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Home My WebLink About0075 LOMBARD AVENUE 70� � ° a r r f� i I' I Mai I O. xtordNO. 152 1/3 ORA EELS° 10% «i1iFY.rt Lr+ i Tp Town of Barnstable *permit# ,C3-16 — 5 S(cz� p Expires 6 months from issue date Regulatory Services Fee saxxsresie. �p $ Richard V.Scali,Director Building DivisionESE �� Tom Perry,CBO,Building Commissioner �G 200 Main Street,Hyannis,MA 02601 LIAR 10 2016 www.town.barnstable.ma.us Office: 508-862-4038 DOWN OF WIC►(SAA&2po EXPRESS PERMIT APPLICATION - RESIDENTIAL. ONLY _ _ Not Valid without Red X--Press Imprint Map/parcel Number l,s S �03 Property Address 7 6- L-0 Fz) A-" UJS Residential Value of Work 4 > o Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address (2- L t `( -7 S' L.-® t A P3 A'►Z b Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) �— Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor 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 Reque (check box) f L!JVRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �❑� roof(hurricane nailed)(not stripping. Going over existing layers of roof) ' l-�'Ke-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: Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 040215 i 1 he ComnromveaIth u,f 1Vassaclrnsetfs Departumxt o,f Ind-ush ial Accidews f3,frce of invMtigations 600 Washington;street Boston,MA 02111 >' im,Y nasmgovldia Workers' Campensation Insurance Affidavit:Builders/CuntractarslEIecEri,cians(Plumbers APPEcant IIIfGnn-ation Please Print E,egib Name(Bn a ganim ion/Ifldvidual) O t-.,z Address: 7 L ry-, 1� A f) 4.v It . GtWstatelzip:. W Fl R w S 7/A 1,r= Phone-,u-- o V 2S1 � Are you an employer?Check the appropriate bo=: 'type of project(required): 1.❑ I am a employer with 4_ ❑I am a general contractor.and I employees(full an,dforpnrt-time). * have hired the sub contractors 6. ❑New constructiazz 2.❑ I am a sole proprietor orpartaw- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition wod-ing for me in any capacity. employees and have workers' [No n a3cers'comp.insurance comp.insurannel 9..El Budding addition eclrured 5. ❑ We are a corporation and its 10-❑Electrical repairs or additions 3. am a homeowner doing all work officers have exercised their 11.❑Plumbingrepairs or'additions myself[No workers'comp. right of exemption,per MGL 12.❑Roof repairs insurance required.]y c.152,§1(4),and we have no employees-[No vmdcers' 13.❑Other comp.insurance required_] *Any W ic daat cbecla box R msst also fill outthe sectionbelawshoidag their wadcere cumpensatiaaporcyiafnrmaaca t&ameowners Who submit dus affidam infcatntg they are doiv-all Woak and rhea hire outside contractors aamst submit a new affidavit i"aicztmg sacs, TCantractos that check this boat mast attached ai addition sheet showing the name of the sub-comtrsctom and state Whether"not those entities have -employees. Ifthesub tantadneshave emplos-ee%theynMstpmvide their workers'comp.policy number. I am art erreployer flaatis providing tvorkers'congertsatiart irrsairance for my cHrplo3.ees Below is the policy arrd job site information Insurance Company Name: I Policy A or Self--ins.Lic.#: ExpirationDate: Job Site Address: CityJStatel7.tp: Af4ach a copy of the workers'coompensationpolicy declaration page(showing the policy number and expiration date). i Failum to secure coverage as required.under Section 25A of MGL c.152 can lead to the imposi dou of criminal penalties of a fine up to$1,50a 00 sndlor 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 y-mifrcation. I do hereby certify render dig pains and penakfes ofpetfury that the urfor ma imr pm idrd abm a is bare and correct Sitmature: Date: Phone A- Official use and. Da trot write in thb area,robe campieted by city artown official City or Town: PerrmtlLicense# horning Authority(circle one): 1.Board of Health 2.Building Department 3.Cityf£own Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: phone#- information and Instruc-lons ' Massachusefts Geheral Laws chapter 152 reqaires an enTjoyen tD provide workers'compensation for fbei r cmpIoyees. ' pmmuaritto this ,an.0nPIoyee is defined as."_.evezy person in the service of another under any contract of hue, eo`pre=or implied,oral or writ " - oration or other I e E y,or any two or more An employer is defined as. an mdrvidnal,partnership,association,corp seuTstives er a deceased employer,or the of the fnregoi ag engaged in a Joint entmpise,and including the legal repro receiver or trustee of an individual,Partnership,association or other legal entity,employing eunPloyecs_ Howeverthe owner of a dyml ing house having not more than three aparfineafs and who resides therein,or the occupant of the - dweHiag house of another who employs persons to do maml>nance,construction or repair work on such dwelling house or on the grounds or budding appmtmaritthemtD shallnotbecanse of such employmentbe deemedto be an employer." MGL chapter 152,§25C(f7 also states that"every sty or local Tired agency shall withhold ffie issuance or renewal of a license or permit to operate a business or to construct buufld ags in the comm DrLwealth for any appliczntwho has notproduced acceptable-evidence of compfian.ce'F n the irsur-ance•eoverage required." Additionally,MOIL chapter 152, §25C(7)states"Neither the Comm mwmn nor any of its political subdivi-lions shall enter into any contract for'the performance ofpublic word umhl acceptable evidence of compliance with the insurance._ requirtments of this chapter have been P=ent�d to the contacting aafhonaty_" Applicants Please fill oitt the wo,3mrs'compensation affidavit completely,by checking the boxes that apply to your situation znc�if necessary,supply sub-contractors)name(s), address(es)and phone number(s) along with their certificates)of hmn—,rce. