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HomeMy WebLinkAbout0021 BROOKSHIRE ROAD Application number �.:..l...��.q.......... Fee ................ ............... - �,�, t Building Inspectors Initials.......... ... . .................. 26 c .� Date Issued..............:. ...................... M! BU Map/Parcel.. .... .......... ................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SID1NG/VVINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTT-TWORMA-TIONZ--y Address=of=Project: 2 J 113 r o o K-516-r g- S-�• t4 y C4-h n L S NUMBER STREET VILLAGE Owner-'s Name: a �son Phone Number �S 0 9 2j 2 -5 2`O b Email ddr ss: `� v e�Is r� �''1ti c Cell Phone Number Project cost$ (4 1 " Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: �� �-�" `'""�" Date: (TYPE-OF-WORK Q Siding Efwindows (no header change)# '1 1 F-1 Insulation/Weatherization 0 Doors(no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 201bs. or>Yes No , if yes, a gas permit is required. Natural Gas Yes No ,if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'-S LICENSE-EXEMPTION Homeowner's NameV, & "17- C9 f'--)y':3 fTelephone=N_ umber g) 29 2 S 2 a Cello Work number e ')29 �Z©"' I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signatures Datea� APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. I r The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaD]e--(Business/Organization/Individual): �.� 531y\ cQspyZ) �Acidres9 ZI C ityfState/Zips Z G (D t Phone#: (S o,,3) 25 L - S 2- 0 `9- Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.$ �,/�e ed 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions A3'.L/1 I am a h meowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.E]Other 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. lContractors 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 the policy 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 certify under the pains and penalties of perjury that the information provided above is true and correct Si at[ae: L. v IZ.D'ate ,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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any coverage required." uced'acce table evidence of compliancefiance with the insuranceg q applicant who has not prod p. P states"Neither the commonwealth nor any of its political subdivisions shall Additionally,MGL chapter 152 25C( , Adds y, P ,§ � enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.- Applicants Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates)of insurance, Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town-that the application for.the permit or license is being requested,not the Department of y__-_......_.7' ...+3.e 1.,.,r n,.if vnn are.remrirr:A to nhtain a wnrkezS' 1-ndustnal Accidents. Should you have&r quc1G LIGns rer—M3— lure va —o-�.. L - compensation policy,please call the Department at the number listed below. Self-insured companies should enter their ce license number on the appropriate line. self-insurance City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or,marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The COMMGR vealth of Massachusetts Dgwtmennt of Industrial Accident Office of Investigations 6N Washington Street Roston,MA�2111 Tel.