Loading...
HomeMy WebLinkAbout0781 OAK STREET (CENT./W.BARN) rf UPC 12543 No. 53LOR HASTINGS,MN �I ..s� r:i'ia'sa`�crrerma•� -- _��ti_, Town of Barnstable Building A r . xsrner Post This Card So That it is Visible From the Street-Approved Plans Musfbe Retained on Job and this Card Mustbe Kept M"E& Posted Until Final Inspection Has Been Made. Permit ibsp -_ 1 11 111 r R Where a Certificate.of,Occupancy is Required,,such Building shall Not,be Occupied until a Final Inspection has been made. Permit No. B-18-2581 Applicant Name: Matthew Harris Approvals Date Issued: 08/14/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 02/14/2019 Foundation: Location: 781 OAK STREETS/W.BARN),WEST Map/Lot:_215-014-001 Zoning District: RF Sheathing: Owner on Record: MERRITT,MARJORIE F Contractor Name:'`-,MATTHEW D HARRIS Framing: 1 Address: 20302 SAPPHIRE CIR Contractor License: CS=105679 2 MAGNOLIA,TX 77355 '~ Est. Project Cost: $4,000.00 Chimney: f Description: Insulate attic # Permit Fee: $85.00 Insulation: Project Review Req: + Fee Paid;' $85.00 Date: 8/14/2018 Final: jZ Plumbing/Gas I Rough Plumbing: 4 Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within'six months after`issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access Street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. _ Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this'permit. Service: Minimum of Five Call Inspections Required for All Construction Work:1 1.Foundation or Footing .~ Rough: 2.Sheathing Inspection - 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Perso on ing with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: �C_ All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT i Town of Barnstable Permit: Regulatory Services Date: i 1(,>4 f i� Ft"E rq� Richard V. Scali,Interim Director 3 Fee: A Building Division ' BARNSrABLE Tom Perry, Building Commissioner 9 MASS. i639. 200 Main Street, Hyannis,MA 02601 menu a www.town.barnstable.ma.us I Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: M q �,.1 0 f i e- -�, M e r r ��- Phone: L�Q) 530-YOB y Install at:_ g I _OAK S _ —Village: WeS t 1J rh s A e _ Map/Parcel: a I S O ( 4 001 Date: 07 �0 . 1 ' Stove A. New/ se B. Type: dian /Circulating ` �+ C. Manufacturer: K 6, 4 q(1 s Lab. No. G L A r93 W.j1h D. Model No.: Chimney ` A. New/Existing (If existing,please note date of last cleaning) 66 10 ICJ W B. Flue Size 3xl_3 C. Are other appliances attached to Flue? 11.0 D. Pre-fab Type and Manufacturer (o" 'J el f 1 f 3 1 b*; t„AQ,r E. Masonry: Unlined Hearth A. Materials: /h Q S o h t-y B. Sub Floor Construction: L oh C rely Installer Name: Address: Phone: Location of Installation: H.I.0 Registration# Construction Supervisor# OR check X Homeowner Installing, no license required LICENSED INSTALLERS SIGNATURE: APPLICANTS SIGNATURE: APPROVED BY: Please make checks']�a able to the Town qf Barnstable This constitutes_ an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev 11/4/13 I— ' r 77M LOMMMMUM ofHasslac3llfsPflS ���'I�Sbtad�Icddu�s M4 021LI www masxgov/dta W,wl,ers' Campensatian Lww2ncz A M&vit:Buff&rs/Cants.ctors/Rectricians/Plundbers AyaFwmt Iufatnnation Please Print Legibly Name ��o Address O C;�- c ityfstater -M , -O 773^_ a5�- y - s�o 0 Are you an employer?check&a appropriate box: Type of project(required): L❑ I am a employer W& 4. ❑I aw s Sawral,contractor and I 6. E]New consWxtion employees(f d audlorparthe).s have hired the sub-contracim listed on the attached sheet: 7- ❑Remodeling 2.❑ I am a sole proprir�or orpartner-stop and have no empl T�sob-ooa'ftactors have oyees 8- F1 Demaliti worldng far me iia any capacity. emp1"MM and base wodmrs' 9. ❑Building addition [ATa woos'camp.insurance comp-in uxa'cr �j 5.