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not rr quired to carry workers' compensation iasoraiice If an LLC or LLP does have empIoyees,apolicy is rmpa-ed. Be advis ed that this aff idayit may b e submitted to the Deparfinent of Industrial Accidents for confrnnation of insmaiice coverage. Also be sure to sign and date the aidavit. The affidavit should be retumed to thLe city or timm that the application fur the permit or license is being requested,not the Department of TndustriaT 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 iminber lisiEd below. Self-insured companies should enter their s eif-insTTrar ce license number an the appropriate line. City or Town OfEiciaTs . t Please be sore,that the affidavit is complete and pry d legibly. Ue-Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to full in the peumitllicense number which will be used as a reference number. In.addition,an applicant that must submit multiple penmit/Iicense applications in any given year,need only submit one affidavit indicating policy in�rnnation cif necessary)and under`fob Site Address"the applicant sor hould write"aII locations n (cam' town)--A copy of the affidavit that has been officially stamped ormarked by the city or town may be provided to the ' applicant as proof that a valid affidavit is on file for future peumits or licenses A new affidavitmvst be,filled Olt each j year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commea cial ve�e (it,. a dog license or peuunit to bum leaves etc.)said person is NOT required to complete this affidavit The O ffice of Investigations would like to thank you izt a&ance.for your cooperation and should you have`any questions, please do not hesitate to give us a call- The Department's address,telephone and faxmmniber- The Ca=DQaweatth of Massachnsf t- Depattrnent of liachistzal Accidents duce of lavegtikatio= 600,washivan t Bostou,MA G2111 Te,-L 1617727-49QO QXt 06 car 1-977 MAI'3SAFF Fax 9 617-727-7M revised 4-24-07 � gQg��a oF�rqy, • swaxsresi.E. . "� • 9� i639- Town of Barnstable �� pTED MA't� ' Regulatory Services Richard V.Scali,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 A Builder 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) . I Signature of Owner Date i Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPFILES\FORMS\building permit formAMTRESS.doc Revised 040215 Town of Barnstable Regulatory Services r . �S Tqy Richard V.Scali,Director ti Building Division s,►axszi+sta. Tom Perry,Building Commissioner Mess v� 1659. 200 Main Street, Hyannis,MA 02601 QED MAt 6 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 7 S L 0 +j A 2>7 V Ali !� - 1� GZ O✓5 Z r3—C i/!. number streetl — "HOMEOWNER": Q Y !V( rJ ID /_I_ S/ G 7 — name home phone# work phone# . CURRENT MAILING ADDRESS: L O ✓» / f2 (/_ q, t3-4/,P s;a 3 ��. N1 . 4 a Z6,6 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. l 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. _C Signature of Homeowner i Approval of Building Official I 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. i 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. Q:\WPFILES\FORMSMS\building permit formsENPRESS.doc Revised 040115 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Maps Parcel d 3 Permit# S^� -7 I Health Division tA) —03N TOt" -H OF 19ARNSTABLOate Issued r �� Conservation Division w�c� 3a► dD 2065 JUL 18 AIM 8. 5 ree Tax Collector rw Treasurer Ply - ------- - - -- Planning Dept. DIVISION Chec1i50 SEPT10 SYSTEM Date Definitive Plan Approved b tP�nnin g Board q 109__S__'#OF BEDROOMS Historic-OKH Preservation/Hyannis Project Street Address d� �� 4f ?Zz�G Village Owner Address Telephone Permit Request i 4 •.� 5 /l Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Valuation 10. 000 Zoning District Flood Plain Groundwater Overlay Construction Type o 0 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family C5r/ Two Family ❑ Multi-Family(#units) ' Age of Existing Structure istoric House: E Yes ❑ No On Old King's Highway: ❑Yes ®'No Basement Type: ull ❑Crawl ❑Walk o t ❑Other Basement Finished Area(sq.ft.), Basement Unfinished Area(sq.ft) /Q.�?.52 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 Q'OiI ❑ Electric ❑Other Central Air: ❑Yes CYNo Fireplaces: Existing _� New Existing wood/coal stove:-Cl Yes �lo 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 �K9-14� �o� -� Telephone Number ®� ' Z' Z,Z 1 Address d/+ZZ i7 License# h.r,L Al Ste/¢ g L. Home Improvement Contractor# Worker's Compensation# AL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 77 > . 0 . FOR OFFICIAL USE ONLY PERMIT NO.. DATE ISSUED MAP/PARCEL.NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL F i GAS: ROUGH s FINAL FINAL BUILDING €J DATE CLOSED OUT % ASSOCIATION PLAN NO. G °F3�Er Town of Barnstable Regulatory Services BA1XMABLF, ` Thomas F.Geller,Director bass. 9�AjE0 3.�b � Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 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 buil ' e done by registered contractors,with certa' ptions,along with other requirements. y / 5V Uhl'e GU60 9 � Shy✓ Type of Work: Q/ � 4/K/ ' / � Estimated Cost 400 Address of Work: en:) Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Jo nder$1,000 ❑ ding not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED - r 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 apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR If ate Owner's Name ,.