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HomeMy WebLinkAbout0010 PERCHERON WAY� v } 1 0 , V Oftide NO. 152, 1/3 ORA MADE IN UZA. ESSELTE n r +.rr.. ,��--:-"••--r'�r_ �- �Nw-gar'+w.+'�a+�i ---�.rn.ry r... � �.,,:..,...-fir Ywr. _ �::- � - - "- - -- - _ �as. � -- - - f `7 2���f �, �, �: �I ,�-..._, t oFTME T�,,, Town of Barnstable Regulatory Services sasraB Thomas F.Geiler,Director Mass. v�AIED 39. 16%. Building Division Peter F.DiMatteo,Building Commissioner 200 Main Street, Hyannis;MA 02601 Office: '508-8624038 Fax: 508-790-6230 Q9 00 PERMIT# I�D / FEE: $ -R�5/ SHED REGISTRATION 120 square feet or less Location of shed(address) Village Property owner's name Telephone number -7 LI/Q) P4 , 13 R Size of Shed Map/Palcel# CD �0 N w Signature Date D -.c o Hyannis Main Street Waterfront Historic District? o xNP n x Old King's Highway Historic District Commission jurisdiction? _ co ,� N r— Conservation Commission(signature required) 7 rn PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:121901 v oFt-v4 spa c I ao•o p lz8 i Fov4b Arjoi4 1 . X � //4 ,2Z 1 aA- 1 µ ! '•'Ir.w � ��I� S�jSGC 'Sv����rSiorJ _ cE,e7'i�i.Eo .LOT o,�.4,v / CST—E-' _-Y 7-1-/47- 7-/-/f-:� F061.UDATi0/J (OG47 S.�-inl�ciiv hiE.eEO.(/CO/�lioL YS Gr�IT/� SC,q L G— d i Tti S/OE,C/.c/E ANO SE7-B.4 C,4_- /^ . A) 29 93 .�EQI/�,L E�'lEiC/TS o.� T.v� TOWiV o.� ADZ-AAl 2 i /C'� PAlsT 8�� ,q.vo /s NET L dT 1 Q1 ,---ZoaaoG4/y �/U CIT��Z h`l LL SEG /NST,eU�1.�ic/T .2EG/STE,2E•O ,C�c/p SU.eYEYa.c D� SU,21/EY� TyE �STE.21i/.C,C�a z'. Eh 7-2� OETE cc- .4Oi�L i 0 Assessor s office 1st flag Mar 7 I at 1. 05 7 rercmt# Conservation Office 4th floor) 6 1 JZO .S � �- Date Issued -Board of Health 3r9 floor)(8:30-9:30/1:00-2:00) 1 ^ Fee 540 .00 Engineering Dept.(3rd floor) House] �� � __ ��BE --- �����SYST a Planning Dept.(1st floor/School Admin. Bldg.) 11 .�� ® IWE De ' ' ' e Plan Approved by Planning Board 19 �rll AND LWHONME TOWN OF BARNSTABLPWN R � Building Permit Application r VStreetddress /(Y Ir ,1 ! 1AM y /Village 1� c� 2Z2 4 Cr42 /ate! � ,p Owner P�r �� g /2�'//�/!AT t / 4—Address �� / e Ea c:; C jli1 Telephone Permit Request s /Q X/Z/ .,-,Total 1 Story Area(include 1 story garages&decks) �LA square feet Total 2 Story Area(total of 1st&2nd stories) square feet Estimated Project Cost $�� ��,� 70,eo Zoning District Flood Plain Water Protection Lot Size I�� 0fs Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type E Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached. Other Detached Structures: Pool Attached Barn None Sheds ��� Other Builder Information ._ant rbar L fOo Name (;1 (a Telephone Number 1156 8- 7w Address � (`r ,ram /�/j dLicense# �� � ^ 5 D e n n t 5 i r ` A Home Improvement Contractor# Worker's Compensation# qio e IW 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 (-�" -Qt7IlkADATE BUILDING P MIT DENIED FOR THE OLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. #6453 DATE ISSUED June 21, 1995 ; MAP[PARCEL NO. 174.001.057 " ADDRESS 10 Percheron Way j VILLAGE West 'Barnstable, MA OWNER Richard J. & Virginia !C. Ruggiero DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ' ROUGH FINAL i GAS: ROUGH FINAL FINAL BUILDING. DATE CLOSED OUT:; ASSOCIATION:RLAN NC►. " 1 11/02/9� 1 i:02 '$617727 7 122 DEPT IA'D