##617-727-4900 ext 406 cr 1-977-MASSAFE Fax#617-727-7749 Revised 4-24-07 w.mass,gov/dia Town of Barnstable *Permit# o�?rQ�Q1 Expires 6 months from issue date Regulatory Services Fee-43a rIq Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner Val� 200 Main Street,Hyannis,MA 02601 ® as v www.town.barnstable.ma.us q 2 2006 -Office: 508-862-4038 AVG F'ax: 508-7 EXPRESS PERMIT APPLICATION - RESIDENTIAL O BARNS�C� Not Valid without Red X-Press Imprint -T O ®f Map/parcel Number� �SL_I I Property Address 200 )R '!! Residential Value of Work 9q 7 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Vr l ge6n JE S M-4 036611 Contractor's Name Bit,- y6wotie Telephone Number_ 9000-'213,2 7 73 l Home Improvement Contractor License#(if applicable) Con Sapervisoi's-L-icens (if appiiealrle) - ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name F-1211 e1-1-0j lkwle Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Ue'Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is-required. M� SIGNATURE: Q:Forms:expmtrg Revise061306 E I 10 '" I;" fF 4 �,,•NL S J ;,I tk� ill," '7' �4„�� 1 �t {f F iA J ()!'•, + " J q t IJ t i{ kf'Y�a rf Il ip4i �e,., M. c d + nF4�rE v'. .. 1.,._�.�-.":..I'­,,���:I,..',.�-..,-t:,..V"._-;;;._.1:,'ll...'l'--�­.,I�, 1-. �I—9—�-.,�i.;I,._.,1­.­�-'eI-.4!�,L­L,,L,.�.--�_�.�1 I"1-,0 I­-,-_'_'',�r..­._�I1:r._,',I,.�I;�r i.�Lg-'�.,1�..I,LI_I,,�a��:�I.0—)._-�j A.�,.��­.I-''!,�ri`";..­1"1..—'.�i,�L'',"�--,�1._,,.:,..:'."­��.,*—:l.'..L.�L-�1�'-_,,—.,._-1L�..q'tt.I'.�',..�,,,'�'.''.­�.`,_,�.�,,�:,L..rL.,rI_�_j.I�_�.':.�";I_.._."__�,_,;�t_.;_�r.,.-I-'�-'.yr��_,..��_7,jI.�_­,;�V,-%.,��.I�,I,1-L,,..,,..--'-1-_`l'�'I.�._.�:i__�.:.L L.,�,_—.,7'.''_1r:L,"..q�r�I-.-,.",­,­.,,�1,Lar"...a;Z1I.--I�,-�'�,"�....6.I.,I_�. II.�'.t.1.I.1�-�r.r.�11111-"-',;.:-i..1,.Ii r L�.L .i-i7 l,d�l.7It 1L�.I:L.7�l t--I't--",.I-�,"��-I-,T�''L�,*.!I1-I1,i�,tLr_4.-,I":�IC.�t��-1I-�",.-.,­,t1 7_I-,_r-,;;a, 'r-..1,0..�­4.'1. ..­,;,.�.!t.,i_1.'-.!1­,I,:%:,..I__:�1.,.'I..�.,,'1�.9.:.,e.,,:..rI`.4: r. rr ��oT:­A ITj'-,-^�.I 1 �r a t Il,, •� ,�, c` L �J,� 1 tl S w1 X' 1 .i 1 �-`� �`f d'' i I iy�rk y 4` 1 �"�'kit i .�+. ' Sa1�s�,1: 8666C 3853'1, " SOLD, FURNISHED & INSTALLED BY r + ® oo �11=��y Alurninurn 51Cti11g Corp4 t'� ' ~Service%Repairs: ,' k1 z k Of Queens, lnqo 888 245,:7294 „ k1 ' . r 232oaas 190 Cedar .ill Road',, Marlboro 4 Flp No ,� IA Q1752 1 OB# MAINE LIC,.NO.DD1893.-NH LIC.NO. MASSACHUSETTS LIC:NO.IZU456 i VERMONI LIC NO 'RHODE ISLAND LIC N0;13707 ' NEW.YORK CITY DEPARTMENT O CONSUMER AFFAIRS N0.0730686 •.NASSAU LIC.No.H2704150000'r TUFFOLK LIC:NO 21199HLi YO. . 1397 PUT<4AMPC ., WESTCHESTER WC0613-H87 LONG BEACH GC2001;c. NEW JERSEY LIC.N0:9949269 CONNECTICU DEPARTMENT OF CONSUMER AFFAIRS LIC NO 00532774. s',. SOLD TO / r DATE v`. I , ~ZIP I ADDRESS" ;; .< ; STATE 1� °� EMAIL PHONE HOME(. 