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0001 BROOKSHIRE ROAD
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Yes Is the business a sole proprietorship or home occupation? _________ Ye No If yes then a Home Occupation Registration is required—See Building Division Staff Name of Business �� T S Kol S UL�J X._)S1'A1V6'6 Business Address Type of Business S '� ss1 �(��✓ ,ems Q uildin Cissioner Off e Use Only omm Conditio (� Q t-Q e . S� Building Commissi i Date Clerk Office Use Only B uildiag Department Services 'X °fTHE T°w B dart Flo rence,CB °* Building Commissioner ' F BARNSTABLE, � 200 Man Street,Hyannis,MA 02601• buss wwmtown.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Name Phone# 7 7 a�g-Ll7f 7 Address: �f ge: kd�Name of Business: (��d N Type of Business: gcpd'�' Sj � Map/L.ot: 'JA r_ UA D TI'ENP: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation Within single family dwellings,'subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discemL-ble from outside the.dwelling. there shall be no increase in noise or odor,no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • •The activity is carved on by the permanent resident of a single fanny residential dwelling unit,located within that dwelling unit. •" Such use occupies no more than 4.00 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no-outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage.or use of toxic or hazardous materials,or flmmmable or explosive materials,i a excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equip== • There are no corn nercial vehicles related to the Customary Home Occupation, other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked m the same lot coutammg•the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shaTl bg employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. L the undersign ve read and agree with the above restrictions for my home occupation I am re ' • g. Applicau Date: aomeoo.doc Rm.06&0116 MUST COMPLY WITH HOME OCCUPATION RULES AND REGULATIONS. FAILURE TO COMPLY MAY RESULT IN FINES. mC+DEPARTMENT OF THE TREASURY INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0023 Date of this notice: 08-30-2018 Employer Identification Number: 83-1754732 Form: SS-4 Number of this notice: CP 575 A GOOD DADS ROADSIDE ASSISTANCE AL-JAMEER WHITE SOLE MBR 1 BROOKSHIRE RD For assistance you may call us at: HYANNIS, MA 02601 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN) . We assigned you EIN 83-1754732. This EIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 940 01/31/2020 Form 943 01/31/2020 If you have questions about the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. if you need help in determining your annual accounting period (tax year) , see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the .year at issue) . Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. If you are required to deposit for employment taxes (Forms 941, 943, 940, .944, 945, CT-1, or 1042), excise taxes (Form 720) , or income taxes (Form 1120) , you will receive a Welcome Package shortly, which includes instructions for making your deposits electronically through the Electronic Federal Tax Payment System (EFTPS) . A Personal Identification Number (PIN) for EFTPS will also be sent to you under separate cover. Please activate the PIN once you receive it, even if you have requested the services of a tax professional or representative. For more information about EFTPS, refer to Publication 966, Electronic Choices to Pay All Your Federal Taxes. If you need to make a deposit immediately, you will need to make arrangements with your Financial Institution to complete a wire transfer. (IRS USE ONLY) 575A 08-30-2018 GOOD B 9999999999 SS-4 The IRS is committed to helping all taxpayers comply with their tax filing obligations. If you need help completing your returns or meeting your tax obligations, Authorized e-file Providers, such as Reporting Agents (payroll service providers) are available to assist you. Visit the IRS Web site at www.irs.gov for a list of companies that offer IRS e-file for business products and services. The list provides addresses, telephone numbers, and links to their Web sites. To obtain tax forms and publications, including those referenced in this notice, visit our Web site at www.irs.gov. If you do not have access to the Internet, call 1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office. IMPORTANT REMINDERS: * Keep a copy of this notice in your permanent records. This notice is issued only one time and the IRS will not be able to generate a duplicate copy for you. You may give a copy of this document to anyone asking for proof of your EIN. * Use this EIN and your name exactly as they appear at the top of this notice on all your federal tax forms. * Refer to this'EIN on your tax-related correspondence and documents. If you have questions about your EIN, you can call us at the phone number or write to us at the address shown at the top of this notice. If you write, please tear off the stub at the bottom of this notice and send it along with your letter. If you do not need to write us, do not complete and return the stub. Your name control associated with this EIN is GOOD. You will need to provide this information, along with your EIN, if you file your returns electronically. Thank you for your cooperation. Keep this part for your records. CP 575 A (Rev. 7-2007) Return this part with any correspondence so we may identify your account. Please CP 575 A correct any errors in your name or address. 9999999999 Your Telephone Number Best Time to Call DATE OF THIS NOTICE: 08-30-2018 ( ) - EMPLOYER IDENTIFICATION NUMBER: 83-1754732 FORM: SS-4 NOBOD INTERNAL REVENUE SERVICE GOOD DADS ROADSIDE ASSISTANCE CINCINNATI OH 45999-0023 AL-JAMEER WHITE SOLE MBR 1 BROOKSHIRE RD HYANNIS, MA 02601 i I Mal Io.P W- ,A,1 L.�IL/ I i I I�! .mot// iaL./i, �,i/�/ �✓aL/ //L / /. ,L / � l RA -M" - WWI 2 0-4 WK,d, / "..eilam l . i 1'� Mae I WIN I I I J +m �ie -77 L-1 - DLO S -L II i i- i f roo 1� How to Start a Roadside Service Bizfluent Page 1 of 4 biz fluent _ ©X) 1 3 Easy Steps 1. Click'Start Now' 2. Free Access-No Sign up! 3. Get Free Templates Yourtemplatefinder.com How to Start a Roadside Service byKatebo-Updated September 26,2017 A roadside service business requires you to be available 24 hours a day,seven days a week.Customers will need you to unlock their cars,jumpstart dead batteries,bring them gasoline,repair a flat tire or tow them to the closest auto mechanic. Items you will need Gas can Tow truck Jumper cables Locksmith tools Map Cell phone Flat tire repair tools Obtain all the tools of the trade.You will need a reliable tow truck,large gas can,locksmith tools,flat tire repair tools and jumper cables.Of course you must also know how to use these tools or hire someone who does.Or you can subcontract out some of the specialty work such as locksmith work.If you can afford to,purchase a flatbed tow truck so you will be able to service more customers with large vehicles. Apply for a merchant account online and purchase a credit card machine.Charge set fees for each type of service you offer.Add a surcharge to any late night services.If you hire an employee to cover the late-night shift,take that added expense into consideration when setting your evening surcharge price. Define your coverage area.Decide what is the farthest you wish to travel to service a