❑ We are a corporatimrand its 14-0 metrical repass or additions 3. I am,r officers bave eaercxsed th3-XJ am, eir 1�Pl>m>bmg repairs or additions hOmstrva doing all Woz1C myself[Nowo�rs'comp- zig�tofe�emrptianperbft�L 120 Roafregairs msusance required.]f , L . ) a 15Z§1(4 and we have no �ayem[N 13 Other �7 Gc�cr p�PQi�etS comp-inw ance required.] �a�y appt�rt had dip bcw tl—sc also f�ana t�secfioabetoarshoviag nun vn,��eompen o>tpa>iCs dam GA 78 l DAM i 18a$mae�Who sab=idds.Ee ar r �7r ase dmng auuadc�aeu$hbe oam�e cm mm�Solo�a afsa�rt m g wrb fCa�ucma9mtdreclt�icbmrmastatla[hedmaddiSoaalaheetshaairthemmoeaffftesp4�naoors�dateleRhethararuat�oseliave Mj C>4,661 em&ycrs. Ifthe solreaa4aaarc e�foyaes,�eymust pmvsde their tivarkas'comp.policy number I am an employer thadis pmvid*g workers'oo n&smmnce for my engdgyaex Below is die panty curd job silt irljbrmatiara lummmee Company Name: PbEcy;g or Self-ins-Uc.#: Fxpiration Date: Job�Address QwSta dziip: Attach a copy o srorkere compeaufim policy dedaratition page'(showing the policy number and ration date). Failure to s coverage as requaedun&x Section?SA of MGL c.152 can lead to the impaeitirori of criminal penalties of a fine up 1.500.OQ andlor one-y�earimpds as well as ciml pemtlties in ihe forma of a STOP WORK ORDFR and a fine of $250.00 a day against the violator- Be advised that a copy of this s maybe forwarded to the Office of gations of the DIA for insurance coverage vacation_ I do hereby certify under thirpamns andpenaliies ofpm7my fieat 9ie inforMaIffnn provided abeve is hue and correct t� Date: - ,,201 ' QVW aI use only. Do Trot wrier in mis area,to be completed by cn4p or tbwn official City or Town: Prnzaitl Iceme ff bsmngAuthorntg(anteover- L Bond of Health 2.Bw-J mg Jkpart meat I CitgfFown Clerk 4.Electrical baspector S.Ptambing)nspector &Other Cbatsd Pexsun: Phone#: 6 i - Town of Barnstable Regulatory Services s i Thomas X� s, Garr,Director 65�.,•� Building Division Tom Perry,Building Commissioner 200 Mann Street; Hyam*MA 02601 www.town.barnstsble.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER UC iSE MMMOIY Please Print JOB LOCATION: e number street village ` -n "HOMEOWNER:_ r to r i e �RVMgrc iA, raw-() aSro y name home phone# work phone CURRENT MAILING ADDRESS: Q� S n��1 7�j--Vn5 �71?-_�,SC5 mY s :dp fie' The current exemption for"homeowners"was extended to include owner-occtmied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,pM3 ded that the owner acts as DE1INMON 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-homily dwelling,attached or detached structures accessory to such use and/or fame structures. A person who conshncts 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 resnonsrble for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsrbu3ity 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 reguurements and that he/she will comply with said procedures and requirements. Signature Homeov 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 Constriction Control ROMEOWMIS E2MMMON The Code staDas that "Any homeowner perforarmg work for which a building pec>mt is wired shall be�.Wt from the provisions of Eris section(Section 109-1-I-Uceosing of construction Supervisors);provided that if the homeowner engages a prim*)for hire to do such world that such Homeowner sW act as supervisor." Many hommwners who use this exemption arc unaware that they ue assuming the tesportsr'brlities of a supervisor(scc Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious emblems,particularly when the homeowner hires unlicensed persons. In this rase,ma