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Home My WebLink About1894 MAIN ST./RTE 6A(W.BARN.) IW717"41 S o UPC 12543 �a No. 53LOR HASTINGS, CAN �'.. ...� -..-...r•-.•_ -- ''` - _ - - - _ ten..,•Y',/�'�.• _ - ..r n ..• Wit':,... ...�. ... �._. _- - �... -:....- ., f3UILD111G DEP i Application number... .. .............. .. . . FEB Fe&.....L.(a18(U:..... s � V�1v v1- ur.i uvv 1At3LE TU Building Inspectors Initials...(W..................... Date Issued. ... ©.... Q.... ............ ............. .. ... . .. . — Map/Parcel......�:I.� TOWN OF BARNSTABLE SCANNED EXPEDITED PERMIT APPLICATION: FEB 1 1 1020 ROOF/SIDING/WINDO W S/DOORS/TENTS/STO VES/WEATHERIZATION PROPERTY INFORMATION Address of Project: A->q V 1�d ,� � ` /�dV'✓' d�`� NUMBER STREET VILLAGE ' Owner's Name: ��' J c �f� �fe�; Phone Number — / r I j—a —36z.-- oq Email Address: lnar'l� L t—i ti j, jA 6,Akr!/f ");, Cell Phone Number Project cost$ 2-6 co, . 46 Check one Residential_ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a boil ' ermit in ordance with 180 (AIR Owner Signature: Date: TYPE OF WORK 0 Siding 56 Windows (no header change) # 0 Insulation/Weatherization 0 Doors(no header change)# Commercial Doors require an inspector's review ED Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY11S IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X 'I?- V1 .fk'Xdditional tent dimensions can be attached on a separate piece of paper. vPurpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or> Yes No ,if yes, a gas,permit is required. Natural Gas Yes No , if yes,a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: CLY G� �� W J�y 7CZ Telephone Number ,5-0 - 3 6 Z -q ZO ��r Work number Z-Z/ 7.S43 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date 2-/o` 2 o2,p APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. y ' ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IF 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,/ Please Print Legibly Name(Business/Organization/Individual)' IN/YC7 0±A4 _ Address: c / ee City/State/Zip: �',� d.,oU OPhone#: �1� ._Z2, Are you an employer?Check the appropr' to box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 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.= required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 30offI am a homeowner doing all work icers have exercised their 11.❑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' 130Other �&/A/hou/S comp. insurance required.] *Any applicant that checks box#1 must also fill 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 such. tContractors 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.policy number. 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 ai and pen d of perjury that the information provided above is true and correct Signature: 7 Date: 2 `'/O rZV 29 Phone#: - — - — _ -- - - l�d �Z2./ 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#: t r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing 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 dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." 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 Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,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 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. Self-insured companies should enter their 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 the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant 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"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. 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 Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia oF1HE r� Town of Barnstable *Permit# P� Expires 6 months from issue date Regulatory Services Fee '* BARNSrABLE, 1639. �m� Thomas F. Geiler, Director �t P IT Building ]Division SEP — 2009 Tom Perry, CBO, Building Commissioner N' 200 Main Street,Hyannis, MA 02601 TOWN OF SARNSTABLE www.town.barnstable.ma.us Off ice: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2 v Property Address TT b c a �— Residential Value of Work Jd Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address Contractor's Name ----_— _ Telephone Number I Ionic Improvement Contractor License#(if applicable)__�� Construction Supervisor's License #(if applicable) ❑Workman's Compensation Insurance Check onc: am a sole proprietor ❑ t am the Homeowner - ❑ I have Worker's Compensation Insurance !nsurance Company Name fVA-tt0N()(-- GR19% IL-No i tl k Co rl,c pt`t Workman's Comp. Policy# / Copy of Insurance Compliance Certificate must be on file. Permit Request (check box) ❑ Re-roof(stripping old shingles) All construction debris will betaken to_&"5A, t� rdl ❑ Re-roof(not stripping. Going over existing layers of roof) ®Re-side 5 kV It—, ❑ Replacement,Windows/doors/sliders. U-Value (maximum .44) *where required: Issuance of this pennit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. i r A copy of the Home Improvement Contractors License is required. I SICNATURE;: — -- Q:'WITILESTORMS%building pennit lonns\EXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street , _ Boston,AM 02111' °�. www.mass.gov/dia Workers" Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationadividual): . Address: City/State/Zip: Phone.#: Are.you an employer? Check the appropriate box: :Type of project(required):. i.❑ I am a employer with 4. F1 I am a general contractor and I * have hired the sub-contractors 6 ❑New construction . employees(frill and/or part-time). 