ACCID Q 00 n - 7 l� /7 Oli2/nojutip.attil O/ rWaMac i ttdettj I� ' �ltpa/hnenl oJJ-,.Lt M ✓VCCiJ4Ab 600 1Nadhin�ton..S'b+sst James J.Campbell &ton, ///addachw a 02111 Commissioner Workers' Compensation Insurance Affidavit a.LL:�t� I, with a principal place of business at: do hereby certify under the pains and penalties of perjury, that: () I am an employer providing workers' compensation coverage for my employees working on this job. Insurance Company Policy Number () I am a sole proprietor and have no one working for me in any capacity. () I am a sole proprietor, general contractor o homeown circle one) and have hired the contractors listed below who have the following workers' compensation policies: Contractor Insurance Company Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number () I am a homeowner performing all the work myself. I u�derstzr,d that a copy of Lhis s:ztement will be fomzrded to d:e Office of investifations of cite DIA for co%Trage verification and that failure to secure cove-age s ree.ired under Section 25A of MGL 152 ca�i lead to the imposition of criminal penalties consisdne of a fine of up to S 1,500.00 and/or cr.. \ - years' imprisonnent as well civil penalties in the four.of a STOP WORK ORDER and a fine of S 100.00 a day against me. X Signed this day of Z 6�2� `- 19 �S Licensee/Permittee Building Department Licensing Board Selectmens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375 T1]T,T\T (_l_r-,RARNQTART F TMTT T)TTiC PFRMTT �� v OF U- 4 I vv-op ram° � 1 `� a• n J&q h 90 So'r_ m off. i P004D ATiofJ //4 .22 io cis ti i 7c, y4�i / C,�eT/�,✓ Ti=//�T T/-/,�-: 1-ro— l DATiO4 LOG4T/OTC/ S,ZiL51wly,yE.2E0.(/CO�'1,oL YS G1//Th/ S'C,4 A A/O SE7-z9A C/< / � � /° 2 9 93��2nlSTA /.S O �DT L 0T� CA TES W17'y/1c/ Th�E ,�Loa��G4/.f! 0,4 TE,- Z9 "13 / b ,aA XTE,C?6 Tip//S o.CA�v/S it/aT BASSO G,v ,4. //NST,e/j/�'/�i(/T i2EG/STE.eElj C�qc/p SU.eYEya� o�-�sETS syou%y S.�/av�z> ,croT N p o sX -- �d ---- ------------ Q n� N x O TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. . DATE JOB- LOCATION Number Street address Section of town "HOMEOWNER" 1 ` C,C 1 Name Home phone Work phone . . PRESENT MAILING ADDRESS cc)q- 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 such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides- or intends to re- side, on which there is, or is intended to be, a one to six 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 Off icia on a form acee-ptaable to the Building Official, that he/she shall be responsibl for all such work performed under the building permit. (Section 109.1. 1) The undersigned "homeowner" assumes responsibility for compliance with the Sta Building Code and other applicable codes, by-laws, 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. r—HOMEOWNER'S SIGNATUREgpkAl�l APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet,. or larger, will be required .to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION ' The code-state that: "Any Home Owner 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 Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming ) the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for licensing Construction Supervisors, Section 2. 