Board cannot prpceed against the tmlicersed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately respom'bla To ensure that the homeowner is fully aware of bWhcr rexporw'bt'lities,many communities require,as part of the permit application, that the homeowner cat fy that he/she undevsta: s the resporrstVities of a Supervisor. On the last page orf this issue is a form currently used by several towns. You may rare t amend and adopt such a fom/cettifieation fat use in your eoanun»ty. Wornw.ho>rreciompt i d Town of Barnstable *permit#L �7�5 -�� Expires 6 months from issue date . Regulatory Services Fee ��`� � Thomas F.Geller,Director S Building Division q 1001 EP e 4 ? ?terry,CBO, Building Commissioner ` roVV/V 9F 00 200 Main Street,Hyannis,MA 02601 SA www.town.batmstable.ma.us Office: 508-862-4038 rgBLE . Fax: 508-790-6230 EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number / Vol-) 1 Property Address 7`t3 t' O a L S'Tn e e l tv, 13a rl ti s f Residential Value of Work <0 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address /L an 7 o3a 2 Sa oo 4 , ,..t C ^�1 L' t1�L r<-o L !{ li,i4F. . Contractor's Name �J 1�ru j Telephone Number 07 q,6 71 Home Improvement Contractor License#(if applicable) /0 2 / 7 9 Construction Supervisor's License#(if applicable) 6C) S Y D 9 ❑Workman's Compensation Insurance Check one: © I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance n Insurance Company Name Sy/i/`o. �A^ I'�-� �ti ��S�I� 1 1 n�u j.a Workman's Comp.Policy# 20 o f k 0 2 o 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 AL Kf S �`t'ti z 1� ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. 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. A copy of the H e Improvement Contractors License is required. SIGNATURE: Q:Forms:exprntrg Revise061306 Page 2 of 13 JOHNSON STREET 102149 JOHN JOHNSON PO Box 118 160 W. Barnstable MA 02668 Johnson, JotLo- 102761 Church St JOHNSON HOMES 143 Palmer Ave Falmouth MA 02540 Johnson, David l� INC.. PETER EDWARD 7 PENELOPE U� _ 102785 JOHNSON LANE COTUIT MA 02635 Johnson, Peter KYLE J. JOHNSON = 0 102949 GENERAL 26 Sunset Drive Williamstown MA 01267 Johnson, Kyle CONTRACTOR Oil- 103160 RICH G.JOHNSOSO 17 BAILEY AVE. Beverly MA 01915 Johnson, Richarc ON 103422 D & D CARPENTRY P.O. Box 390/44 Williamsburg MA 01096 Johnson, David Briar Hill Rd. 103554 FRANK J. JOHNSON F50 Nagog Hill Rd. Littleton ®01460 Johnson, Frank COMMUNITY 103834 BUILDERS 24 Webster Avenue Somerville MA 02143 Johnson, Arnold COOPERATIVE LLC 103979 SCOTT E. JOHNSON F147 Monument Rd. Orleans I®02653 Johnson, Scott 104020 FRED G. JOHNSON PO Box 1084/ 2 EN'S DR Nantucket MA 02554 Johnson' Fred HEL CALDER 105131 OVERHEAD DOOR 38 Baldwin Street E. Longmeadow MA 01028 Johnson, Willian CO. OF MASS. IF- IF n� file://C:\DOCUME-1\permit\LOCALS-1\Temp\EL49NM20.htm 9/4/2007 The Commonwealth of Massachusetts Department of Industrial Accidents € 6ffice of Investigations _ d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers"Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Organization/Individual):. J." N 5 a Address: / o c �Y•� S c r , City/State/Zip: I�A�r-.� Sc v*`21 ss o Le*hone.#:5bY 3 62 -2!::� 71 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 T . employees(full and/or part-:.time). have hired the sub-contractors 6. ❑New construction . 2.® I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance comp. insurance, 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ P 3.❑ I am a homeowner doing all work officers have exercised their l 1.E1 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.[]Roof repairs insurance,required.] t c. 152, §1(4),and we have no employees. [No workers' . •13.