HomeMy WebLinkAbout0028 BUMPUS ROAD 0
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�0� Town.of Barnstable *Permit#
� Expires 6 s from issue dare
Regulatory Services Fee
hrnss $ Richard V.Scali,Director
163 TABLE
TOWN Building Division .
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION' - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address tG lA ��,�� . : ��A A/5 Af
❑Residential Value of Work$ y� ' — Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address 7a
'ye,1" ,o yr
Contractor's Name Klr,2 FA Telephone Number
Home Improvement Contractor License#(if applicable) 966 ems/ S Email:
Construction Supervisor's License#(if applicable) ��.� 0',�(0®9
❑Workman's Compensation Insurance
Check one:
❑ am a sole proprietor
[Y]�I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Rest(check box) ' o
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to X yo, l P,-,409,t5
�e-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders:U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required. ,
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. +,
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE: ,,
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
� I
Town of Barnstable
Regulatory Services
��oFi r°iyy Richard V.Scali,Director
°* Building Division
* snxrrsrnatr;. Tom Perry,Building Commissioner
MASS.9� $ 200 Main Street, Hyannis,MA 02601
pTEO 1iu�a www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-623 0
HOMEOWNER LICENSE EXEMPTION .
Please Print
DATE: -1Z /
� ,y l
Red LOCATION: � rGL aw LZ5114 r�u,aol/0
number O street r/ village
"HOMEOWNER": C ��,oe
4
name .y home phone# work phone#
CURRENT MAILING ADDRESS:
city/to - state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under'the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations. -
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedure and requirements and that he/sheewill comply with said procedures and requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner
engages a persons)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor,
(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible. ,
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that,the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently.used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc.
Revised 061313
oF�Tory
f
* BARNMMY. r .
�$ ' � Town of Barnstable
Regulatory Services
Richard V.Scali,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601 L
www.town.barnstab le.ma.ns
Office: 508-862-4038 Fax: 508-790-6230
\ '
- Property Owner Must ,
Complete and Sign This Section
If Using A Builder
I, Ci' M Ye5n 6tL-me 14 , as Owner of the subject property
hereby authorize ,00 � to act on my behalf,
in all rnatters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
Q:\WPFILES\FORMS\building permit forms\EXPRFSS.doc
Revised 061313
d
Information and Instructions
Massachusetts General Laws chapter 152 requires=aIl employers to provide workers'compensaton forttheir contract
op h rees.
pu rsuantto this statute,an employee is defined as _._every person in the service of another under any
express or implied, oral or written
<= artnershi association,corporation or other legal entity,or any two or more
An employer is defined as an individual,p p,
of the foregoing engaged ina Joint enterprise,.and including the legal representatives of a deceased employer;or the
artaershiP�association or other legal entity,employing employees. However the
receiver or trustee of an individual,P
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 ry also states that"eve state or Iocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwlth uiredy
applicant who has not produced acceptable evidence of compliance with the insuofits 'coniccoveragereq
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance vzith the insurance
requirements of this chapter have been presented to the contracting authority
Applicants.
Please fill out the workers'compensation affidavit completely,by check:iug the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone n=ber(s)along with their cei Dficaic{s)of
insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employ gees other than the
ve
members or partners, are not required to carry workers compensation,ncuran e-L I anthe PC or LL o oes ha real �
employees, a policy is required. B e advised that this affidavit may be submitted
Accidents for confirmation of in�nCe coverage. Also be sure to sign and date the affid2 it. The aflddatnt should
be returned to the city or town that the application for the permit or license is being requested,not the Deparbment of
Industrial Accidents. Should you have any questions regarding the law or if you are required to ob tails a workers'
compensation policy,please call the Department at the nu nber listed below. Self-insured companies should enter their
self-insurance.license number on the appropriate ae-
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a spac att the bottom
of the affidavit for you to fill out in the event the Office oflnvestigations has to contact you regarding` applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an apPli cu nt
ent
that must submit multiple pennitJlice- se applications in any given Year,need only submit one affidavit indicating
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations liz
(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 afTidav it
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call_ ,
s address,telephone and fax number:
The Department J
The Common) `eaTth�of MdssachIiseitts '
Depaztmcat of In(justial AccideZts
Office of lavestigatiam
6Q�Was b'n an S1rce
c on IAA 02111
TeI. 17-72 -49Gt 4€16 ar 1-&-MAS
Fax# 617-`127-
,�
Sze Co mwo mfe- t of Massacha[seffT
D;e1wh t of1?rdras&id Accidents
-- - Owe ofrmlestkwfians
600 Wayhingtua&reef
.$`astar4 MA 02
-' wr't-�tv rxrrs�gr�fdir�
Workers' Compensafion Insurance Affidavit_BuildersfC'o-ut ractorsMectricianMumbers
Applk ud L fm-mation Please Print Lef�iby
C'Ro'-x 0wr
Name(Basm� onffndazid=Q_ &�Gla,�
Are you m,employer?CAeckthe appropriate box; - T , . of pripiect.(requared
.
a_ ant confractor and 1 _.... ..
f._El I am a employer with 4 ❑ I 6_ ❑New caastiisctfo;t
employees(full anrVorpart-time)* have hired the sub-contractors.