7, Remodelin 2'.L"J i am a'sole proprietor or partner- These on the'attached sheet ❑ g ship and have no employees These sub-contractors have g, Demolition ' -working for me in any capacity. employees and have workers 9 ❑Building addition comp. insurance.$ [No workers'.comp.insurance 10.❑$lectrical repairs or additions required.] 5. [] We are a corporation and its re 3.❑ I qu a homeowner doing all work . officers have exercised their 11.[]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 fill 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 such. tContractors that check this box must attached an additional sheet sbowing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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 maybe forwarded to the Office of Investi ations of the DIA for insurance coverage verification. X do hereby certify un a the pains and penalties of perjuty that the information provided above is tru and correct. Date: �� Si ature: r / Phone#:11 70fficialonly. Do not write in this area, to be completed by.city or town official.n: Termit/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#: JLA1A V A AAA 64 E.A"A% d JL&%A gttav n.a %AIL Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hiie, express or implied,oral or written." An employer is defined as "an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing 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 dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." 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." Addition-My,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�tlie 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-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies•(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members'or partners, are not required to carry workers' compensation insurance, If an LLC or LLP does have employees, 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 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. Self-insured companies should enter their 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 the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant 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" the applicant should write"all-locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate tc give us a call. The DepaFUnent's address,telephone-and fax numben The Commonwealth of M.a SWhusetts Dgparmimt of IndwWai Aeaidmts Offlcs of InvestigaUQUS 600 Wasl i atozi Street Boston,.MA Q2111 • . Tel. # 61 7-727-4900 ext 406 or 1-977-M.ASSAFE Fax#617-727-7749 Revised 11-22-06 - www.mass.gov/dia .N Town of Barnstable Regulatory Services BARNSTABLE, y MAB& g, Thomas F.Geiler,Director �'°lFpMpra`� Building Division Tom Perry,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) 7 -ZG 6 � Signature of Owmer Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:F0RMS:0 WNERFERMISSION Town of ]Barnstable mop SHE 1p�y Regulatory Services EARNsr,BLE. ; Thomas F.Geiler,Director . Building Division 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 DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code. The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended.to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes 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.Deparhnent ' minimum inspection procedures and requirements and that he/she will comply with said procedures and t—requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. 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 can t amend and adopt such a for ✓certification.for use in your community. a Q:forms:homeexempt 1 -'"�. Vi�issachusctts- 7ep. 1-tmcnt.of`Pulilie Sz'ifeN-; . Bo;ird..of•B,uildinu-Rclulat�i rjsw�ritl St indiir(l < ,Construclio.n`.Supervis '-SLicense; ` License GS SL 99406 •� d Restricted to: RF,WS,DM KIM BASSETT 3775 MAIN STREET CUMMAQUID, MA 02637 . Expiration: 1 2/1 21201 1 "i ('unuuissioiecr' Tr#: 99406 wN<� nrd of Ewldi ��.�✓�WAOiLfLQ F£T hct j .��y g Regulations and HOME IM�PPRROyE MEN- T dONT�RACTO�i L!censeor registration valid for indrvtdul tlso i before the'Pxptration date. If found return t�� Y RE9'stration� 159706` ' Board of Butldtng Regulations and Standards * s Exptrat�on—5'19/2010 One Ashburton Place Rrn]301 P Tr# 268660 _ ype.J:: -[Vidual i Boston,r4a•02108 KIM.M BASSE' a KIM BASSETT* 3775 MAIN ST ` zc 6y •ey Q Y..o. � Y:� ^� CUMMAQUID,MA 02637 Administrator - Not valid witbOut signature . I I , Town of Barnstable °6�3�5 *Permit;� Expires 6 months frorn issue date L Regulatory Services ..-Fee Od n Thomas F.Geiler,Director n eon . Building Division X-PRESS PERMIT. t1 Tom Perry,CBO, Building Commissioner SEP 15 2006. .. Q . 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us TOWN OF BA13NSTO- 9 6230 Office: 508-862-4038 EXPRESS PE RNIIT APPLICATION. - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint Map/parcel Number Property Address 6� d(�. Minimum .00 for'work under$6000.00 �tesidential Value of Work .