0) 1 W01 ( �-- y JOB SITE ADDRESS+(IF DI FERENT)'' ` ;- 4 i APPLIED ROO -ING SYSYEIIA'{, i 'S ' Y f General Descri tton of Work at bove Addressy Type of House Frame ❑Masonry p �&-- t (REQUIRES Appr..oX Start late -., r ApprOX,( Orllpietl0n Date (WEATHER 8 MATERIALS.PERMITTING) FIBBING) `, i ' Approved materials will be furnished and installed to these specifications. PLEASE READ CAREFULLY:ONLY ITEMS CHECKED"YES"ARE INCLUDED IN YOUR ORDER. N0 YES�JO:. YES {a, 24; �CARPE TRY REPLACE FASCIA BOARD 1 ❑ REMOVE EXISTING1a ers of roofing down to 15'.'❑' APPLY ROOF LOUVERS '' ❑ N wood deck or Wood lats Specfy 0 FlontElev ❑ Rear.Elev ❑ LeftElev. O'1X6' 0 1X8' , Specrfy:O FrontElev:. ❑ R rElev O`LeftElev Areas ❑ RightEiev'_ Q Other 25.�[❑ CLEAN Ut?,Property at completion of work: Areas q RightEiev; 0 Partial Enllre 16.p-SOLID VINYL"SIDING ry Cover only flatwall 26, ❑ INSURANCE;All workman s compensation ❑ Do_rmer(s) areas designated for siding and liability tO be frlatotamed x Size CDIDr ail to customerrafter ❑ Other 27 ❑WARRANTY/i M Pattern Package corn legon and full payment Is received O Qelarls Custom comerposts color P r 28 ❑ PAYMENTS,on NON FINANCED.orders 1 ,7.❑ SIDING ON DORMERS BJOR ADJACENT AREAS = installer I"`authonzed to collect' 2. ❑1(RER.00F remove any curled ordiAgure' roof Spe ily ❑ FrontElev. D RearEley.` ❑ LeftElev:" progressive payments,"_ shingles &discard a rifscrehoh of installer Areas ❑ RightEiev. ❑ Partial 171 Entire , Specrfy 0 FrontElev ❑ R atEley O.LeftElevs ❑ Oormer(s) 9 NOt Spl Clfl Cd Above- Areas ❑'RightEiev ' ❑ P ~flat ❑ Entire D N L 2r ❑ PDE IDTIO.A GWORI(. A O other Work No to-Pe Done 1 ❑ Dormer(I O Details p Repair or eplace ther.Following r ❑ Other ', , i .'i i T ;F�7� y/ � ❑ Retails k 5 � . r 18.� ❑ GUTTERS/LEADERS Not re�onsible for damage r1 J¢L. t` , ;•'Q_Remove Existing Long remova �/1/� 3.1K❑ APPLY NEW ROOFIN SHINGLE, ❑ Discard ❑ Save,for`Homeowner �' Brand (s�� X Re Install Existing, 0 Replace with new custom seamless/ '��L `� t .- Sme 4 utters &. leaders: '❑ White ❑ Brown i Color Other v 4. ❑ NEW ROOFING SHI LES will be a plied 19O APPLY VALLEYS O 9' 0 10 ;- to the following are- only 20.❑ F,ATTIC FAN No Electrical ( Specify ❑ fTontEl" ❑ ea Elev 0 LeftElev 21"'❑ �;SKYLIGHT(S) Apply Flashing ®L�'` i eDr /� Areas: ❑ RlghtEI V ` ❑ artlal �Enbre ❑ Dormers 2? q [SOFFIT Cover with app roved O ` ?SOLID VItJYL SOFFITSYSTEM 1/3 Vented �� �,,>f )r - x k� r J. I ❑`Other Color O Details 23 ❑ KFASCIA Custom wrap with approved VINYL CLAD ALUMINUM ,ii 5. ❑ APPLY GS Fllntlastl Gold Applied Modrfied Color ; itumen Rubber Rd firi.g � , Mop applied wlOp6ori n B. ❑ ROOF DECKING I- i 30•Year Manufacturing Warranty �Qta'! $ale,� I _ ti . Furnish&Install 5/ COX Plywood #.I j2 Year Full Labor Warranty ', ieoipPAAYMoNM of 7. ❑ ❑ SHEATHING Replace any dama a Sheattling !. at an additional co t�nf$ ". Mf9 De osit With Order 33%$-0_ 8. ❑ APPLY ICE &WATE BARRIER... ea 'Style Colgr p / Valle S; around sk° j hts and Itch changes Total Invest Payment on 33%$ Y y 9 � P ment $ (Included withMasterE'lePackage), I "' , ` .. Measure Or Start 9.)4❑ APPLY NEW ALUMI UM DRIP EDGE Balance Due on / p nufacturin Warrant Substantial Completion 34%$s at eaves & erime[ r of roof areas Year Ma g y 10.