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Home My WebLink About0147 BRISTOL AVENUE Aw. l r Town of Barnstable Final Inspection Affidavit Date: Thomas Perry, &0 Building Division 200 Main Street Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, This affidavit is t certify that eAl work completed at: Street: t v Village: has been ins ected b a certified it Y Building Performance Institute BPI Inspector. All work g (BPI) P performed meets or exceeds federal and state requirements. Permit applicatio nury ber:2AI D(�� 1'1 Issue date: 0A I; Sincerely, Francis Sheehan President Frontier Energy Solutions, .Inc. - 502 Harwich Road Brewster, MA 02631 Office: 774-237-0410 Email: fssfrontierenergy@gmail.com �'THE p0�nflll"rown of Barnstace ble *Per # ,,g�' G 4 Ex�i m issue date , �T + BMWSUBLE ' 201�. Mass. �' �T 2 5 Thomas F.Geiler,Director s0;9. prFO MA'S& __ _.:. --...-- ---- - _ - - .............- Building Division TaNN OF 5 Tom Perry,CBO, BuildingCommissioner., _ 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-463 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address ❑Residential Value of Work 69614JZz Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address U e c z Contractor's Name Telephone Number ` 3 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable)v RC ❑Workman's Compensation Insurance Check one: I am a sole proprietor I 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 Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors 'E'Replacement.Windows/doors/sliders.U-Value_ ('3 (maximum.35)#of windows 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:\WPHL.ESTORMS\building permit forms\EXPRESS.doc Revised 053012 y 3, }} y it x vk Ili / r R p 1 . + * 4{n t J/ ^ e ulation r� F usiness 1Z g a� of Consumer Affairs are � : . 5170 OTIce ��M e to P.ark'P1aza f;us_02116 lgassady i I Boston; w e istration rovement,C tl °r.R g 114141 i Hp111e IITlp _ — Registration: Ind! vidual 215051 TYpn 81812013 4, Expiratio . Z s All, ro DON KEITH ALD KEITI--, �.. 4—h pON CMA61E RD 154 CAPT " � y j` NISPORT n;1A 02639 �!,r �� Update Address and return cardEm �kn►e "� Lo DEN r> �` Address Renewal. [j 50M 04104•G101216 R -.,pPS-CAI Y1 assachusetts- Department of Public S fett' k Board of Buildinl- Regulations and Standardsi" Construction Supervisor License. f ir'" Licerlse: CS 22393 n DONALDA KEITH 154 CAPT CHASERD DENNISPORT, MA 02639 ,E ; Expiration: 10%1/2013 k. ('ommissiuner Tr#: 5432 The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations - 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/Organizadon/Individual):�Jd iv Address: /Y City/State/Zip•-%�y i f �� : :�� 3!� Phone.#: (C/7 i `� ��zw 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 employees(full and/oz part time). * have hired the sub-contractors 6. ❑.New construction,. 2. I am a sole proprietor or partner- listed on the-attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have '8. Demolition working for in any capacity. employees and have workers' $ • 9. ❑Building addition [No workers' comp.insurance— required.] comp.insurance. 10. Electrical re airs or additions 5. ❑ We are a corporation and its ❑ p. 3.❑ officers have exercised their I am a homeowner doing all work 11.El Plumbing repairs or additions:. . myself. [No workers' comp. right of exemption per MGL , 12.0 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. $Contractors 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. 'I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob 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 certi nder thepains•and enalties of perjury that the information provided above is true and correct: Si ature: %� ' Date: Phone#: 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): .'L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6. Other Contact Pelson: Phone#: . .. oF�V�x * * • r * BARNSTABLE, Town of Barnstable __�_.. _-- _- _. 