15) . This lack of awarenes often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home ""wrier'- actin as supervisor is ultimately responsible. j To ensure that the Home Owner is fully aware of his/her responsibilities,. man communities require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. I i i i i i : . . : The Town of Barnstable . RARszAM.L �e� Department of Health Safety and Environmental Services 116 �• Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-775-3344 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-eadstiag 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: � cS f Est.Cost r7 Address of Work: t7 C.t'1 4 UU Owner Name: Rt G� Date of Permit Application: 6 -kQ -q 5 I hereby certifv that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000 Building not owner-oocupied 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 apply for a permit as the agent of the owner: Date Contractor name Registration No. OR -'10 Date Owne e :ofAMONWEALTH DEPARTMENT OF PUBLIC SAFETY OF ONE ASHBORTON PLACE AgSSACHUSETTS BOSTON,MA 02108 EXPIRP 55C 5 EFFECTIVE DATE LIC-NO. RESTN'' ° 03/31./1.994 045 L W JAMES O MCGRATH ?? c Po OOX .706 � jST,:0 ES MA C26,pQp DNLYIFEE:, X SIGNED BY LICENSEE AND OFFICIALLY HEIGHT: OR _•,I,NATURE OF i11E caM.rlsslOfNERDOB:THIS DOCUMENT MUST BE SpNAiUfE Oi LICENSEE MiS.JONER CARRIEOON THE PERSON OF THE NOLDER WHEN EN � llNi� GAGEDw'tfnSOCCUPATgN. V HOME IMPROVEMENT CONTRACTOR ' Registration 109374 ype - INDIVIDUAL Eipiration 09/11/96 PINE HARBOR BUILDING CO.,INC. JAMES D. McGRATH j ceMw rtoPO BOX 708/120 GT WESTERN.RD A(M,NI4STRAf0R S DEfflas SA 026607 "T ==� L Assessor Tice(1st Floor): - r l?�� l _V1 ,TALLE SYSTEM fit; a � TN( / Assessors map and lot number [ (� C S o� >o ( ) D IN COMPLIANCE ,�,�� `• Board of Health 3rd floor �l � LE J Sewage Permit number WITH TIT Engineering Department(3rd floor): ENIVI�IONMENTAL CODE AND t Dsna9TGDLL House number ID �"�S` °° 1639. Definitive Plan Approved by Planning Board 19TOWN REGULATION p ''fo Barnstable R 0 V G APPLICATIONS PROCESSED 8:30 9:30 A.M.and 1:00-2:00 P.M.only Consery TOWN : O V B A R N S T Conservation �q���sst°n SIgne —�-- BUILDING INSPECTOR Date APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION `7 19 q TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location a U-t l Y y �"�' I /Ar Proposed Use f� Zoning District Fire District Q �� Name of Owner Address l Name of Builder Address ' Name of Architect Address Number of Rooms Foundation Exterior Roofing ��✓ Floors �L�/ ""�— Interior A� Heating ��� � Q Plumbing Fireplace /�Z2/L�iCI lc� �'L�`> e% Approximate Cost zo Area Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name /t'ey`'av Construction Supervisor's License I BAYSIDE BUILDING CO. \ " No :6 2 8 2 Permit For 1 z S tort' Single Family Dwelling Location Lot #14 9 , 10 Percheron Way West Barnstable Owner. Bayside Building Co. Type of Construction Frame Plot Lot Permit Granted November 2 , 19 93 j Date of In ection i 19 Leo 19 2 ay p I r TM(� TOWN OF BARNSTABLE Permit No. ..3.6282...... ` BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash 7 •M� ego• HYANNIS.MASS.02601 Bond ................ CERTIFICATE OF USE AND OCCUPANCY Issued to Bayside Building Co. Address Lot #149, 10 Percheron Way West Barnstable, Mass. USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. February 22 94 ... ..... .. . ..... ...... . ..... 