�❑ APPLY UNDERLAY ENT ❑ Shinglemateo' Year Full Labor Warrant 0 301b Felt Paper 151b Felt Paper 1 --� ' , ; Total Amount of 11. ❑ APPLY NEW VENT IPE BOOTS.`` " .I Mf Balance to be Financ 12. ❑ NEW COUNTERFLA ING AROUND CHIMNEYS) e, T,9.CT Color / manced balance a a e i monthly 'installments of appr in ely per month, ❑ Lead 0 Copper ❑Aluminum ;ment $„ ir fo nt ctor tiu if Tot„ -:.. a ,Hues Fiber Roof Cement , - payable by Owne co t financed by Owner 13.❑ APPLY RIDGEVENT TO RIDGES then Owner will pay said a ount fo the lending plus such Year Marlufact Long Warranty interest and credit service charge of said lending institution 0 Cobraq ❑ OinkQ payable dlrecily to the lending Inshtugon loaning such monies Specfy ❑ FrontElev. ❑ RearElev; ;''❑ LeftElev tN! Year Full Labor Warranty to;l Owner and wdl execute a a.x t,. Retail lnstallme tobligationand ;, Altoisiougisuavea Areas O.RightEiev. ❑ Other n >r nnppla4 t Mfg any documenfs requRed qy such r qr, 14,❑ EAVE VENTILATION < a oa�� .d pm Supply and install Round Vents : Siyle Color lending InsUtgVon In connection tMBre' },fi"'SNg ry Total Investment $ * wjthsaidloan' -~ - - FINISH: ❑ Mill 0 Black � _s ,." .r-I . .3',. ..'t �.,. i,; all Ilr.ii 6? r,i. , T..�,i ,.h�I.$41 a,., �`� •CONTRAC.TOR IS NOT RE P•'ONSIBLE"FOR ANY:PAINTL_:G,SECURITI/,SYSTEAIIS,;ACCE$$ORIE6r SATELLITE ISHES;A!I MNAS,ELEC RICAL.FIXTIJRES:'OR ANY DAMAGE DIIE TO VIB ATIONS:'`liki'.REMOVEy" —WINDOW TREATMENTS,`''WINDOW MOUNTED.:AI,R CONOITIONER5;'PICTURE$, OR ANY OTHER ITEMS OR PERSONAL EFFECTS FROM THE WORK AREA.:INSTALLERS ARE NQT RESPONSIBLE FOq THE REMOVAL',OR INSTALLATION OFITHESE TYPES OF ITEMS. CONTRACTOR NO RESPONSIBLE FOR LANDSCAPING, SHFILIBBIll FLOWER BEDS OR OTHER OUTSIDE ITEMS IN THE WORK AREA. .- - ; NOTICE:If financed,any holder of this onsumer Credit Contract is subject to all claim;and defenses which the .SALESMAN NAS NO AUTHORITY TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN debtor could assert against the seller of nods or services obtained pursuant hereto or With the p'roceeds,'hereof. CONTAINED IN THIS CONTRACT AND"OWNER"REPRESENTS THAT NONE HAVE BEEN MADE TO OR RELIED UPON Recovery by the debtor shall not excee amounts paid by debtor hereunder. , ` BY"OWNER".YOU ARE ENTITLED TO A COMPLETELY FILLED IN DUPLICATE ORIGINAL OF THIS CONTRACT. OWNER REPRESENTS TO HAVE READ NU RECEIVED A DUPLICATE ORIGINAL OF THIS CONTRACT AND TO BE ,,YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD ` . .THE AUTHORIZED AGENT OF ALL"OWNE s"OF THIS PROPERTY UPON WHICH THE WORK OR THE MATERIALS ARE BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE ATTACHED NOTICE OF CANCELLATION FORM FOR TO BE SUPPLIED. AN EXPLANATION OF THIS RIGHT.ON ALL ORDERS CANCELED AFTER THE RECESSION PERIOD CUSTOMERS NOTICE TO THE HOME OWNERIS►,GU RANTORIS),IESS11i ;CO-SIGNER S11.'00 NOT SIGN THIS CONTRACT J WILL BE RESPONSIBLE FOR A 45%ADMINISTRATIVE AND RESTOCKING FEE." BEFORE YOU READ IT,OR IF 1T CONTAIN ANY BLANK SPACES�B IF IT DOES�OT CONTAIN EVERYTHING AGREED ' - UPON.ANY PERSON WHO SHALL HAVE O-SIGNED,GUARANTEED OR SIGNED ANY CREDIT APPLICATION OR NOTE SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITIONS.BY SIGNATURE BELOW,OWNER AGREES TO THE RELATING TO THIS CONTRACT HEREBY,CCEPTS To BE BOUND BY THIS CONTRACT. TERMS OUTLINED ON THE REVERSE OF THIS CONTRflACT. i .. ,n k e N , ! :c II..55 Y DATE p Contractor Acce tad" lure Print 1 SatesmansName J Signature (Customer Srgn ere) � `_ s ` SalemaRs # 3 x a r ass tr� �Icense No ''" # ;� a + ; r Signature t ' - c -'� s `5+.3.r -t. N, t ,� - �, �. . r ,n ! r -+ r r '{ `'r{r,r J (Customer Srgn-I4j re) #.', *y,-r'. ram' - [�2005 Bit Ray GroSp AIrBJghts Reserved 1nl5 Fr- E �, i i' �'� y. `,+ t >r tv`'.a i .a ,.�; , „r w" ' , �- _, ,vr 3 .� a 'a}.e at`;.' !w ,' h',' '; r�r,..°r.�s, �Y' .' 1>sf —�'i_- .v..,.�e.z: +'�u •• - i - .�_�._-_.�,...��.__ ., - - t 1 l �,(re-n�aminuow�ealtli o�✓f/�aoar,�zcrae�a .._ . Boardof Building Revelations and Standards. LiceAse or registration valid for'individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date, If found return to: Board of Building Regulations and Standards €- 0456 One Ashburton Place Rm 1301 E s00$ Boston,ll�a..U2108 p E pI ment Ca L RAYPLUM �AL•lL �F��' Y• . o% 40 ELItIII ZZE of void. si EL ddnistratar without r' i. ' 77ie Commonwealth of Massachusetts Depariment..of Industrial Accidents Office of Investigations _ 600 Washin- on Street r e Boston, MA 02111 www.mass.gov/dia borders' Co >Aensatiola�nsuranee caclavit: B-�ders/Contrastoes/Electr cians/Plumbers AD-Blicant formation Tease �i�t e biv N-=e (Busmessl0raanization/Individual): Address: City/State/Zip: -re you an employer?-Check the appropriate bog: Type of project(rennired): L X I am a employer with f 4• ❑ I am a general contractor and I 6 New'construction employees(full and/or part-time).* have hired the mib-contractors Este on the attached sheet 7• Remodeling ' 2.❑ I am a sole proprietor or partner- i ship and have no employees These sub-contractors have 8. .F7 Demolition working for-mein any capacity. workers'comp.insurance. 9. Building addition o workers' comp.insurance 5. ❑ We are a corporation and its [N p_ 10:[❑Electrical repairs or additions regt�red.]v officers have exercised their riQ t of exemption per MGL 11.[]Plumbing repairs or additions 3-❑ 1 am a homeowner doing all�work mP p I myself. [No workers' comp., c. 152,,§1(4); and we have no. 12.0 Roofi epairs su inrance required-]t employees. [No workers' 13 Q Omer comp.insurance required.] *_Any applicant that checks box#1 must also a out the section below showing their workers'compensation policy informarion Homeowners who submit this arndavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lCont—,actor that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy inhimation. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Q Insurance Company Name,/ 1t)&d n Policy#or Self-ins.Lic_r: / "-7 Expiration Date: Ci /State/Zi �tJA/1 ®, Job Site Address .