3.9 ♦ 7. - --- - -- - s Thomas F.Geiler,Director µ Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.ba rnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, A � �� , 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: 1 Y 19hS h--7p 6 (Address of Job) S ature o wner Date JVb(4 A kG Cl Print Nam If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on,the reverse side. Q:\WPHLES\FORMS\building permit forms\EXPRESS.doc Revised 070110 Town of Barnstable P p Re gulatory ulator Services g Y sAxrtsrnsLe• " Thomas F. Geiler, Director MASS. FVMF�A`� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 0260 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EX MPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home ph� # work phone# CURRENT MAILING ADDRESS: city/town / state zip code The current exemption for"homeowners"was exten d to include owner-occupied dwellings of six.units or less and to allow homeowners to engage an individual for hire who d,es 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%sbe 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 Department minimum inspection procedures and requirements and t at he/she will comply with said procedures and requirements. Signature of Homeowner 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. 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\FORMS\building permit forms\EXPRESS.doc Revised 070110 'h TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 91 -7 Map :2�'I Parcel f .d ..Application # ot�6(P Health Division Date IssuedAl ' Z - Conservation Division rc' Application Fee ,v Planning Dept. Permit Fee. Date Definitive Plan Approved by Planning Board _ Historic - OKH Preservation/ Hyannis Project Street Address 4 BR1 STDL AV E Village H48NNIS Owner -TUD1 'R ff M1 Address 1 Ll"1 5 VuSf`Tb L ft F Telephone _ Permit Request PDT 7-% I C1 C, JULWLO5JF 1 NS. OPEN H'! c 56P5L AMD<- 1 en6 62M EN7 Square feet: 1 st floor: existing proposed 2nd floor: existing _proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �&0_0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family '❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑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: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No 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 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ¢N19, �1C�I� _ Telephone Number 33�1-S 32 2,1b 13 Address 3 71a TZl'EF 13 D Su Z�g ITE G License # D SftLJ>W iCH , mA 62563 _ Home improvement Contractor# t 66 SSY Worker's Compensation # (P D1 SCI S L4 01 Z 012 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 150-U R,1J E; L hNJD r-I 1. L_ SIGNATURE �,�yt�r1 .J DATEI— FOR OFFICIAL USE ONLY APPLICATION# ,,.:_DATE ISSUED -,�_;�-►. - _ i _.. '-MAP-/PARCEL NO. 5Y , ADDRESS VILLAGE OWNER'' DATE OF INSPECTION: G,_'FOUNDATION FRAME INSULATION y,4 FIREPLACE 4. ELECTRICAL: ROUGH FINAL f. 4 ' PLUMBING: ROUGH FINAL -- GAS:,r, ROUGH ,4� FINAL " ..iEJNAL.BUILDING :DATE CLOSED OUT ` ASSOCIATION PLAN NO. r The Commonwealth of Massachusetts Print Form Department of Industrial Accidents R - Office of Investigations 1 Congress Street Suite 100 . Boston MA 021I9-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansJPlumbers Apiplicant Information. Please Print Legibly Name(Business/Organization/Individual):'FRONTIER ENERGY SOLUTIONS ' Add ess:376 ROUTE 130, SUITE C City/State%Zip:SANDWICH, MA 02563 Phone#:339-832-2823 Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 8 . 4. [] I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. employees and have workers' 9 0:Building addition [No workers'comp..insurance comp, insurance.: required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 1.1 Plumbing repairs or additions myself o workers' right of exemption per MOL Y �. comp. 