND TOWN,, REGULATIONS,,— ,*THE SOWN OE BARNSTABLE • BARNST"LL i "b 9 BUILDING INSPECTOR war°'• G APPLICATIONFOR PERMIT TO .................................................. , ....................................................................... TYPE OF CONSTRUCTION G ..................19.7 3. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit �-a�- cording to the following information: Location ;! ..; .. ............................................... .... ........................................................................... ProposedUse ....YZ.41111.. . .../l,t....'`. ................................................................................................... ZoningDistrict ........................................................................Fire District .............................................................................. Nameof Owner ................... .............. "..................Address .................................................................................... Name of Builder .......� lf'��...................................Address .....�L� �111 ..... - . . D .... .............. .�. .............. Name of Architect ... Y� . ........... .Ryt�--•�..............................Address ...�........................... ................................................... Number of Rooms ....9...... °-...................................Foundation .. .. ................................. Exterior .. �. .............. .... ...a.... :...Roofing ...... i .. . ......... . ....... ................ Floors .... :.�..... !'. .. ....... :.. A.....Interior �� f G�iL Plumbin /Y... Heating ` ....................... g .... rG% :.:`. ............................................. Fireplace ......(&.)...................................................................Approximate Cost ...1 ...... .................................... � ... Difinitive Plan Approved by Planning Board -------------------_-----------19_______. s 41, Diagram of Lot and Building with Dimensions 0" ?s _ 3_9i6 PA 0 • 216� I hereby agree to conform to all the Rules and Regulations of the T wn of Barnstable regarding the above construction. Name ........................................... .................................. Giavanone, Anthony ; 16212 two story - No ..............:.. Permit for .................................... single family dwelling ............................................................................... Location 5&a Wianno Avenue Osterville ' ......................................................................... Anthony Giavanone Owner .................................................................. i. Type of Construction frame r j ................................................................................ . Plot ............................ Lot ................................ Permit Granted Na 3.0 ....19 73 Date of Inspection . �.....19 73 `. Date Completed ......................................19 PERMIT REFUSED ....................... ..................................... 19 ........................................... ................................ ............................................................................... ............................................................................... Approved .............................................. 19 1 ............................................................................... ............................................................................... Map Parcel 3 ermit# f 6 6 Conservation Office(4th floor)(8:30-9:30/1:00- 2:00) Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) T`a'' SY N �.I jS T FJE .7 PO 7717 Engineering Dept. (3rd floor) House# , �j �p,Q W AeA�CE IWN RE 19 f0 MPS� TOWN OF BARNSTABLE / Building Permit Application Project Str Wetess341a Village / Owner ^)✓ L� �, Cte Address / Telephone tea-. i J Permit Request F' First Floor square feet a ,Second Floor square feet 4o.00 Estimated Project Cost $ ��, f) .Zoning District �� / Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential •� Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure_ow Basement Type: Finished Historic House lid Unfinished Old King's Highway /J d / Number of Baths ��a2 No. of Bedrooms t0 Total Room Count(not including baths) `� First Floor Heat Type and Fuel a Central Air Fireplaces Garage: Detache Other Detached Structures: Pool IJQ Attached Barn /✓� None Sheds /Jd Other /� / / I Builder Information 'f 3 �ame__"1&ry� (� ��o S 5 ILA I(A —"telephone Number (�j0 8 yZ 4�2n dress 1-6icense# 0 q,7$5 0 t'0n C? O?6ly hlmoe Improvement Contractor# j 2 11Worker's Compensation# G ZCM ;j; 1i NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATL:4 '& BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY P MIT NO. D, ISSUED MlP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION ` L FRAME INSULATION FIREPLACE • ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: �_ib dRQUGH FINAL ; FINAL BUILDING'S za-9 e DATE CLOSER 8i ASSOCIATION f LA 'I:NO. i txi � r kit The cont»uinlf'ealth o•f Massachusetts gin: _... �_�_r Departm/ent of Industrial Accidents �` ;E =r•:�' 61111 Hikrlrinfton Street _.. Buxton.Maser 02111 Workers' Compensation Insuranee.AMdavit �ADniica—n reformation: name• location- city phone# ❑ 1 am a homeowner performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers' compensation for-my employees working on this job. company name: address• city: phone#: - insurance co. nelin,# ❑ I am a sole proprie eral contractor,o homeowner(circle one)and have hired the contractors listed below who have the following wo Ices.