��k5�{/ F® ty' P 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 oft 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 o�le DLA,for ms1 rance coverage verification. I do hereby certify under the pains andpenalties o fperjury that the information provided above is tale and correct Si mature: . Date. Phone# -7-3 2- Official use-only. Do not write in this area, to be completed by city or Town officiaL City or gown: permit7License#, Issuing-kathority(circle one): 1.Board of Health 2.Building DepartiAent 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other i Contact Person:- Phone#:>. r� 5CS PAGE 02 9 1412005 16:24 5166255H57 DATE iMr�antY1^rYS Oaio - Q9/14�l05 _ h9A', =R OF INFOR&SP.TIpN CON rERs NO RIGHTS UiabN TH=CcRTiFiCAiaa CE THiS GEF'-'1'1F1C;A_T-'IS ISSU^D *A PROnuaE;1 ONLY AND $CS Ag'r+zV;`r Inc, yCJLDER.THIS CERTIFICAT—tt ODES NOT �'ND OR 220G93 ALTcRTHE GOVERAGEAFFORDED BY1H=POLIGI'c5 BLOW. _ St'tr_te 300 NATO� 1.1 G_aas Avenue ^ J d G.eat Neck NY 1�Oyu 0-g3 RS A60FE COVERAGE INSURE 7 =a�-i;p07 x+ x:5�d-$29-5857 ?tiSalla:D.•fi-- INSuRUIA: aaxmite4e S¢�uren C•�eey INSURED INSURER[i �mcinut �� t,lsoawee ce. I 1a305 INSURER C: .,,,_ieL•7.us:a.aan xd�tL:aaas Cn. 3i1 Ray 7zsLi7szm� g'�ding Cn=Q• IN5uRER Dv 1 a0 Elmaat Road3 INstlRERF: r]mollt N=' GCy\fEF2pu $ NAMED ASOW_'FORTHc POLICY PERIOD INpICATED."IpT^11TH`UTANDINO c TO THE INSURED R=BPtGTTo VVH1,^,HTHIS CEFt[1FICA7E►AAY 8E T95UED OR NY CONTRACT OR OTHER DOCUMENTS H -�15,JS=sION5 AND CONOMONS OF E LI H 7HE?OLICicS OF 1NSURANuE LISTED EELOW HAV fi�N I.SUED ;Ny -OUGceMENT, �iIOR:ONOiT]ON THE FOLK'ENDESCRIBEOHEREIN�gUBILv?�ALLTHc NAY?:FTA1N.Tr==INSURAN:E AFFORDM BEEN=.-.DUCED BY PAM CLAIMS' _ - uMttiS _•i, DRT=IMhVDOM1 t'1 r{�Q Q r Q Q FOLiGI'�y.AGCREGATE1J111T5 SNDWN MAY HA POLE'.Y NUMEER DATti fMMlOOl1 Y} EACH OCOURFI-eNCE L-i RINS11D .7YPc G?INSURAND' _ I S }0 Q j Q0 0 s;sNmZAL LIABILMY D B/Z 5 j 0 S 0 B j 25 j 0 6 PREMISES Ea MIS P== 5,0 0 0 WEDr71Pi�+vP '")� g CDUMEROIAL GBJ137AL I.lA81LIT1' HGi:a E 9�7 0-0 5 PERSONAL S ADV INJURY s1,13001000 CLAIMSMAD=_ Z OCCUR DOO O,QIEfiAL AGGREGATE -------------- PRODUCTS-COh1PtoP AGG S 2,00D,1300 GEN'LAGCRc;C�S—fEUMR APPLIES PERI . POLSOX 1 1 JEC'T LOG GOMBINEO9fNaL= iT S �aoddC+I) AI COMOSIL UAHILTTY ANY AUTO (Perr pemoon) S ALL OW Nm AUTOS SC�.?DULEDAU'tO5 (PeOramtnetSIUIRY �5 HIRED ALTT06 4 NOWOWN=D AUTOS IPeOi aco�seTMennAMAGE 5 AUTO ONLY•FAA iDeNT S THAN EA AC:. i GARAGE LIAHILnY A=ONLY: AGG 5 ANY AUTO S - EACH D^,,,CURRt3VOE AGGREGATE s meSsIUMBRELLA.UAEILRY O=UR CLAU.%MADE L 5 DE.DU=M-9 TDRY L I IMTT`3 ER` ' RETENTION S EACH ACID-cH7 "�1 0 D❑D Q tiroli nse:oMPeNSA:IONAND 091Z4j0 09 j24ID6 rtrY - s I000D0 EMFLOY-W UA81LfT1 QQG'°3 O S 3 E OtSEASE-EA B AN`tPROFAIELORIPARL ER0=UTPE DL9=ASc•FCILIOYLIMIT S}p0UD0 OFFtCERlMd1>363EXCG =1 lip&=jibe inter 9 WL PA13VI5NN5 he}wr g watut^JT oTI�R 10/O�/os so/01/0E 1.7g4036 C DESORIFTiON OF OPERATIO}I a J LOCA7ION5I VEHICLES I EGOLU5IDN5 ADDED HY ENDOiLSElAFNi 1 SPECIAL PRDVt91DNS CANGF-I.I-ATIDN cm:rm:ICATaHOLDER TDiRI40MI SHOULD AN YOFTHEA9DYEOSSGA�t3mPOWCIP386GANCMAILD30 EOAYZwanTN DATETHEREOF0'THE I33Ln"g INSURER WILL ENDPAMOFcTO MAIL NOTICETD THE Om n vgcATE HOLOEFLNAMFDTO-,RE LEFT,BUT FAILuRETO DD 50 SHALL i}SPnsE HO CIBLIS47ION OR LIA9tLiTY OF ANYKiND I SON THE IK9URER,FTS AGENTS DR O �.NTA'i'IU2E. AUMOR►iESr REPRE5t5NTATIVE 6?AZORD CORPORA'i1ON 1981 'j AGORD 25(20011D8}