?_❑ I am a sole proprietor or partner- listed on the attached sheet" 7- ❑Retnadeling
sbip and have no employees These soh-contractors have 8_ ❑D molifion
w forme in an c ci employ and have workers'
offing y � �- _ 9_ ❑Building addition
uworkers'comp_insurance comp-ms Harm
] 5_❑ We area corporationMd.ifs lf3_❑l�trical repairs or additions
Zreqpired
I am a homeowner doing all watt officers have exercised them 1 S_ lumbing rep aiI3 or anions
myself.[No warkeu'comp- right of e.1 .tiara per IviGI 12.[6 hoof repairs
in s ante required.]1 c-152,§1(4} and we hen a no
ern£rinye� 13_❑Other
[No
C6ntp_m-r rance required-1
yllxry saprDa=t that checks boa l-1 most slso fill out the section belaw shooing their wa lee corm-ensation golirg is m
9 Homeowners Who submit this affidavit i�)CXdE%they are doMg sll ntidc and the!MMM outside COotIRCMIS such-
vide tiL!E warps'camp-pali[p ntanbrr
i=am an d job site
irr;fornrutiart. .
Insurance GoinpanyN=e_
Policy 9 or Sel€ins Lick Expiration Date:
Joh Si#�--Addfess: city/Stat&zip:
Attach aE copy of the ssorkers'compensation policy declaration page(showing the poEcy number and expiration date).
Failure to secure coverage as required nudes Section 25A ofMUL c 152 can lead to the imposition ofrrirmnal penalties of a
fine up to S 1,5O0.Oa and/or one year imprisonment,as well,as civil penalties in the form of a STOP WORK ORDER-and a fine
ofup.to$250_00 a,day against the violator- Be advised that a copy of this sfiatement may be forwarded to the Office of
Im a stigations of the DIA for rnsirsrnctt coverage vetffiiva#ton
I do hereby ePxiify comber tka pedns andpenaffes alf`pedw y that irea{bnrruitun prmide�d above is h�u/a unrit correct
Siaaature �G��jy• ...6�1L�Lrs�i it Date_ /d.�
Phone 9
0JEd.al else only. Ell not write in this area,#a be camps` W by kit}'or town officiaL
Cite or Town: PMMIR License#
Fssuing Auffiority(circle one)-
1.Board of Health 2.$uiIding Ikpartment 3.OitFri own Clerk 4.Electrical Inspector S.Plumb ngg r=pector
6.Other
s
Town of Barnstable
�TME Regulatory Services
Richard V.Scali,Interim Director
. .
Building Division
MAC. Tom Perry,Building Commissioner
s6gq.
Eo Mp't 200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 ax• 508-790-6230
APProved:
Fee:
Permit#:
HOME OCCUPATION REGISTRATION
Date: 12 ✓,1'
Name: 64,;4` , A -nmo-l• Phone#: 4bl-4W-QO ?48
Address: X& Aody,ouu s /yc., Village: 96r17,1'16
Name of Business:--,Ai c4S1� —CGS ---- ---- --- — --
Type of Business: 0a1na4'1rt Map/Lot:
E TENT: 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 discernible 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 airr 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 carried on by the permanent resident of a single family residential dwelling unit,located within
that dwelling unit.
• Such use occupies no more than 400 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 flammable or explosive materials,in 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 equipment.
• There are no commercial 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 on the same lot containing 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 shall be employed in the Customary Home Occupation who is not a permanent resident of the
dwelling unit.
I,the undersigpd2 have read and agree th the above re ' ti ns for my home occupation I am registering.
Applicant: i Date:
Homeoc.doc Rev.103113
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form 'at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: Ae F'll in please:
�.