customer.If it's 25 miles,then take a map and draw a 25-mile radius circle around your home to define your coverage area. Check with th.eaocal police departments to see ifthere are'any-roadside_assistance:restrictions<in;force m your;Eove;tag a ea 7When,you speak,to the.police,a'sk how;to get'on their;call list forwhenathey need.to call roadside as-sistdnce o a scene foran' �4•= ardent Check out your competitors and see how they market themselves or what special services they offer. Advertise on roadsideservice.com,craigslist.org,the yellow pages and in your local newspaper.You may also consider affiliating yourself with companies like AAA,Allstate Motor Club,or Best Roadside Service. Set up a business phone number and cell phone dedicated just for business and answer your phone 24 hours a day.If you are in a rural area that doesn't get cell phone reception,you may need to get a CB radio for your driver to communicate with you at your home base as well as a dedicated landline with a business phone number for receiving calls. Tips Call a small roadside service company in a neighboring city to ask questions about their business.Because you won't be competitors,you may be able to find a small business owner who will mentor you. If you can afford it,consider purchasing a franchise for a quick start-up with less trial and error. Warning https:Hbizfluent.com/how-5882569-start-roadside-service.html 9/5/2018 i rr, t How to Start a Roadside Service I Bizfluent Page 2 of 4 It may be hard to compete with companies who have!a large customer base and"can offer services to their members for a flat yearly membership fee. References • Gaebler;.com:Opening a Roac side Assistance Eusiness Resources - Roadside Service,a naticnwid-e directory of roadside service companies About the Author Katie B.Marsh is a self-publisied aithor,article writer,screenwriter,and inventor.After graduating from South Coast College of Court Reporting,she worked ss a congressional and,freelance court reporter for eight years.She began her writing career in 2005. Her content may be found or amazon.com,booksfcrsharing.com,and ezinearticles.com.She completed her first screenplay in October 2009. [D AdChoices Car Roadside Assistance How to Set Up Own Companv Repair and Service To Start a Small Busi less Business Service To Emergency Roadside Related Articles y A rs o %`, zr f g9,v.� fit.•"� � �" ^5 � '���i { i a ye x b 44.1% ""�t'' How to Get Insurance fora Car Rental Business What Is Garage Liability Insurance? il -r -41 , h r �P y Y, ; r, , t https://bizfluent.com/how-5882569-start=roadside-service.htm1 9/5/2018 . "° Town of Barnstable Building g Post�This,Card So-,That rt,is�U�slbleFrom the treet-:A ; roved:Plans MusLttbe�Retamed on lob and this Ca�d�Must bey e`t> T NAM Rosted..Until i6 4 Inspect>on Has Been.Made. :j � � .:,Y ; ., .. _ram+ Wherea°Certificate of Occupartcy�s Requiresuch 8u�ldirt shall Not.be.Occu ied,until,a-,F.mal.lns ect�on has beensmade Permit � . Permit No: B-18-2411 Applicant Name: Rebecca Collins '4 Approvals Date Issued: 08/01/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 02/01/2019 Foundation: Location: 1 BROOKSHIRE ROAD,HYANNIS Map/Lot: 328-028 Zoning District: SF Sheathing: Owner on Record: BARNSTABLE HOUSING AUTHORITY R Contractor Name REBECCA L COLLINS Framing: 1 a Address: 146 SOUTH STREET A� Contractor License CS 072020 2 HYANNIS MA 02601 � � Est Project Cost: $28,674.00 Chimney: Description: SIDING,TRIM AND WINDOW REPLACEMENT h PermrtFee: $160.00 x r Insulation: Project Review Req: ' Fee Pald.- $ 160.00 8/1/2018 Final: rDate �' Plumbing/Gas Rough Plumbing: -._: ' BuildingOfficial • x Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authoniedll b,this permit is commenced within six months afterissuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction document c� rwhich this permit has been granted. All construction,alterations and changes of use of any building and structuresashall be in compliance with the local zoning by'Flawsand codes. Final Gas: This permit shall be displayed in a location clearly visible from access streetor Tod shall shall be maintained open for public mspectwn for the entire duration of the work until the completion of the same. y k. Electrical The Certificate of Occupancy will not be issued until all applicable signatueesA the Build ng�and Fire Offiaa�ls are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing `;� u'r Rough: 2.Sheathing Inspection ' ftrih!" s �" .. 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: "Persons contracting 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: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT z"Erg Town of Barnstable 200 Main Street Tel.(508)862-4038 1HA3S: a '°TfoMa<A`0� INSPECTION REPORT Permit: Building - Sid ing[Windows/Roof/Doors Use: Date: 7/26/2018 8:37 AM Inspector: barrowsd Permit Number: TB-18-2411 Name: BARNSTABLE HOUSING AUTHORITY Address: 1 BROOKSHIRE ROAD, HYANNIS Unit No. Inspection Type Inspection Item Status Comment Building Admin - BA- Property Owner NIC need owner authorization Construction Authorization, if Builder is Applicant Inspection Overall Comment: Overall Inspection Status: FAILED Re-Inspection Date: s: Inspector Signature Owner Signature Total Score: 100 Town of Barnstable REc�i3PT " 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit E� Application No: TB-18-2411 Date Recieved: 7/25/2018 Job Location: 1 BROOKSHIRE ROAD,HYANNIS L Permit For: Building-Siding/Windows/Roof/Doors Z —.1 Contractor's Name: REBECCA L COLLINS State Lic. No: CS-07020 r— Address: FALL RIVER, MA 02722 Applicant Phone: (508) 678-5201 o0 (Home)Owner's Name: BARNSTABLE HOUSING AUTHORITY Phone: (508),771-7222 (Home)Owner's Address: 146 SOUTH STREET, HYANNIS,MA 02601 Work Description: SIDING,TRIM AND WINDOW REPLACEMENT Total Value Of Work To Be Performed: $28,674.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Rebecca Collins 7/25/2018 (508)678-5201 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $28,674.00 Date Paid ( Amount Paid Check#or CC# F Pay Type Total Permit Fee: $160.00 7/25/2018 $160.00 +)XXXX-X)00"-?C{ Credit Card ........ ......... ..: ... .... 1239 Total Permit Fee Paid: $160.00 . I ►.` ��� '���` THISIS�N�OT-� PERMIT �- � �� � �� - ... r- -`- -- r --- � ��� � 3 � �� � �� `�� TOWN OF BARNSTABLE Building 201 1 102844 • * BARNSTABLE, # Issue Date: 06/21/11 Permit 9 MASS. qj i63 Applicant: TONELLO,JEFFREY R Ar�O MAC A Permit Number: B 20111260 Proposed Use: HOUSING AUTHORITY Expiration Date: 12/19/11 Location 1 BROOKSHIRE ROAD Zoning District SF Permit Type: RESIDENTIAL INSULATION Map Parcel 328028 Permit Fee$ 35.00 Contractor TONELLO,JEFFREY R Village HYANNIS App Fee$ 50.00 License Num 53202 Est Construction Cost$ 1,500 !`— Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND WEATHERIZATION.AIR SEALING,WEATHER STRIPS.DOOR SWEEPS THIS CARD MUST BE KEPT POSTED UNTIL FINAL ATTIC INSULATION ADD R-19 CELLULOSE INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: BARNSTABLE HOUSING AUTHORITY BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 146 SOUTH ST INSPECTION HAS BEE ADE. HYANNIS,MA 02601 Application Entered by: TP Building Permit Issued By: THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR.ANY PART THEREOF;EITHER TEMPORARILY OR PERMANENTLY ENCROACHMENTS ON PUB RTY,NO SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE:NRISDICTION, 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 TIES PERMIT DOES NOT:RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE'SUBDIVISION , .RESTRICTIONS MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). - 5. INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ao t qq Map _5Z'$ Parcel ozS Application # Health Division Date Issued " Conservation Division Application F Planning Dept. Permit Fee - Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address �,1no�_ Sea. Z Zo A 1 Village Owner Qk ,:" Address Telephone -3-oIq Permit Request o� , '� , z � Ccs�.., �. "Z C Q.wC._,> NZ, ,S , GcL�V�.oSE Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation t tbo. 