❑ Other comp. insurance required.] . *Any applicant that checks box#1 must also fin out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating inch. 1C6ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policynumber. Iam an employer that is providing workers'compensation insurance for my employees. Below isthe policy and fob 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 CIA for insurance coverage verification. I do hereby certify:ender the pains•and penalties of perjury that the information provided above is true and correct. Sip-nature: Date: v 2 Z 0 7. Phone#: fy ? 2 ' 2Ss 7 Official use only. Do not write in this area,'tb 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: oF ' ti Town of Barnstable; Regulatory Services US&nBs,E, Thomas F.Geiler,Director �ATF �b,� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.maxs 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 h ti a -vr 6 �v: to act on my behalf, in all matters relative to work authorized bythis bi ilding permit application for: . (Address of Job) Signa of Owner Date Print Name QFORMS:OWNERPERMES ION 1 •. J c Board of Building egulations One Ashburton Place, F�m 1.301 Boston, MatI02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE c�?" Birthdate: 06/21/1946 Number: CS 005409 Expires:06/21/2008—`� Restricted To: 00 IN 1.2 JOHN J JOHNSON f� S t PO BOX 118 W BARNSTABLE, MA 02668 Tr. no: 28262 Keep top for receipt and change of address notification. DPS-CAt Co 50M-05106-PC8490 i FRIEDLINE&CARTER ADJUSTMENT, INC. 436 Main Street, P. O. Box 338 Hyannis, Massachusetts 02601 i Te (508) 771-3232 (508) 790-2344 TO: Building Commissioner or Inspector of Buildings Board of Health or Board of Selectmen ( ) Fire Department TOWN OF Barnstable TOWN HALL MA RE: Insured: MAKI, Frank& Ervina Property Address: 7> 1 OakySt.- W. Bamstable, MA Policy Number: H0325492 Type of Loss: Lightning Date of Loss: 8/2/2005 File#: 102905 Claim has been made involving loss, damage or destruction of the above captioned property,which may either exceed$1,000.00 or cause Mass. General Laws, Chapter 143, Section 6 to be applicable. If any notice under MGL, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of this writer and include a reference to the captioned insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by First Class Mail. N. LAGUE Adjuster 8/4/2005 I� Town of Barnstable - Planning Division TME TOE, Old King's Highway Historic District Committee << * 1ARNSfABM MASS. 1639. MEMORANDUM TO: Building Commissioner FROM: Beth B.:Maples, Principal Division Assistant (862-4784) DATE: /�///a/ SUBJECT: MODIFICATION TO PRIOR APPROVED PLAN A minor modification to a prior approved plan has been approved by the OKH Committee for the applicant(s) named below. The modification is briefly summarized and I have attached backup material for your records. Applicant(s): Address of Proposed Work: `7"r/ Assessor's Map & Parcel Number: 1S Meeting Date Approved by OKH: Minor Modification: �� Gt2/L-C �`z? /�.�TL't/ t�i�'GPi�O�> W��l1�d�-✓ .4' RUS. D Dorothy . Stahley, Chai Date Town of Barnstable Old King's Highway Historic District Committee r ' 7 r • a - . y _ � • r + : �� ►� - - a n TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 0 4 - 60 I Permit# Date Issued 4 --7 1 _%9 Fee Tax Collector. vP Treasurer Planning Dept. �6.Y M ' Date fDefinitive Plan A roved by Planning Board > Historic-OK eservation/Hyannis Project Street Address r 9 l 691: 6M567— village Owner v /C )01,4 k Address 3&Pn�. Telephone Q Permit Request D ) -7 SQ GSa tc,�l tx�7�PL AS /r-X i'M JG, l Repo cr fyfSr7A(6 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost 6-6b Zoning District Flood Plain Groundwater Overlay Construction Type W.. I S1� Lot Size Grandfathered: O Yes 0110 If yes,attach supporting documentation. Dwelling Type: Single Family Two Family O Multi-Family(#units) Age of Existing Structure Historic House: O Yes Q1,<o On Old King's Highway: dYes ❑No Basement Type: ❑Full ❑Crawl 0 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: O Gas ❑Oil O Electric ❑Other Central Air: I]Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 0 No Dgtached garage:O existing l]new size Pool:O existing ❑new size Barn:O existing ❑new size Attached garage:O existing ❑new size Shed:El existing 0 new size Other: Zoning Board of Appeals Authorization O Appeal# Recorded❑ Commercial ❑Yes Wo If yes,site plan review# Current Use l�r9?22it/ Proposed Use R/hPf>tf BUILDER INFORMATION ' Name M91 ZL f}D>-nF ,nk&_ . Ar;MA'-1T "-Telephone Number` q Address l��S ll� i7JGJ�1 �1), License# Oz Jfl,2 0014i17-. 4114 i oQ6 3_15 Home Improvement Contractor# 100 fz Worker's Compensation# LJ C 5 Fa &G F/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO fner7 0&n P&i�,Se SIGNATURE I�CyL[.P�It , 7 , ��•QLh, DATE _ A ,_ 9� FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO.. ADDRESS VILLAGE^ ✓/ ` OWNER � t -'t • DATE-OF INSPECTIO FOUNDATION { FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r - PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING -ly 1r2-o od 1 ' DATE CLOSED OUT • ASSOCIATION PLAN NO. i � .V` 'a , C -The Town of Barnstable • viRfICTAiLtc • Department of Health Safety and Environmental Services 1659. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only 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. ,gq 0 Type of Work:cS lP B art'& AAfAl�nCEst. Cost !�r cra Address of Work: Owner's Name /9'�11� �'►�A ICE , - Date of Permit Application: Lf _ �� R I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under 51,000. 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 PROGZAM 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. eel P OR Date Owner's Name The Commonwealth of Massachusetts r.. -- Department of Industrial Accidents office o119YOUFAaUoas - 600 Washington Street Boston,Mass. 02111 Workers' Coinv ensation Insurance Affidavit name: location: city t)hone' # or ❑ I am a homeowner performing all work myself. ❑ I am a sole et or and have no one work m in acity I am an employer providing workers' compensati n for my employees working on this job. >an .Via:»= EA e> `> : Em {:$� ..in . 4iiii24iiiii�.? . i :: :: i :v;}y!i;}•j;?;;$. ...:S ..... i' Y :•iiii:^i:?�:i jai :i :;:iYiv:Ji:S i:!::ii:(!iiii: ::.iiii}i:'i;:.>:::tit•:<::•:•:•:':::?: :iiiii:'::,y.+y::" :•:::•::::::ii::i::`'ti::i ;:}}:::::i:::•::i.G:;Siiii :.::. 00. •:••..• ?.. :.. „ ::. 00 hone:#: . ::::::. olkcv>#::>::>:._ ❑ 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:..................................... m coma v ........ mo .................:...........••::••::;;....::v:•:}::::: :h::•'!.?ttti+.iy}}}ii:y}}}}}}?i::}:tiy�i:i<!vi:t•i?:?•i:•:4i???i:Yi:4:i?y;?:;{>.:??)i}?}?}:v??i}}:;i t'v:::i ii;:j?i v;?iiiiiiii:i'1.L4;;:i•i?i:;:;:;:ii?i?}•i?:?yi?}i}?}}}:;ii??:Y.i:{:i ?:i'i <!h::4Y:4?i?:4}i::!4i}?:?t•ii}::•.:w:.�:}::•:v:'w: :::.......... w:•}:^}:iri4i?Y. ... •: :i}??:4i??}i:!4}}:i?•}:•}i} :•;J?i}}}i}}i:{•}}??}??::: v::::::.�::.::; •?}:•i:•}}:�.....• .}}}}•.}i}:�::iii}: •.::::::::n.::: address.::..::...........:..,......:.:::..:............,................:.....:.......:::..::..::.::.:.;.::.}}:.?::!•:•}:. ,:,:<._::.:.>:;:.?::>:::::.:.:.:!:::..::.:::;::::t::.:.}:::::.}:;.:.:;.}:.:;::::::::.::::::?:?:.}:.}:.:;.