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 1.3.0✓ 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. $Contractors that check this:box must attached an additional sheet showing the name of the sub-contractors and sate whether or not those entities-have employees. Ifthe 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:AIM MUTUAL INSURANCE Policy#or Self-ins.Lic.#;60129r54012012 Expiration Date:7/25/2012 Job Site Address.: 147'BRISTOL AVE City/State/Zip: HYANNIS, MA 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 certi. under the airs and genalties o er'u that the in ormation provided above is true and correct s' Date 12/2/11 Phone#: 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#: DATE(IvOY1/DD/1'YY) . CERTIFICATE OF LIABILITY INSURANCE 10/18/2011 THIS CERTIFICATE IS ISSUED AS A MATTER of INFORMATION ALTER HEC COVERAGE0AFFORDEDUBYNTHEEPOLICIES BELOW.THIS CERTIFICATE CERTIFICATE 4:... or . DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, AUTHOAILED REPRESENTATIVE OR PRODUCER, AND THE INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), CERTIFICATE HOLDER. 71, is IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, tSe Pireean1endIs'L1,endorsement. statement on8thisTcertificateEdoes not t to the terms and conditions of the Policy, certain policies may require confer rights to the certificate holder in lieu of such end�orcemeunTt(s)- PRODOCER - "�' FAI Rogers & Gray Insurance Agency °;ONE No. 8NC): (A/C. No): E-MAIL Inc AODRSSE: PO Box 1601 PRODUCER CUSTOMER ION• NAIC N South Dennis, MA 02660 INSURED(S) AFFORDIND COVERAGE INSURER A: A.I.M. Mutual Insurance Co 33758 I14.eALE Frontier Energy .Solutions LLC INSURER B: 39 Siasconset Drive y INSURER D: .. Sagamore Beach, INSURER E: 1 N6UREft F: REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENNT WITH RESPECT TO WHICH THIS CE[tTIFICATE MAY BE ISSUED OR MAY THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUI T, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN pECRTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, bW HAVE BEEN REDUCED BY PAID CLAIMS. POLICY [X - LIMITS POLICY EFF Iw/Pe/YYYY) . - POLICY NUMBER (wrRD/Yxvr) ' ia TYPE OF INSURANCE 6 EACH OCCURANCE GENERAL LIABILITY DAMAGE TO RENTED 6- f PR@1ISfi6(Ee.�ec�Yreneel ❑.C•IN•�f::IA1.JEIJEIJ:L LIABILITY . MED ESP-IAnYperaon) 4 ❑OTC L.tiIFL.FNC•E �':J'CR'. . PERSONAL i ADV INJURY 6 OGENERAL AG=GATE 6 ❑EIEL A•IGI'.EVATE LIMIT APFLIE3 ER: - PRODUCYS-COMP/OP AM •I - 6 ❑E�:LI•-i ❑PF'JE•:T OL• E COMBINED SINME LIMIT 6 - ' lea aeddene) '. AUTCMOBILE LIABILITY BODILY INJURY (pee pataen) 6 . ❑AI•ri RUT'_ MALL iwIJED.AVM:': - BODILY INJURY(P.r Accid-L) S - ❑E:HECI�I.EL AV'D:• PROPERTY DAMAGE 6 . (PAY SNent) ❑NTREC•NJTiS 6 ❑ EACH OCCURRENCE 4 ❑LWRELLA LIAb CCUR _ AOOREGATE, 4 ❑E:v:E3:`. LIAD ❑ =LAIIti;4U1C•C 6 . ❑DECUC'Ii6LE 6 - -❑I:ETENTIC•N 4 ® EC ETAA- oTa- Y:uY 6l Na WORICrRS COMPENSATION - 1 000 000 AND EMPLOYEES LIABILITY E.L. EACH ACCIDENT 6 r r THE F'PoiYf;I ETOFt/FAF:TNEFSi - - - A E}:ECUTIVE OFFICES ARE - E.L. DISEASE-POLICY LIMIT 4 1,000,000 ❑ irl_1 ® a -=1 6012954012011 07/25/2011 07/25/2012 E.L. DISEASE-' EA RIPLOYEE 4 1,000,000 CONNOTE/DESCRIPTION OF OPEW1ONS OR LOCRTIONS:ALL MEMBERS ARE EXCLUDED FROM THE WORKERS'COMPENSATION POLICY. CANCELLATION CERTIFICATE HOLDER FCONSERVATION SERVICES GROUP sFFovLo ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EID?IRAT ION DATE THEREOF, NOTICE WILL BEDELIVEEtID IN ACCORDANCE WITH THE POLICY PROVISIONS. INGTON STREETAUTHORIZED'REPRESENTATIVE OUGH MA 01581 Js j 4 a Y x U azo " U Jl. N 9 C w O O 0 �- > c 0 CL ° O r^ i C7 Z 5 W ° a O cn a Y � o N ww +� w w U. w r = I u zv�sm _� w w waCo L O w Z O r.. e w O Y Z p ` w� ¢ ,a Z :t± 0 IM S.