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 �ci o Historic House: ❑Yes ❑ No On Old King'.s ighway:'-0 Ye!.EF ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other _.j Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) -3 Number of Baths: Full: existing 1 new Half: existing new'' Number of Bedrooms: Z. existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ C�Gas OiI ❑ 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 Z�.n _ —K ;as -c> Telephone Number 0 Address License# 5cac-aa�o�c. Ev-,e_4A 1, w,u. o Z Home Improvement Contractor# i bz i s�3 Worker's Compensation # w r-7-3 i s-3 i es ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# -DATEISSUED MAP/PARCEL NO. i ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME R: ' INSULATION ' FIREPLACE yfr ELECTRICAL: ROUGH FINAL f=4 PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 1 FINAL BUILDING ` DATE CLOSED OUT ASSOCIATION PLAN NO. t i l I!M[ASSISTANCE FNMGY '- HWNIE 1"UTAIR ION , , ( rr CORPORAI f t, i�il cs,� 7iit'S HOME OWNER WEATHERIZATION WORK PERMIT&FUEL RELEASE: PLEASE FILL OUT AND SIGN TICS FOB IF YOU ARE THE APPLICANT HOME OWNER. I V)h€ a;.fi hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation (herein after referred as "Agency") on the property located at: 1 � SHE s-r 9� The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather-stripping&caullang of windows and doors,insulation of attics, sidewalls&basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows.In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to the "Agency"its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five(5)years after the weatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. Home Owner: (Signature) y_ r Date: :3IBe ? i F Agent: (signature) Date: 3 a HAC approved Weatherization Company: Caliber Building&Remodeling Cape Cod Insulation Cape Save Creswell Construction Frontier Energy Solutions Lohr&Sons Peter Smith esolution Energy Rock Solid Construction All Cape Insulation 460 West Main Street HOUSING Hyannis, MA. 02601-3698 Y ETIERGX & HONE REPAIR ASSISTANCE 2 (508) 771-5400 F (50.8) 790-2425 CORPORATION TlY on all lines www.haconcapecocl.org LANDLORD TENANT �- >4r —T- Pik PHONE PHONE Dear Landlord, Your tenant is eligible for services through the Weatherization Program. Program regulations permit us to spend an average of$5,000.00 in materials and labor per dwelling unit Program regulations require us to weather=strip and caulk doors and windows; insulate attics, sidewalls and floors. All work is professionally done by established private contractors. We will conduct a final inspection to make sure that all work is completed to specifications. Prior to making the inspection and doing the work we must have your permission. If you want your tenant to participate in the program, please sign the agreement and return the form to me_ This agreement states that: 1. You will not raise the rent because of the Weatherization work or for one year from the time the work is completed. 2. You will not evict your tenant for one year following work completion date except for good cause related to the tenant's failure to pay rent or serious or repeated violation of the terms of tenancy. 3. If you sell the property during the specified period, either the new owner must assume the obligations under the agreement prior to sale, or you must refund to us the entire amount of materials and labor we spent in weatherizing the unit. If you request, you will be informed of the estimated measures before they are done and provided with a list of the actual measures and costs following the completion of the work- We also need proof that you own the property. A copy of a CURRENT TAX BILL.OR DEED listing you as the owner will satisfy this requirement Please fill in all blank areas of the enclosed agreement and return with the proof of ownership as soon as possible. Failure to fill out the entire form will result in a delay in processing the application. If you have any questions please call Michael Sartori at 508-771-5400, ext. 105. Sincerely, 't"s21(aa& b , Ruth Bechtold Assistant Director u; a Energy and Home Repair De artn ent Ck M —. Doc umt t�,,1?;.• `sej Landloj-d_T nanL_comr"GI_';e! 'r 11. For breach of this Agreement by the Property Owner, the Property Owner shall reimburse the Agency in an amount equal to the cost, as certified by the Agency, of the Weatherization materials installed and labor performed on the premises, as well as attorney's fee and court costs. The Property Owner may also be liable for damages to the Tenant in accordance with appftcable law; in such instance,the Property Owner shall reimburse the Tenant fnr attorney's fees and court costs. Without limitfnq the foregoing,the Agency may at its option terminate this Agreement, by providing written notice to the Property Owner and Tenant, in the event of breach by the Property'Owner or Tenant. 12. Performance of the Weatherization work hereunder by the Agency is contingent upon the availability of funds to the Agency from the commonwealth of Massachusetts and the federal.government, as well as the eligibility of the Tenant under WAP.program requirements- The Agency may terminate this Agreement, by providing written notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility of the Tenant warrants termination. 13. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor.Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement. Property Owner' .r -� >r. Date ... �_..�...2 Signature: > � t.�.r �� �.c._¢-- --�..--- LL— Phone: ) Address- d am fta bole Housing Authority - Hyannis, MA 02601 Tenant Signature Date Agency Signature i ' Date, )/ G d .�`l I TENANT/PROPERTY OWNERIAGENCY WEATHERIZATION AGREEMENT 1. The Parties to this Agreement are the following: (hereafter known as Tenant)," (print your tenant's name) (hereafter known as Property Owner) (print your name) and Housing Assistance Corporation(hereafter known as Agency). In consideration of the mutual promises hereafter stated,the Parties agree as follows: 2. The date of Agency's signature will be the effective date of this Agreement 3. Property Owner and Tenant consent and agree that the Agency may do the following with respect to the property located at(street;town) unit# ,and currently leased or rented to the Tenant a) Enter the premises for the purpose of performing a Weatherization inspection. b) Enter the premises to perform Weatherization work which the Agency determines in its discretion is necessary and appropriate as a result of the Agency's inspection of the property and in accordance with the appropriate priority list for the type of dwelling. The Agency and the Agency's contractors may also enter the appropriate common areas of the building for the purpose of accomplishing the Weatherizabon work. The Agency and representatives of the Commonwealth of Massachusetts,Department of Housing&Community Development(DHCD)may further enter the property to inspect any and all work hereunder. The Agency will provide reasonable notice of the timing of the Weatherization work and inspections. The Weatherization work will be performed in accordance with the. Property Owner's consent as further specified below. INITIAL ONLY ONE OF THE FOLLOWING''r I consent to performance by the Agency and its contractors of any y� Weatherizabon work determined necessary and appropriate by the Agency as a result of its inspection of the property. I understand that the Agency will provide (I a detailed statement of the actual work performed and the associated value at t the completion of work I will provide a separate consent to performance by the Agency and its contractors of Weatherizabon work following my receipt of the Agency's inspection report and a statement of the estimated work and associated value. This additional consent will be sent under separate cover as Attachment A. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work. 4. The Property Owner understands and agrees that any and all work,including related repairs for which the Property may also be eligible,will be performed at the Agency's discretion. The Agency estimated completion of the Weatherization work by the end of 2010. 5. If the Property Owner is required to make repairs to tte property prior to the commencement of Weatherization work by the Agency,the Property Owner will be notified by the Agency and will be required to make the repairs as soon as possible. Except where the Property Owner receives a written extension from the Agency,time is of the essence in the performance of repairs by the Property Owner. r I 6. The Property Owner and Tenant authorize the Agency to receive a statement from the fuel supplierlutility supplier as to the quantity of fuel/utilities used at the above address in each of the.past three years and the future three years. The information is to be used only to determine the cost effectiveness of the Weatherization improvements. 7. The Property Owner agrees that the rent for the dwelling_unit will not be raised because of any increase in the value thereof due solely to the Weatherization work performed. 8. In consideration of the Weatherization work hereunder,the Property Owner further agrees that upon the effective date of this Agreement and during a period extending through 2009110,.approximately one year from the time the work is completed, a) The present rent Oer month will not be raised for any reason. (The rent amount must be filled in). However,this Paragraph(8a)will be waived by the Agency in writing if,and only if,the premises are leased under a state or federal rent subsidy program,in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program Please state which Housing=Subsidy program your tenant is on and through Ag which ency: " l( `S'Acr14Q - �-S a ri b) The Property Owner will not institute any summary process action for possession_ except in the case of non-payment of rent or other good cause related to the Tenant(or any successor Tenant). c) In the event the Property Owner decides to sell the premises, Property Owner shall comply with one of the two requirements below: --The Property Owner shall not sell the premises unless the buyer agrees(with a copy forwarded to the Agency) in writing prior to sale to assume all obligations of the Property Owner set out in this Agreement; or --The Property Owner shall pay the Agency an amount equal to the cost,as certified by the Agency, of the Weatherization materials installed and labor performed in the premises as of the date of sale. Said amount shall be paid to the Agency immediately upon sale. 9. (Applicable only if Tenant's heat is included in rental payment and blanks are filled_ in) At the end of the period set forth in Paragraph 8 above,the rent shall not be raised more than_...._ %per -.... _ for an additional period of one year, and the provisions of 8b and 8c above shall continue in effect for such period. However,the rent provisions of this Paragraph 9 may be waived by the Agency in writing jf, and only if, the premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program. 10. The Parties agree that the terms of this Agreement are incorporated into any other lease or agreement between the Property Owner and the Tenant, and between the Property Owner and any successor Tenant, and if there is any conflict between the provisions of this Agreement and the provisions of such other lease or agreement, the provisions of this Agreement shall govern. However, if such other lease or agreement, including without limitation a lease or agreement under state or federal rent subsidy program, contains stronger protections for the Tenant, such stronger.protections shall apply. US I 1` G ASSISTANCE C. z s ����.? �.TA ON i �_l t on oll Ili ie, I!'1.!'�t'. +::rC"' ;�'!c'c: ii HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN U&S FORM IF YOU ARE THE APPLICANT HOME OWNER. I ,f,E e i-A hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation ( herein after referred as "Agency") on the property located at: j-4fA,3 i The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather-stripping & caulking of windows and doors,-insulation of attics, sidewalls &basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows.In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to the "Agency"its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (S) years after the weatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. Home Owner: (Signature) Z-14 Date: Z3 7<>1 r G' J Agent: (signature) ----_. Date: !; f -,-11 HAC ztpproved Weatherization Company: Caliber Building&Remodeling Cape Cod Insulation Cape Save Creswell Constriction Frontier Energy Solutions Lohr& Sons Peter Smith esolution Energy Rock Solid Construction All Cape Insulation i 460 West Main Street L HOUSING Hyannis, M_A 02601-3698 o ENERGY & HOME REPAIR 1v ASSISTANCE r 508) 771-5400 F (508) 790-2425 ''Y{yj4b, f9s':1 CORPORATION TTY on all lines WlvX7.haconcapecocl.org arc 'Cape C'.a� i � It � I► LANDLORD je TENANT cwti j_c' c .emu z Q fl �1� _ • ' PHONE PHONE �7 -� U " 3d.0'7 Dear Landlord, Your tenant is eligible for services through the Weatherization Program. Program regulations permit us to spend an average of$5,000.00 in materials and labor per dwelling unit. Program regulations require us to weather-strip and caulk doors and windows; insulate attics, sidewalls and floors. All work is professionally done by established private contractors. We will conduct a final inspection to make sure that all work is completed to specifications. Prior to making the inspection and doing the work we must have your permission. If you want your tenant to participate in the program; please sign,the agreement and return the form to me- This agreement states that: 1 You will not raise the rent because of the Weatherization work or for one year from the time the work is completed. 2. You will not evict your tenant for one year following work completion date except for good cause related to the tenants failure to pay rent or serious OF repeated violation of the terms of tenancy. 