}:.;...........:::::.:::::. . xxx ......................................................................................................................................?....... . n?}???iaa•i:•}}}?i>::•>?i:.}?}}:•;}}::::::::::ii..:}::?::ry::v•..W*.^!S2"•:j`.�}: .::2?^.;:.; .......................�.v v•::w:v:::.:...........�.........w;v;•vv:..::...............................:................... .:::.;.:...: ::::of2 :isY;:;:;:; >::;.';;5::;i?;'; ::%iii:'i::yi::::isi::;::::; :::_i;:?+:':i::<:`•:: .................... . :.........:::::::::::::::::... ............... ... .:.:.�.:.�:.:........�...............:::.. .....:...........................::.�:::::::::::::::. , ...........:..:.. ..f....................................... ........... ...}:•:::}?::•?:•}:.>:•}:•}:•?:•???:>?:•}??:»>??:.}::?:.?:?•:?:•»}i;.;.o•>:•-•.......::::.1.::;?t is ii•:............ ....................:::............... hsnrance.ca::,:....................:,..:...,...;.......................:..:.:<:;..:.?}•.:.;:.<._:•?::::,:::::::::.::.?}}:.}:.;:.:.}•.:.:..:..:..::. •::.;..?::}:}:}..::::t.:.::«::......:...::���;�.::::::.,.:.�:::::.,•:.:: i:y{::iiiit'ii:!ii:Y+.y:�•:4}??:ti•}}^G:<:j;: 6:aii •>;:;k;>:;:;i:;:iiame�.:l.?:iiii:::$Y�is�:�i:�i:v�i iii::�}ji:?:}}'{:':is��Sitii ii ?:�i:i:Yi'J?is�'�i:;'::ti:;:i:y!y<:�'��vi::�ii:::''iiii}::::::}Ji jai:;:;:yi:::::(ii:::::Y:i:::4::i:.`iii:�ii:isly;':;:::L:i:(v::':!............: r.::4i}:<:ii::j::}::;:i}iiy.}t:•:^:<O:^.~�:•:v}:}}}::L:v.!.�•:::: gmnanv'n :. :,.. 'aiiifreas ..a.::...:::,.:. 'b lime. ::......:::::::::.::::::::::::::::::::::::::::::::::..: :.:.............: ... }:....:::.::: i.:.:i.:.:.::. i.}i:.;:.;;::... ii::?::i::i::ii::i::::i:>.i:.:;:::i::; i::i:.::::ii?:•:<:ii::<;::>::ii:;:.}:. tw ...:. :. .:•}:;?;.i:.ist :.:.:}:i:.:??:::::.:;;•::.:;:?•;i:.i:.i::.;:.:;.i;:.i:::.i;>;:.isi.?};:.i:.:.;::.is.:??:•??:•;?:•:.;:.:i.;?:.}:•:: :.}:. ...:.....:........... :.. .....:: ::"::...:..:: .......:... ................:;.; ......................... ... ::::;.:::•,�?>.......i•.::p.; .... :iiS:'ii:':iiii. ce:coz'>:::::i:>.:::::::<.<...<i;::::::^::>;:>::< :�>: <x..:::::>:'>::::«:::::>':?:�::::=::.?'.;:.i:.is.:.::.i:.:.:.;:.i:.:;.i:.i't.:?:?;.:: tillev Failure to secure coverage as required under Section 25A of MGL 152 an lead to the imposition of criminal penalties of a fine up to 51,1-OO OO and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification 1 do hereby c er tify under the pauu and penalties of ppedury that the information provided above it bu. 'and'coned G Signature Date Print name c�JEIZI C�c . (� f�S N Phone / J 95 �l7 official use only do not write in this area to be completed by city or town official city or town: permit/license f! ❑Bunding Department ❑Licensing Board ❑checkUhunLe inde response is requited ❑Selectmen's Office (:)Health Department contact person: phone iN, _ ❑Other OrAnd 9/95 PW I ✓/te Ur ol".101Ytivealt1b , ..%(J�CWJaclit"JelC dEPARTMENT ''•F ?LIJ.II/ AZ`i": "iNSiRUCTIOI SUPERV'SO° Number; ,per CS 307464 fi2 �.��,e0�, % . \ - 74�aam�nostu�ea�i Restricted To: i0 y � /Ta`. GAPItii HOME-IMPROVEMENT CONTRACTOR` •NONA ` Registration =4100740 : . :bps NE4dTOlJN :'sl -: Type =-.PRIVATE CORPORATION COTUIT, MA 26 °`✓'Expiration `.06/23/00 i _ CAPIZZL HOME IMPROVEMENT, INC G� h as,Capizzi', Sr. ADMINIST"TOR I Newton~Rd Cotuit MA 02635 J DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION•SUPERVISOR LICENSE Number: Expires: 1L - Restricted To::. 0 THOMAS X. CAPI?2I JP. PERCIVAL OR _W BARNSTABLE,, NA 02668 "` ✓fie -�a»vntarzu.�eall� o. ,G`cza DEPARTMENT OF PUBLIC SAFETY ' CONSTRUCTION SUPERVISOR LICENSE J Number: Expires: Restricted To: 00 I FREDERICK V 'RASCH II: i769 BOURNE RO PLYMOUTH, MA 02360 i