• cl�_ name: /� • C ro 55 I�ln IJUI ;/ocMress: L1 0060re,►1 01, �eih•: /t l O��� n�' At dI y .Ali 6 26`'T phone#o 2IF Insurance rn_ (� tier// 6 UO� Sea Ly u�,c:a; `�,•°.:.T.:-.. = _ remsrt+.a:..'.i ?es.•'•_-'S"TR'e.f ^' }43'-' .:oL _— •T�Afr77.�•�:T. �s�!nS!'�J..AS,_3* _ - '�^.�'#1 cnmparn•name• address- city: phone#., IaSnrh ice en ppHey 0 :-Attach'a dditlgoal'sheet if .'*"M . Failure to secure coverage as required under Section'3A of MGL M"can lad to the imposition of criminal penalties of fine up toSI.500.00 and/or one vars'imprisonment as 14vel)as en•ii penalties in the form of a STOP NVORK ORDER and aline of S100.00 a day against me. I uaderstaad that s copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. I do hereby certij}}•and re alas red a/ties ojperjuT that the iajorarwio>r provided a�ovr is rrtrePaitd COMM signature J/ / 196 XPnnt name 6�y S lAP(!-1 one f! 5o L�Zy —D 20 official use oniv do not write in this area to be completed by city or town of vial at}•or town: permit/Iteem 0 ribuilding Deparim`ent Ol.1censing Board:- 1 ` check if immediate response is required Cseleetme 's Oltice C3I1ealth Department contact person: phone#; nOther Information and Instructions w Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for their employees.- As quoted from the"law", an emplmvee is defined as every person in flue service of another under any contract of hire, express or implied, oral or written. An empinrer is defined as an individual, partnership,association.corporation or other ;-gal entity, or ant two or more the fore�soing engaged in a joint enterprise.and including the legal representatives of a deceased employer,or the receiver or trustee of an individual , partnership. association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the ns to do maintenance,construction or repair work on such dwelling hou! dwelling!rouse of another who employs perso or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 1'52 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal.of a license or permit to operate a business or to construct buildings in the commnn+•ealtlr for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha been presented to the contracting authority. .��,�w•.....+..+�e �. L7 4 .1 i�.. .,.. . _1 11- _!wA �Wit:r+:aY:n:v�4.✓ J'r'��r7�L'.- 1• _ I„�:•T•:V� .l �. •�:T i.•-,`�"�!•�ir. .w.�-• i�1•r" `.L'.w.l.�!7ft 4'.1'iCA i.'V.it:_.y(,." �I- .. - .. - 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 as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affida�•it. 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. n.•... 7. ;: City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plea: be sure to fill in the permit/license number which will be used as a reference number. The aff davits may be returned tc the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any question: please do not hesitate to give us a call. .The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street _ — Boston,Ma. 02111 '.. fax#: (617) 727-7749 phone #: (617) 7274900 eat. 406, 409 or 375 : The Town of Barnstable . g Department of Health Safety and Environmental Services Building Division Ma 367 Main Strut,HYanais MA 02601 Ralph Crosses Office: Sob 790.6227 Building Commissions Fax 508-775-33" For office use only Permit no. Date AFFIDAVIT HOME MOROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERWr APPLICAIION MGL c. 142A requires that the"reconstruction,"reconstruction, renovation,ttpair,modernization,conversion, eco owner ooarpicd improvement,.izn►cn-4 demolition, or construction of an addition to any pm'� .�are adjacent containing at least one but not mom than four dwelling units or to stmcs with other to such residence or building be done by mZ ered eonuacxors,with certain acaga along g requi[remellts- Type of Work: Est. Cose . D7J7> �L Address of Work: J7 6 Oaner.Name-A44L Date of permit Application: I heretg certify that: Registration is not required for the following reason(s): Work excluded by law Job under 51.000 Building not owner-ooarpied Owner pulling own Pam# Notice is hereby given that: CONTRACTORS OWNERS PULLING THER OWN PERMIT OR DEALING DSO NOT HAVE LESS TO THE FOR APPLICABLE HOME IMPROVEMENT ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the cm-ner. - �� C Goss Ipin 1121�� Registration No. Date Contractor name OR - . ._ .. Owner's name ✓X. eo'i'"noanavea&1z, a 1,116djac1.dee6 t. DEPARTHENT OF PUBLIC SAFE-TY. CONSTRUCTION SUMVISOR LICEZIS) s. Nt!nber; Expires: Restricted.To: :G r '{ARE C GROSSLEIN � 4 DEBORA`:i DP, HARSTON" IjI4LS, RA 02648 At `y%}i�M t RtlV tlff{I401 TRACTOR'S tstr'atf "I'l � tis � "*�yPI��allteMf"'� ►43I42/ �1si ' .` ,xtRKC 6RQ55lEIf� , �y r 1�Ak wQSSi ESNOL � :.. 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Description: Inquiry 0 Description: For Office Use Only Inspector's Action/Comments Date: Inspector. Follow-up Action 7- Additional Info. Attaclied '� ('nnt•niscibuaon: L�'�11tG-DepdJf777ent File