3. If you sell the property during the specified period, either the new owner must assume the obligations under the agreement prior to sale, or you must refund to us the entire amount of materials and labor we spent in weatherizing the unit. If you request, you will be informed of the estimated measures before they are done and provided with a list of the actual measures and costs following the.completion of the work- We also need proof that you own the property. A copy of a CURRENT TAX BILL OR DEED listing'you as the.ownerwill satisfy this requirement Please fill in all blank areas of the enclosed agreement and return with the proof of ownership as soon as possible. Failure to fill out the entire form will result in a delay in processing the application. If you have any questions.please call Michael Sartori at 508-771-5400, ext. 105. Sincerely, . '.'!1 aP Ruth Bechtold Assistant Director Energy and Nome Repair Department Q .• ` � i its-i c? + 1',1•.t1S�I'�'77i�1 t;,ri`.`t� Documenis', ccise Lendlo3-d T--nal)t_contr"c, lft — II TENANT/PROPERTY OWNER/AGENCY WEATHERIZATION AGREEMENT 1. The Parties to this Agreement are the following: (hereafter known as Tenant), (print your tenant's name) (hereafter known as Property Owner) (print your name) and Housing Assistance Corporation(hereafter known as Agency). In consideration of the mutual promises hereafter stated,.the Parties agree as follows: 2. The date of Agency's signature will be the effective date of this Agreement 3_ Property Owner and Tenant consent and agree that the Agency may do the following with respect to the property located at(street,town) ,unit# .and currently leased or rented to the Tenant: a) Enter the premises for the purpose of performing a Weatherization inspection. b) Enter the premises to perform Weatherization work which the Agency determines in its discretion is necessary and appropriate as a result of the Agency's inspection of tha property and in accordance with the appropriate priority list for the type of dwelling. The Agency and the Agency's contractors may also enter the appropriate common areas of the building for the purpose of accomplishing the Weatherization work. The Agency and representatives of the Commonwealth of Massachusetts,Department of Housing&Community Development(DHCD)may further enter the property to inspect any and all work hereunder. The Agency will provide reasonable notice of the timing of the Weatherization work and inspections. The Weatherization work will be performed in accordance with the Property Owner's consent as further specified below. "*INITIAL ONLY ONE OF THE FOLLOWING'"`* I consent to performance by the Agency and its contractors of any y� Weatherization work determined necessary and appropriate by the Agency as a result of its inspection of the property. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of work. I will provide a separate consent to performance by the Agency and its contractors of Weatherrzation work following my receipt of the Agency's inspection report and a statement of the estimated work and associated value. This additional consent will be sent under separate cover as Attachment A. understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work. 4. The Property Owner understands and agrees that any and all work,including related repairs for which the Property may also be eligible,will be performed at the Agency's discretion. The Agency estimated completion of the Weatherization work by the end of 2010. 5. If the Property Owner is required to make repairs to the property prior to the commencement of Weatherization work by the Agency,the Property Owner will be notified by the Agency and will be required to make the repairs as soon as possible. Except where the Property Owner receives a written extension from the Agency,time is of the essence in the performance of repairs by the Property Owner. i 6. The Property Owner and Tenant authorize the Agency to receive,a statement from the fuel supplier/utility supplier as to the quantity of fuel/utilities used at the above address in each of the.past three years and the future three years. The information is to be used only, to determine the cost effectiveness of the Weatherization improvements. 7. The Property Owner agrees that the rent for the dwelling.unit will not be raised because of any increase in the value thereof due solely to the Weatherization work performed. 8. In consideration of the Weatherization work hereunder,the Property Owner further agrees that upon the effective date of this Agreement and during a period extending through .2009/10,,approximately one year from the time the work is completed, a) The present rent$ � per mon ' will not be raised for any reason. (The rent amount must be filled in): However,this Paragraph (8a)will be waived by the Agency in writing if,and only if,the premises are leased under a state or federal rent subsidy program,.in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program Please state which Housing,Subsidy program your tenant is on and through which Agency: ' 1 O b) The Property Owner will not institute any summary process action for possession except in the case of non-payment of rent or other good cause related to the Tenant(or any successor Tenant)- c) In the event the Property Owner decides to sell the premises, Property Owner shall comply with one of the two requirements below: —The Property Owner shall not sell the premises unless the buyer agrees(with a copy forwarded to the Agency) in writing prior to sale to assume all obligations of the Property Owner set out in this Agreement; or —The Property Owner shall pay the Agency an amount equal to the cost,as certified by the Agency, of the Weatherization materials.installed and labor performed in the premises as of the date of sale. Said amount shall be paid to. the Agency immediately upon sale. 9. (Applicable only if Tenant's heat is included in rental payment and blanks are filled in) At the end of the period set forth in Paragraph 8 above,the rent shall not be raised more than %per 4 for an additional period of one year, and the provisions of 8b and 8c above shall continue in effect for such period. However,the rent provisions of this Paragraph 9 may be waived by the Agency in writing if, and only if, the premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program. 10. The Parties agree that the terms of this Agreement are incorporated into any other lease or agreement between the Property Owner and the Tenant, and between the Property Owner and any successor Tenant,and if there is any conflict between the provisions of this Agreement and the provisions of such other lease or agreement, the provisions of this Agreement shall govern. However, if such other lease or agreement, including without limitation a lease or agreement under state or federal rent subsidy program, contains stronger protections for the Tenant, such stronger protections shall apply. f 11. For breach of this Agreement by the Property Owner, the Property Owner shall reimburse the Agency in an amount equal to the cost, as certified by the Agency, of the Weatherization materials installed and labor performed on the premises, as well as attorney's fee and court costs. The Property'Owner may also be liable for damages to the Tenant in accordance with applicable law; in such instance,the Property Owner shall reimburse the Tenant for attorney's fees and court costs. Without limiting the foregoing, the Agency may at its option terminate this Agreement, by providing written notice to the Property Owner and Tenant, in the event of breach by the Property Owner or Tenant. 