•„Q:forms:homeaffidav I Town of Barnstable pFTHE h Regulatory Service_s Thomas F.Geiler,Director snaxsr BL% 1 MASS. ,0� Building Division rfD MA't p Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print r / DATE: 7AS- JOB LOCATION: nu stree villag�605' 6Q�f "HOMEOWNER": iA�V � ?7b ../63> name ome phone wor hone# ✓ / CURRENT MAILING ADDRESS: , city/ wn state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellines 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 109.11) 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 procedures and requirements and that he/she will comply with said procedures and req7ents. Si afore o 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. 1. 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. Q:forms:homeexempt r I Application to. E Pay"O 00. � Old King's Highway Regional-Hisporic District Committee in the Town of Barnstable for a CERTIFICATION.OF EXEMPTION Application is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7 of Chapter 470, Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans,drawings, or photo- graphs accompanying this application. TYPE OR PRINT LEGIBLY DATE ADDRESS7OFPO' SED WOR, V'� ASSESSORS MAP N0. OWNER �� ASSESSORS LOT NO. HOME ADDRESS a/n � • ��- Q TEL. N C.4 AGENT OR CONTRACTOR cle ADDRESS 41-60p7?' TEL. N This application is for exemption of proposed exterior construction on the ground that: �❑ (1) It will not be visible from any way or public place. (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission. (Check applicable box) PROPOSED WORKDescribe and furnish plan of proposed work, showing location on lot,and, if an addition is involved, show. ing location o xisting build`ng. X S o� SIGNED Space below line for Committee use. Owner-Contractor-Agent Received by H.D.C. The Certificate is hereby ().M Date Time gy �� Date Approved ❑ The categories of work entitled to exemption are listed on Disapproved ❑ the back of this form. The Commonwealth of'Massachusens Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston,MA 02111 ..' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leydbly Name (Business/organization/Individual): Address: 10-1 . G �2 City/State/Zip: �./ Gt vl�SfC� e Phone#: Are you an employer?Check*the,appropriate box: . Type of project(required): . 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/orpart time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet x Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition workers' comp. insurance 5. ❑ We are a corporation and its equired.] officers have exercised their 10.❑ Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions ,152 ,and we have no myself. [No workers' comp. c. §14( ) 12.❑ oofrepairs . insurance required.]t employees. [No workers' 136ther r2 a,'r�X comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation po cy information' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp--policy-infonnatiom I am an employer that is providing workers compensation insurance for my employees. Below is the policy'and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: 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$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 pena ties of erjury that the information provided above is true and correct. Signature: Dater d Phone D CV J 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide we oef another under any contraccompensation for their t�oflohire, w - Pursuant to this statute, an employee is defined as ...every person m the serve express or implied,oral or written." n employ A d as`.`an individual,partnership, association,corporation or other legal entity,or any two or more er is definehe A the foregoing engaged in a joint enterprise, and including the legal representatives of a decease employer,or tof the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. erein, Or the occupant of the owner of a dwelling house having not nor rsons to do aamtenance than three aprtmentsnconstruction ord who residesrepair work on such dwelling house dwelling house of another who employs persons ant thereto shall not because of such employment be deeiiied�o-fe-m-enVloyer- or on the grounds or building appurten MGL chapter 152,§25C(6)also states that"every-state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of'its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s) along with their certificate(s) of . insurance. Limited Liability Companies(LLC)or Limited Liability Partnerssh pe IfLP)an-LLC ono employ does s.ot er than the members or partners, are not required to carry workers compensation msur employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. -Also be sure.to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the the la license if yo are requested, required to obtain Department r of Industrial Accidents. Should you have any questionsregarding the number listed below. Self-insured companies should enter their compensation policy,please call the Department at self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event be Office �be used as avestigations refeas�ence member ct you regarding addition, applicant applicant Please be sure to fill in the permlt/hcense nun that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" or marked by the city or town ll may be provided to cations in the city or town),"A copy of the affidavit that has been officially tamp applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each comm year.Where a home owner or citizen is obtaining a license or permit not reldad o a leteusiness or this affidavitercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT requlr mp The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, Please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia _b I ,I R` � � i•- r EH ! i } y_-,w aacaews sr mam. .. �w s` A k F 3 s Ll f _ 4 �.a it ¢ +' ... ..,tl '4 r \ r� 3 q � f c _ f Moral �. i. . I: i + f. 1 A ,i 9 . i 1 r • O f _ } I 1 f 1 1 ML It F; / tA ITI 1 � I • I i • i { . j I 01 tA --4- "Lil I N � N x� �i