19................. .................. ........................ Building Inspector ENCLOSE CHECK OR MONEY ORDEI LICENSE. - 'REQUIRED-FEE, EXPIRATION DATE FOR =. 3. CONSTR. SUPERVISOS 06/30%1993 .::-' .L � MADE PAYABLE TO RESTRICTIONS '- EFFECTIVE DATE LIC-NO. ! N0 NE w.. 06/ 071991�'' 005.6.45 "COMMISSIONE � ,PUBLIC SAFETI Y. tl r ,.. BRIAN .T' DACEY fi. '''". -r;.. QUOTS4NMC6�SH)...�. 62, F E RB R 0 0 K -LANE SS 027-46-5956 CENTERVILL .MA.. 02632 P �EASE ..NO INCREASE PHOTO(BLASTING OM � •: ONLY! FEE: .t:.�l.; EIFECTIVARls Z: y "�C• jy NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY • ' fir ?A,ty HEIGHT: ,( `yi�� DOB STAMPED OR SIGNATURE Of THE COMMISSIONER ' ., 19/1956 :. :. 0 •NOT; DE ClENS�j:STI �` �t'R•, I �''' v}�:•'TN* DOCUMENT MUST SE ,�,Z:• �' GARBED ON THE PERSON 0/ �I of LICENSEE « SIGN NAME IN FULL-ABOVE SIGNATURE LINE • �'" ,:� :Y,�'• THE HOLDER WNEN ENOAO• oTNERt•RgiIY'tc ,pyf ED N THIS OCCUPATION. eh✓ COMMISSIONER' 20OM•247.81429 . a• �'-.�... .N nr•l:%'..A ...1 ��ra Y'�:.��.J�- �'ti+..l��fa.'�'Y'..I Y.-v.I_ ♦ .�y . 1...�-. .. .. � _ `1... o��� °•yew TOWN OF BARNSTABLE BUILDING DEPARTMENT = rAU°T = TOWN OFFICE BUILDING rua +639• HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department DATE: June 22, 1994 OC An Occupancy Permit has been issued for the building authorized by BuildingPermit #aa.3 6a2 8 2..._......_....»aa_..............................................................................................................»......»»....... »»»».»..»»_ issued to ..Bayside...Buid)dincr Company.........................._...._..........._...»........_._ Please release the performance bond. ASSESSORS PA..RC " NO. t/ ~ y CONTINUATION Or RO l BC:TD The u::de=sib e_ oc.-ne=/co-t=accor he=eb;J ag=ee to na_:t. =z t..e== road bc-d it farce uct_'_ t;;.e follokzzg c:or'_ti ite=s a:e c--=Ieted to t4he sat4-sfact_en of th= E-C=wee=�.g Sec—:on of the De?arr—went of Psoi=c c:or v ZCc� and see S- a::-, QerS a5 SoCi: c5 Gea-:e_ pe `c / /�✓ /owti1 I • .-7- ..lLDING"PERMIT I PERMIT,,O N Q� 1 36282- AF.PLicANr.___ IND.] io (STREET) (CONTR'S LICENSE) i-i u Ji.i(A! NUMBER OF PERMIT TO STORY o"DWELLING UNITS (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) i ZONING AT (LOCATION) DISTRICT (No.) (STREET) BETWEEN AND (CROSS STREET) (CROSS STREET) LOT SUBDIVISION LOT BLOCK SIZE BUILDING IS TO BE FT. WIDE BY-FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS: AREA OR L, 10 5 .3 0 u PERMIT s 50 VOLUME -ESTIMATED COST $ FEE (CUBIC/SQUARE FEET). OWNER BUILDING DE PT. ADDRESS BY THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE"DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL -APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR CAR PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: D KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN ELECTRICAL, PLUMBING AND 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERS(READY TO LATH). 3. FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE. OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS ;7 7.2 12 2 C*� 3 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT 2 86ARD OF HEALTH c 7 6t ri/i OTHER SITE PLANkU.VEW APPROVAL WORK SHALL NOT PROCEED UNTIL THE INSPEC_ PERMIT '#/!LL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD-CAN BE TOR HAS APPROVED THE VARICULIS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION, PF ISSUED AS NOTED ABOVE. NOTIFICATION. w,.t.-'r.-r•v' -.�.-4=w.• i-�"�n-...n.+t',�: .-4;«..dw�'w.•.f.��- ..iY" . +,..,r.-:-ice.�-%'+�r,iv""'"" ,-x:' tA.. r-t., ."�'•.n. .-Ya.+.: ..'.-, .... ..•�,. �. ,. .. 1 TOWN OF BARNSTABLE Permit No. ...... .36282........ BUILDING DEPARTMENT I ""'r } TOWN OFFICE BUILDING Cash X Doti+` HYANNIS.MASS.02601 Bond CERTIFICATE OF USE AND OCCUPANCY Issued to Bayside Building Co. Address Lot #14 9, 10 Percheron Way West Barnstable, Mass. USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID. AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. February 22, 19 94 .. . . .. ... . ... .. . . ... ... ............ Building Inspector 1 : v i_ OFt Q No•oo Q lLl-9 40 xv Q � M p t-ov►JD AT-iviJ //4 '2�7 --hslillo�i� ;J 4;i1 WfvW •' o:i 8-A•rw:'� '4'� 1y ;! p J N�, ,14.n tip• } _ CE14-2 f 7/.may T/-��1T T�/� �ov,U�ATio�.l �OG,4T/O.t/ Sf/OWN h'E.2E0.C/CO�J,vL YS �//Ty A,c/O SETBA C�1 L G— =� / .�o og�-� /O 2 y 93 C,� S'BAe�✓srA 8� A.vo 457 /47- L VT >aS o cQ 76� /0• 29.9.3 aA X7;E.2s Tf//S P,C�I�v/S�l/o�'g,4SE0 d�v Ate!/ �2EG/STE.2El� !-�4�/O SU.eliEyat� 7-/7/,C �STE.2Y/,Cl�a Hl.4SS. O��S'ETS Sh��L�/y•;$,�,(DVLD ,tlp7-- 8� . !/.S6I� 7'� OET��•j/�E .Lf>T�/NHS QO.�,L/C,�1it/T �i4 cs/D� ,8rJ/!1�� c.v COMMONW.EALTH OF MASS ACHUSETTS DEFARINMEN?OF LNDUSTRIAL ACCIDE 600 WASHINGTON STREET Car-nDOel: BOSTON, MASSACHUSET IS 02111 ;$Slone• WORKERS' COMPENSATION INSURANCE AFFIDAVIT 7 nsec/perminee) _ a principal place of business/rrsidenee ac d,263a (Gry/Smtemp) reby terrify, under the pains and penalties of perjury,than. am an employer providing the following workers' compensation coverage for my employees working on this nce Company Policy Number am a sole proprietor and have no one working for me.. . am a sole proprietor, ncnl contnaor r homeowner (circle one).and have hired the eontnaors lined below gave the following wor ers compensation insuranm politics: of Contnaor Insurance CompanylPolicy Number .. of Contnaor Insurance Company/Policy Number 1 of Contnaor Insurance Company/Policy Number m a homeowner performing ail the work myself. NOTE_ .!'leas,- be aware tiat wb1Ic bamcc-men woo emoiov persons to do mainteaao Cr.'cc ast MCI ioo or repair-aM on a C of not more tint tdree unto to worcL Ibc iorne-owncr aiso resides or on the wounds appurtcnant thereto arc not rC1)er3ll,1' rrd to be empioven under tic Q'oricen' Comor sauon Act (GL C. 152.sea. 1(5)). appiieatioo by a bomeowoer for a lieensc it may eYracacc the 1co sums of am employer under the Woricen' Compensation Act_ snd :hat : copy o;this scat=ncnt w1U be forwarded to the Deoar-cement of Ind Aecdeno' Ofnca of lnsurane for mac ta iron an., :ha: ruium to secure coyeruc as rceuircc unoe: Seenon 25A or MGL 15: an Ieac to the impo iuon of a=izLi per:a)ues ne or: sine or ur to S1500M and/or impruon=tnt or up to one va anc raw m pcnaiues in the for or a Stop'Worc Oral~ ane a •I OMB a day a€a:ns: me. FT E�e l f( EEE��- - II i I. v ; I t i � a iI I � I i i ) I I � . 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