12. Performance of the Weatherization work hereunder by the Agency is contingent upon the availability of funds to the Agency from the commonwealth of Massachusetts and the federa[government, as well as the eligibility of the Tenant under WAP.program requirements. The Agency may terminate this Agreement, by providing written notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility of the Tenant warrants termination. 13. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement. Property Owner' �.`� ` Date__ Sig2,0 nature: -� c•¢W Z: -- Ll� Phone: Address: B, astable Housing Authority Hyannis, MA 02601 Tenant Signature Date Agency Signature Date,), �. �� - Nlussuchusctts- Dcpar-tment of Public Safet} _ ✓! 2' Board of Building Regulation, and Standards P. ze oorzozorzure a �rac -� Office of Consumer Affairs&Business Regulation I Construction Supervisor License HOME IMPROVEMENT CONTRACTOR License: CS 53202 4 Registration:.,-.; 162158 Type: Restricted to. 00 C.r Expiration:._._"f12612.013 Individual — JEFFREY R .TONELLO f„ JEFFREY R.TONBLI O.- PO BOX 1516 i SAGAMORE.BEACH; MA 02562 ` � �fi' JEFFREY TONELLO ti 60 STATE RD. j SAGAMORE BEACH,MA,02562 Undersecretary Expiration: 7/1412011 `- C'nnmiis inaci Tr#: 19157 - -- RgWicted to: 00 - •�U sirlcted -1 2]Family Homes I., I 1. ailure to possess a current edition of the [assachusetts State Building Code cause for revocation of this license. efer to: WWW.Mass.Gov/DPS A .. t r Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations W 600 Washington Street w F d9 w� Boston, MA 02111 www.mass.gov/dia Worker's compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ztsd ,o E ¢ .r s&3 c. Address: City/State/Zip: z _y% 2�s Via►"4 . `"-ca Phone#: Se'g Are you an employer?Check the appropriate box: Type of project(required): 1. Q I am a employer with- 4•❑ I am a general contractor and I have 6. ❑ New construction employees(full and/or part-time).* hired the sub-contractors listed on 7. El Remodeling the attached sheet.$ 2. E] I am a sole proprietor or partnership These sub-contractors have 8• ❑ Demolition and have no employees working for employees and have workers'comp. 9. ❑ Building addition me in any capacity.[No workers' insurance.$ 10. ❑ Electrical repairs or additions comp insurance required.] 5.❑ We are a corporation and its 11. Plumbing repairs or additions officers have exercised their right of ❑ ❑ I am a homeowner doing all work exemption per MGL c. 152§ (4),and 12. ❑ Roof repairs myself. [No workers' comp. we have no employees. [No workers' 13. Y05ther insurance required.] t 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 attach 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 is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: va, Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 32oo�r_ar �.2E v"2o�� 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 eby ce under the pa' s a enalties f perju that the information provided above is true and correct. Signature: Date: Phone#: o — $8 - =tv CP 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#: ACORD CERTIFICATE OF LIABILITY INSURANGF o9ioli2o1 (,781) 344-8578 ONILYCANDIFICONFERSCAT IS ISNOE R GH S UPON D AS A THE OF I CERTIF G'AOTI PRODUCER ' EXTEND NOT AMEND, C.L. Hollis Insurance Agency Inc ALTER THE CIOVERAGIEIAFFORDOED ES BY THE POLICIES ELOW.O 27 Glen Street Stoughton MA 02072- INSURERS AFFORDING COVERAGE NAIC# INSURER A:LIBERTY MUTUAL INSURED RESOLUTION ENERGY INC. INSURER BIALINERICA INSURANCE INSURER C: 43 Fieldwood Drive INSURER PO BOX 1490 _ — Sagmore Beach MA 02562— - INSURER E: COVERAGES THE POLICIES OF INSURANCE R CONDITION OF AO NY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ICERTIFICATE MAY BEDISSOU D OR MAY PIERTA REQUIREMENT,TERM THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUGH POLL II AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PouCY EFFECTIVE PoucY EXPIRATION LIMITS INSR ADVIL TYPE OF INSURANCE _ POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LTR INSRD EACH OCCURRENCE $ — GENERAL LIABILITY - DAMAGE TO RENTED $ PREMISES Ea occurrence COMMERCIAL GENERAL LIABILITY MED EXP(Any one person) S CLAIMS MADE OCCUR � PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS-COMPIOP AGG $ GEN'L AGGREGATE LIMIT APPLIES PER: . PRO- POLICY JECT LOC- 02/27/2010 02/27/2011 COMBINED SINGLE LIMIT $ 1,000,E $ AUTOMOBILE LIABILITY AWN5092655 (Ea accident) ANY AUTO / BODILY INJURY $ , ALL OWNED AUTOS - (Per person). — X SCHEDULED AUTOS BODILY INJURY - $ HIRED AUTOS - - (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) - AUTO ONLY-EA ACCIDENT $ GARAGE LIABILITY OTHER THAN EA ACC $ _ ANY AUTO AUTO ONLY: AGG $ __ EACH OCCURRENCE $ EXCESS/UMBRELLA LIABILITY AGGREGATE $ OCCUR CLAIMS MADE — $ DEDUCTIBLE $ RETENTION S WC STATU- OTH- A WORKERS COMPENSATION AND - WC2-31S-370523-039 09/02/2010 09/02/2011 TORYIIMITS ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500, ANY PROPRIETOR/PARTNER/EXECUTIVE 50-0-,' OFFICER/MEMBER EXCLUDED? / / / E.L.DISEASE-EA EMPLOYEE$ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,' SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS NATIONAL GRID CORPORATE SERVICES LLC DBA NATIONAL GRID, ACTION INC. COLONIAL GAS COMPANY AND N—STAR ELECTRIC ARE LISTED AS ADDITIONAL INSUREDS. CERTIFICATE HOLDER CANCELLATION ( ) — (508) 790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE T ATTN: MIEN F—XPIRAT10N DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO M. - 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,E HOUSING ASSISTANCE CORP FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON T 460 WEST MAIN STREET INSURER ITS AGENTS OR REPRESENTATIVES. _ .- AUTHORIZED REPRESENTATIVE JIM HYANNIS MA 02601-3698 ON (DACORD CORPORATION' ACORD 25(2001/08) Page INSOZS(0168).11.5 - ELECTRONIC LASER FORMS,INC.--(500)327-0545 �, �► z c �o The Commonwealth of Massachusetts William Francis Galvin- Public Browse and Search Page 1 of 2 The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth,Corporations Division One Ashburton Place, 17th floor Boston MA 02108-1512 V Telephone: (617)727-9640 RESOLUTION ENERGY, INCORPORATED Summary Screen Help with this form 6 00st.a Mrti ''u The exact name of the Domestic Profit Corporation: RESOLUTION ENERGY,INCORPORATED Entity Type: Domestic Profit Corporation Identification Number: 000987460 Date of Organization in Massachusetts: 10/01/2008 Current Fiscal Month/Day: 12/31 The location of its principal office: No.and Street: 43 FIELDWOOD DRIVE P.O. BOX 1490 City or Town: SAGAMORE BEACH State: MA Zip: 02562 Country:USA I If the business entity is organized wholly to do business outside Massachusetts,the location of that office: No. and Street: City or Town: State: Zip: Country: Name and address of the Registered Agent: Name: JOHN TONELLO No. and Street: 43 FIELDWOOD DRIVE P.O. BOX 1490 City or Town: SAGAMORE BEACH State: MA Zip: 02562 Country: USA The officers and all of the directors of the corporation: Title Individual Name Address(no Po Box) Expiration First,Middle,Last,Suffix Address,City or Town,State,Zip Code of Term PRESIDENT PHILIP D.HAGLOF 56 SIASCONSET DRIVE SAGAMORE BEACH,MA 02562 USA TREASURER JOHN R TONELLO 43 FIELDWOOD DRIVE SAGAMORE BEACH,MA 02562-1490 USA SECRETARY. JEFFREY R TONELLO 60 STATE ROAD SAGAMORE BEACH,MA 02562-1516 USA DIRECTOR PHILIP D.HAGLOF 56 SIASCONSET DRIVE SAGAMORE BEACH,MA 02562 USA DIRECTOR JEFFREY R TONELLO 60 STATE ROAD http://corp.sec.state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFromDB=True&... 