� i fee of$25 , Owner's Name&Address Telephone Number. Contractor's Name HomelImprovement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor �I am the Homeowner ❑ I have Worker's Compensation onn Insurance Insurance Company Name �/r- Workman's Comp.Policy#: Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ction debris will be taken toed,& ,Re-roof(stripping old shingles) All constru ❑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,e� ***Note: Property Owner must sign Property Owner Letter of Permission. p of the Home r vement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 DepartmentofbidustiialAccidents ' Office.of Investigations: ' a 600 Washington Street t` Boston,MI 02111' S�• www-mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kPiplicant Information Please Print Lie 'bl value (Business/organizahon/Individual Address: i City/State/Zip: -Aay02466Phone#: 62— �?-d�• .re you an employer?Check the-appropriate box:: Type of project(required): ❑ J am a employer with 4, ❑ I am a general contractor and I 6. employees(fall'and/or part time). * have hired the sab-contractors ❑ New const<uction ❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me m any'capacity. workers' comp. insurance: 9. ❑ Budding addition [No workers' comp.insurance 5• ❑ We area corporation and its required-] officers have exercised their 10.7 Electrical repairs or.additions. I am a.homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions -myself-[No workers' comp.• - c. 152,§1(4), and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers- c6mp.imrran ce required.] 13.❑ Other. oy applicantthat checks box#i must alsp fill out the section below showing their workers'compensation policy infbrmation: `. iomeowners who submitthis affidavit indicating they are doing an work and then hire outside contractors must submit anew affidkvit indicating such mtraotors thatcheck this box must attached an additional sheet showing the name of the sub-contractors and their workers,comp.policy fnformation. . tm an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site formation. ,urance-Company Name: ]icy#or Self-ins.Lie.#: Expiration Date: b Site Address: City/State/Zip- tack a copy of the workers' compensation policy declaration page(showing the policy number and Expiration date). dure to.secure coverage as required under Section 25A of MGL c. 152 can:lead to the imposition of criminal penalties of a .e up to$.1,500,00 and/or one-year imprisonment, as well as civil penalties in llie form of a STOP'WORK ORDER and a fine- up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of iestigations of the DIA for insurance coverage verification. `o hereby cerdj�under the pa' s and perjury that the information provided above is true and correct attire:. Date: one#: 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 !..Building Department 3.'City/Town Clerk 4.Electrical Inspector'5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and. Instructions ^ L fassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. ursuant to this statute;an employee is defined as"...every person in the service of another under any contract of hire, Kpress or implied,oral or written." Ln employer is defined aP- an?mdividual P2T%e!bt,:association,coiporation'or other legal er<tity,-or any two or more f the foregoing-engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the eceiver or trustee of an individual,partnership,association or other legal entity,employing employees. However:tlie .caner of a dwelling house having not more than three apartments and who resides therein, or.the occapant of the welling house of another who employs persons to do maintenance, construction or repair woik-ou such dwelling house a on the grounds or building aPPurten?nt thereto shall not because of such employment be deemed tobe an employer." vlGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or •enewal of a license or.permit to operates business or to construct buildings in the commonwealth for any ipplicant who has not produced acceptable evidence-of compliance with the insurance coverage required." 4dditionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its-political subdivisions shall ,nter 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. 11 4pplicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if aecessary,supply sub-contractor(s)name(s),address(es) and phone number(s) along with their certifieate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orpartners,' are not required to carry workers compensation insurance. If an LLC or LLP does have 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 in the city ar 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 can the Department at the number listed below, Self-insured companies should enter their. 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 the Office of Investigations has to contact you regarding the applicant Please be sure'to fill in the permit/license number which will be used as a reference number. In addition, an applican# that nnest 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"llie applicant should write"all locations in (city or .town)."A copy.of the:affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that-a valid affidavit is-on file for.future p ermits•or-libenses..A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i e. a dog license or permit to bum leaves etc.).said person is NOT required m complete this affidavit. : The Offir *of Investigations would like to thank you in advance for your cogperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and,fax member: ' The Commonwealth of Massachusetts . Department of Indnsh ial.Accidents . . • '. . > .Office gf Investigations . - :600'Washington$treet . Y Boston,MA 02111 Tel.#617-727-4900 ext 406 or-1-877-MASSAFE r Fax#617-727-7749 evised 5-26-05 www-rnaSS.gOV/44