�...'LL In k License or registration valid for individul use onlyi before the expiration date. If found return to: Office of Consumer Affairs and Business Regufntion € 10 Park Plaza Suite 5170 F!; Boston,MA 02116 alid without�signatu i OWNER AUTHORIZATION FORM z . eJ (2 (Ow er's Name) owner of the property Located at (Property Address) (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my beha t'f obtain a building permit and to perform work on my property. Owner' i natur Date a AT Town of Barnstable *Permit# 66 l l V 0 IN Expires 6 months from issue date loth gulatory Services Fee (�F �� Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6 30 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint p/parcel Number V perty Address 4 Residential Value of Work h��/�. P Minimum fee of$25.00 for work under$6000.00 mer's Name&Address C/ // ,/o 4 ntractor's Name Telephone Number me Improvement Contractor License#(if applicable) nstruction 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 Insurance urance Company Name Aman's Comp.Policy# py of Insurance Compliance Certificate must be on file. ;mit Request(check box). ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ARe-side Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic.Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. GNATURE: iorms:expmtrg vise071405 The Commonwealth of Massachusetts Department of Industrial Accidents i Office of Investigations 11k;+� r a 600 Washington Street /- i< Boston,MA 02111 4 Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly 1�aMe(Business/Organization/rndividual): Address: /Y-7 /Y--r/ S (W S0 k 26 0 4(.n amity/State/Zip: 4 (i Phone #: D f 7 ,re you an employer? Check the appropriate box: Type of project(required): ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the'sub-contractors El am a sole proprietor or partner- listed on the attached sheet. $ ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. Y P n'• 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 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' 13.❑ Other comp.insurance required.] ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. (omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. )ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. im an employer that is providing workers'compensation insurance for my employees. Below.is the policy and job site formation. surance Company Name: dicy#or Self-ins.Lic.#: Expiration Date: b Site Address: City/State/Zip: ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Lilure to secure coverage as required under Section 25A of MGL c. 152.can lead to the imposition of criminal penalties of a ie 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 'up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. io hereby certify nder the pains a penalties ofperjury that the information provided above is true and correct ature: Date: lone#: 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#: , _� R �, r � �:,s .. � ,; �,- ,> � F. � ` ',��.` �. .. ,; -� :: r � q - - ��. �: - i � JY ,. - ° * �a- � __ ;: a ,_ � ;:; ' a ,,. , .,m _ ,. ,. _. ;�_ ,',��e�-;.,. � � :rdtitl.nf w'. '�s��:�'�5 _-` ,., ,; �;ti:'k" u��,'>4 ir� '1�� .-&'.�`P-+�,;� '0 z":t "�,�_ s.,:'' ��°'ra ,, e d��{ u9�. _ � � .. _ e � • • I ' I , e ; r 1 y v, r+�T , $F A r " .a R„ �` .� � � � f "�M "�'� •�e..m...t 'ilk..Ct �',`�� '3s, ifs x p � .. ... ;....rts .,4` �_ gym' •}-;�, '^"' � 5 's y SSW s ep x W P` `w ��, r •" r1 k + y , 12 - a, a urn } e a� 5" I p ' x a 1 `: \ `° 147 Bristol Ave. ,. Hyannis 11 /7/06 .:k: 6'�' w'?j i � t•,cam � � ^�" :'E . , x h<. q � b i i ' f y Y t f , , - s � a d #a = o e aG i � ➢ �Wl�14 < W 141 l �$; 4 ram: '' � � �. ,Ya�'"A "-" �'A � ,�s,_ I�. 'samkmm, •�"i: .�A"'°"r w,� ,�, !'l� '" b'y l° � , ��'� � �' .. ;"dv',� '" r „«�....e,n'RpImL�aiIM1 M. ..., x .. �, ... aI �ro nIA' , ... I' m t. nl*a� •� a.l „ n �o � r�� {�,'q ^ W uIR rinm �,a w a Oa < *rt t e , =a z � s_t �- tl t y v y yg� # u* Yn v , a Y A J � � t� r i a �!ik . a . 147 Bristol Ave. , Hyannis 11 /7/06 y W'S 1 E, �I � To L- 5,X, I� k 4 xF. / �f a s i�"• Mk. l S few � 4�Y l K Y s y 4-7