6/6/2011 The Commonwealth of Massachusetts William Francis Galvin- Public Browse and Search Page 2 of 2 SAGAMORE BEACH,MA 02562-1516 USA DIRECTOR DONALD IF BRACKEN JR 5 JONES LANE EAST SANDWICH,MA 02537USA business entity stock is publicly traded: The total number of shares and par value,if any,.of each class of stock which the business entity is authorized to issue: Par Value Per Share Total Authorized by Articles Total Issued Class of Stock Enter 0 if no Par of Organization or Amendments and Outstanding Num of Shares Total Par Value Num of Shares CWP $0.01000 100,000 $1,000.00 2,000 Consent Manufacturer _ Confidential Data Does Not Require Annual Report Partnership X Resident Agent X For Profit Merger Allowed Select a type of filing from below to view this business entity filings: ALL FILINGS " Administrative Dissolution Annual Report Application For Revival Articles of Amendment �,� View,�Filmgs � 3 �Ne�Sea cfi' ; Comments O 2001-2011 Commonwealth of Massachusetts All Rights Reserved Help s http://corp.sec.state.ma.us/corp/corpsearch/Corp SearchSummary.asp?ReadFromDB=True&... 6/6/2011 1 ' aoioo 31S9 Town of Barnstable *Permit# OF.T� Expires 6 months from issue date ; : Regulatory Services Fee _ �$ Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us -Office: 508-862=4038 Fax: 508-790-6230 EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number o� '')I Property Address f-()C—) '1c r� go", tIn►�t S—t_ � ' Residential Value of Work'# Minimum fee of for work under$6000.00 Owner's Name&Address t- t ri Contractor's Name S O�i►���) C1C7✓Y1� ��(���vt►vi E'rn+ Telephone Number 56St ] 7.S'11 17 8 Home Improvement Contractor License#(if applicable) 1 O 3 7 5 7 Construction Supervisor's License#(if applicable) 0,5 Cpu`{ ��a ���"� 2<orkman's Compensation Insurance Check one: AUG `" 4 2010 ❑ I am a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTA13LE have Worker's Compensation_Insurance Insurance Company Name Q, pQC,.C -A JVJC�Usir ; _3 c� MPi Workman's Comp.Policy# I.JL. -]OU`,9 U i 0d� Copy of Insurance Compliance Certificate must accompany each permit. f Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to _&V1.M OJI, (-C,VN ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum.44)#of windows *Where roquired: 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 I gr went Contractors License&Construction Supervisors License is req SIGNATURE: Q:\WPFII.ES\FORMS\building permit forms\E}PRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):S n f;V\K_12 tt wg_ =rn 4 fCV2 rV1PYN+ Address• L91�t�it lode- Po City/State/Zip: tL i5 Oa�00 Phone#: 60gq ' 7 7.5 ' l-77 3 Are you an employer?Check the appropriate box: Type of project(required): 1.IJ 1 am a employer with__Ct 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. ❑ 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.t required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions l 3.❑ I am a homeowner doing all work officers have exercised their I I.[I 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 13.p Other KDT employees.[No workers' 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. tContractona 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 subcontractors have employees,they must provide their workers'comp.policy number. 1 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^.#:A(A)G 706%4 9 q �301 kb in Expiration Date: nt0 t Job Site Address: 1 B r0C) 5�1� 9(O�d City/State/Zip: ' nc - Oc?('a01 i Attach a copy:of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to set~ure 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 in 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 Loveratze verification. 1 do hereby eerti t r u n penalties of perjury that the information provided above is true and correct. Si atur : Date. G 2—, — Phone 7 Uj cial use only. Do not write n thisarea,to a comp ete y city or town offlclat City or Town: Perrrdt(License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: I THME f� Town of Barnstable Regulatory Services s ' Thomas F.Geller,Director NAM Eo 31; 16 Building Division Tom Perry,Building Commissioner 200 Main Strmt,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 UsinL A Builder I, �&e4 ?� ,as Owner of the subject property hereby authorize t to act on my behalf, in all matters relative to work authorized bat this building permit application for- .(Address of Job) Signature Date BARNSTABLE HOUSING AUTHORITY 140 SOUTH STREET WANNIS,MA 0281l1 Print Name If Property Owner is applying for permit please complete the Home' Wners License Exemption Form on the reverse side. (1•Ff1RMC•t1VJNF.RPF.RMi.CC1(�N - R�® CERTIFICATE OF LIABILITY INSURANCE OP ID DS DATE(MMIDD/YYYY) SPRIN-1 1 Ol 05 10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden 6 Sullivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 Phone: 508-775-6060 Fax:508-790-1414 IINSURERS AFFORDING COVERAGE NAIC# INSURED !^ —! y (INSURER A: AaeoCiated Industries of MA I . INSURER B. S tinkle HOm@ Im rovement InC. INSURER C. pp P I-----------'--—--— --- 199 Barnstable Rd INSURER D Hyannis MA 02601 — ---t INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, - _ -POLICY'EFi'ECT9VE�PaCfCYEXPltA1T LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YYYY DATE MWDDIYYYY LIMITS GENERAL LIABILITY I EACH OCCURRENCE s -D-A1VIAr,E-T0"REI ---- — COMMERCIAL GENERAL LIABILITY I ? PREMISES(I occurence 5 CLAIMS MADE.❑OCCUR � j i �ME�O'EXP(Any one person) $ ! ,I PERSONAL 8 ADV INJURY !$ GENERAL AGGREGATE 15 GEN'L AGGREGATE LIMIT APPLIES PER:( PRODUCTS•COMPIOP AGG S POLICY JRDT• I ,LOC i I^ ----- I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 1 ALL OWNED AUTOS I BODILY INJURY (Per person) $ SCHEDULED AUTOS I i 1 HIRED AUTOS BODILY INJURY —± '--- NON•OWNED AUTOS 1 (Per accident) I s PROPERTY DAMAGE I —'—'— (Per accident) 1$ GARAGE LIABILITY 1 AUTO ONLY-EA ACCIDENT s _ i ANY AUTO I OTHER THAN EA ACC s i AUTO ONLY: qGG $ EXCESS I UMBRELLA LIABILITY i ; EACH OCCURRENCE—j$ OCCUR CLAIMS MADE i AGGREGATE I S DEDUCTIBLE I j RETENTION $ 'S WORKERS COMPENSATION TORY LIMITS ER __ _ AND EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNERIEXECUTIV YIN AWC7004943012010 I 01/01/10 - 01/01/1.1 E.L_EgcHAccloENr ,$SOOOOO _— OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE_EA EMPLOYEE s 500000 _ If yyes,describe under I — SPECtAL PROVISIONS below 1 E.L.DISEASE•POLICY LIMIT s 500000 OTHER l DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SPRNKHO DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sprinkle Home Improvement, Inc IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Fax #508-775-1350 REPRESENTATIVES. Margo Mack AUTHORIZED REPRESENTATIVE 199 Barnstable Rd. Kelley A.Sullivan annis MA 02601 ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Office f`Co m arrs 6ri'$>fsiaess egu- License or registration valid,for individul use only Ommm HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 03757 Type: Office of Consumer Affairs and Business Regulation Expiration: 12 Private Corporatir l ,i 10:1'ark Plaza Suite 5170 - — Boston,MA 02116 S KLE,HOM _ - T4NC. r Brad Sprinkle r ?i 199 Barnstablie72d ^r '` - _ Hyannis,ali7t 02G� t` �r% Uriersecfetaiy Not valid withoutsign tune Massachusetts- Depa►rtm(nt of Public$afc" ,Restricted to• 00 Board (if Buildim-, Re:ulxtions,and Standards 00- Unrestricted Construction Supervisor License i 1G-1 2 Family homes License: CS 6643 Restricted to: 00 I BRAD K SPRINKLE `> ` + Failure te:possess a current edition of the t90 LOTHROPS LANP-:,'' Massachusetts State Building Code LE, MA 02668 ! is cause for revocation of this license. W BARNS��1B i Refer to' WWW.Mass-Gov/DPS �� Expiration: 10/8/2011 ('------ ---- Tr#: 5478 pf��7p� 1 � � Barnstable I fFo �.,8 Housing Authority Brian Harrison Maintenance Supervisor 146 South Street . Hyannis,MA 02601 . Tel.508-771=7222 ` Leased Housing 771-7292 . Fax 778-9312 . TDD 778-5333 Eft9ineering Dept.(3rd floor) Map 2 SS Parcel ®3,7 R Permit# House# 1 013 Date Issued Iq _, 1 Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) Div \ovA� v&VL OFee '25'�� Conservation Office.(4th floor)(8:30- 9:30/1:00-2:00) Planning Dept.( st floor/School Admin. Bldg.) �►+e rq Defi ' i e Plan pproved by Planning Board 19 • BARNS ABLE, QED MAC p`� TOWN OF BARNSTABLE Building Permit Application Project Street Address f �gZ�u �{S�►rL ���-. Village ,_-�- Owner aArLgroAble hpuri,!b Address loll., S unA .(`nfi,27, 1iYA.n[h[1,r Telephone - ')"a J Permit Request & ^ a,I J 4-V_ First Floor 6000 square feet Second Floor 2 o o 0 square feet Construction Type d)n C)a� Estimated Project Cost $ i�0 , a 0 Zoning,District Flood Plain Water Protection Lot Size • ;V1 ACAXt r Grandfathered ❑Yes ❑No Dwelling Type: Single Family-Ja� Two Family ❑ Multi-Family(#units) Age of Existing Structure GN k h,p,Ai Historic House ❑Yes T4 No On Old King's Highway ❑Yes 16 No Basement Type: Full ❑Crawl ❑Walkout ❑Other �e Basement Finished Area(sq.ft.) — 0 - Basement Unfinished Area(sq.ft) J Number of Baths: Full: Existing�_ New Half: Existing New No.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 WNo Fireplaces: Existing" O -- New Existing wood/coal stove ❑Yes No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) AMA 'None ❑Shed(size) ❑Other(size) r Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use IUD h Proposed Use 12 s-1 DI;FA)c.y&,,1 Builder Information Name ("emu N�v� Telephone Number �;Q Address JAL Tp s_g`yA STY,,aa l License# (S t 1 C) kA r t w-'r Home Improvement Contractor# k Worker's Compensation# [A) / 1) "� Ct a o& 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 �T Siam,i SIGNATURE DATE � ) J a 11 BUILDING PERMIT DENV��J ��-�P' �(S) CG h � k FOR OFFICIAL USE ONLY .. S i PERMIT NO. ` 4 1 DATE ISSUED 1 t MAP/PARCEL NO. 1 K 1 ADDRESS VILLAGE 1 , OWNER , 1 DATE OF INSPECTION: FOUNDATION a FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH ' FINAL ' PLUMBING: ROUGH , FINAL _ GAS: ROUGH FINAL ' FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. IME . . : The Town of Barnstable "AM Department of Health Safety and Environmental Services 6!Fg. P Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-796-6230 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. Type of Work: R-t V-v 0 Est.Cost ?S o. ®o Address of Work: 1 r- o vV� S�►r%�-e H A N Al-IS' Owner's Name 6 Rv vs L^' t Ash . Date of Permit Application: 1 hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. 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 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 Date Owner's Name The Coninton iveafth of Atlrssac h usetts _._. Dcpnrttncnt of 1"(111strial,9ccldcnts . t Y liw F office of111=tfgatioos J."' _r;`' hllll N'ashingron Street Bo ion.A1uss. 02111 Workers' Compensation Insurance Affidavit AnPltcant information: Please PRINT lebtilj� Q 9 , name: 1-1ALnlrl")P HCVritV� / /i?AdML-) location: 144 b t�UiJ'rL STnea`C city -H YKMAn I "' 07A-- e> nhone# e�3z 1; 1 I am a homeowner performing all wort: myself. I am a sole proprietor and have no one working in any capacity • ;,v... .-..w.•...,..---•s.....-.........._n...-..�,evr..-s iZ7w.'+�+/,7�:!r+ *r!w..w!.ww+�t�� ;+...�•.....n_..w. -Lr I am an emplover providing workers' compensation for my employees working on this job. contp•tr y name _a.(LNd`\ol.��� o��s►N 1 /110) address 1146 city: Alij 1, - phone#• insurance en M MAU Wa C• GrWVD i OW S T policy# LU 1 0 3 o O1l 3 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: comnanv name: address: cirv: phone#- insurance cn. —pnliev# __..__.-.... .._ ...�__....... _�_V—YJ L.r:._ .�i.+:JY�'.rr.Jr• r. :tl♦ Z - 4:..I:OrY._... .L_—__ contnanv name: address: tin: Phone#- insurance co. 120licy# .Attach additional sheet if neceisaryr-.=• ; ..,....��-=+ - +� �—~^•r�".£, ''��' �"-•-`��-�^�^''-'`��•'`-' -- ---.... ---•--._ :aY.�� .:.....�.::iriSi' —,s'-- - -•-•Ln..-L.-•� - -:yir•?:t�i...iwr..:n. Failure to secure coverage as required under Section 25A of 111GL 152 can lead to the imposition of criminal penalties of a tine up to 51.500.00 andiur one N cars' imprisonment:ts well:ts civil penalties in the form of a STOP N1.ORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Olricc of Investigations of the D1A for coverage verification. I do herehr certifi•under the pains and penalties of perjun•that the information provided above is true and correct. Si_nature ZA",n;t, Date 7- 11 Print name f)"I n,rJ Iq in f.6LISej_1J Phone#_ S -72 7 -2;L-2. r,."'iofricial use unit' do not write in this area to be completed by tiny or town official city or town: permit/license# r111uilding Department Licensing!bard (]check if immediate response is required C]Seleetmen's Office C311caith Department contact person: phone#: r"tUther s. Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for their employees. As quoted from the "law". an emphtme is defined as every person in the service of another under any contract of hire, express or implied. oral or written. An emplur•er is defined as an individual, partnership, association. corporation or other legal entit\, or any two or more the fore�_oin�� cn�a�_cd in a joint enterprise, and including the legal representatives of a deccasctl cmptoyer, 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 dwcliing house of another who employs persons to do maintenance , construction or repair work on such dwell ng hou: or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section '_5 also states that evenstate 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. 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 11: been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying: company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date tlu 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. 7.7 City or'r'owns 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. Plea. be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned v the Department by mail or FAX unless other arrangements have been made. Tile Office of investigations would like to thank you in advance for you cooperation and should you have any question: please do not hesitate to give us a call. . ,...,yy...r....._. ..._-..� .-...wwr.-r-rv-� � _-s�...i-_....��..r�.w..�_+ ..... ::ti',•, w:R.. The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 «'ashinaton Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 Restricted To. CA 3�2 71 DSFAP,TMENI OF PUKE FAMY CONSTRUCTION SUPERVISOR ITC N.SE Neither: Expires: g rthhl— IA - Masonr.y.only s" 'CS 1..'911O3S i2126/199 o l i:.(25l194. 1 4 2 Fa ,t„ i7nTp5 ' ~Rpstl_^tel� Toi 09 Fai1_ur? t0 pnScacc a current..edition of the Hassachusetts State Puiildinq Code 1�.+�•�'� '�`� '' RI AN U 'FARRISON is pause for revocation of this license. ; 12 HhAND ROAD BR.;YSTER, HA 02631 1