,.,s � ✓ a PLICANT'S YOUR NAME/S. i.y/N C5F,,gp 1W�r.jG1
BUSINESS•'�. ,y; y YOUR HOME ADDRESS: rz'9 ,rlynonn �Q
4d/-lob09
TELEPHONE # Home Telephone Number 17e6 6B.61-04W
IVAME:pF...'CpRPOFIATION,.' eG
NAME O NEW 6USIIVESS sec TYPE OF BUSINESS e
IS THIS A HOME OOCIJFq�IpN? I:. YES NO:
AJ7DRSSO
%PARCEL NUMBER
[Assess�ngJ
When starting a new business there are everal things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need.' You MUST GO T0,20.0 Main St. (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S O VU FFI E
This individual h e n infor. e n p rmit re uirements that pertain to this type of business.MUST COMPLY WITH HOME OCCUPATION
RULES AND REGULATIONS. FAILURE TO
Au herized=na !ur- *
OMM NT COMPLY MAY RESULT IN FINES.
� i
2. BOARD OF HEALTH.
This individual has been informed of the permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
C�
4G
Town of Barnstable *Permit# 6 'S 3
Expires 6 montks from issue date .
Regulatory Services Fee t��~
�� �'SS �� ERM'� Thomas F.Geiler,Director
BAR A 6 Z007 Building Division
Tom Perry,CBO, Building Commissioner
TOWN QF DARNS-TABLE 200 Main Street,Hyannis,MA.02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
hh
Map/parcel Number V ® � '
Property Address U-Y,-N eao Y4 vIJ t
Ukesidential Value of Work /6Z-ZD Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name -- Telephone Number
Home Improvement Contractor License#(if applicable)._ 1 �S
Construction Supervisor's License#(if applicable)
gWorkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy# I it/X &Y 9 t
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
%-Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ 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: . Pro erty.Owner must sign Property Owner Letter of Permission.
Copy t Movement rs License is required.
SIGNAT
Q:Forms:expmtrg
Revise061306
Results Page 1 of 1
Home Improvement Contractor Look Up
Enter Search terms separated by spaces. Search terms can be Town/City, Name, or License number
Select Search type: r. AND r OR ; Search
Search Results
Reg. No. Applicant Street City State ZipI Name lExpirationj
112536 FRASER CONoSTRUCTION 71 TACRRAGON COTUIT a 02635 FIR ASE OWNER 3/23/2007
EAN
Total of 1 Records
Matched.
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BBRS Privacy Statement
3/6/2007
I
,r •, r Sa ti �•x s a ISSUE DATE'
a �' 09/27/06
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
dR AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT:AMEND,EXTEND OR ALTER THE COVERAGE
1SE&QUINN INSURANCE AGENCY AFFORDED BY THE POLICIES BELOW.
449 PLEASANT ST ,
BROCKTON,MA 02301
COMPANIES AFFORDING COVERAGE
- -- coMPANY A HARTFORD UNDERWRITERS INS CO
LETTER
COMPANY B
LETTER
INSURED COMPANY C
FRASER.CONSTRUCTION LEA`
PO BOX 1845-
COTUIT;MA 02635 LE= D
COMPANY E
LETTER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
CO TYPE OF INSURANCE POLICY NUMBER POLICY POLICY LIMITS
LTR EFFECTIVE DATE EXPIRATION DATE
OAM/DDAY) D
GENERAL LIABILITY GENERAL AGGREGATE
CON(ERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $
PERSONAL&ADV.INJURY $
CLAIMS MADE OCCUR-
OWNERS&CONTRACTOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE(Any One Fue) $
MED.EXPENSE(Any one person $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY $
(Per Person)
SCHEDULED AUTOS
HOLED AUTOS BODILY INJURY $
(Per Accident)
NON-OWNED AUTOS
GARAGE LIABILITY PROPERTY DAMAGE $
EXCESS LIABILITY
UMBRELLA FORM EACH OCCURRENCE $
OTHER THAN UMBRELLA FORM AGGREGATE $
STATUTORY LIMITS
A Ve%)RKER'S'C6rAPENSATION EACIIACC_—LWT $100,000
AND 6S60UB-794X6191 09/26/06 09/26/07 DISEASE-POLICY LIMIT $500,000
EMPLOYER'S LIABILITY DISEASE-EACH EMPLOYEE $100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLES/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
ERASER CONSTRUCTION EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
PO BOX 1845 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
COTUIT,MA 02635 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES
AUTHORIZED REPRESENTATIVE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' d 600 Washington Street
Boston,MA 02111
,. www.mass.gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ap licant Information Please Print Legibly
Name(Business/Orgmization/lndividual): ✓l C,cQ.�` 1,
Address: y0 n --
City/State/Zip: jr Phone A:
Are you an employer?Checkppropriate bog: Type of project(required):.
1.C?�t am a employer with 4. E] I am a general contractor and I 6 New construction..
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a'sole proprietor or partner- These sub-contractors have
' ship and have no employees 8. Demolition
employees and have workers'
working for me in•any capacity. 9. Building addition
[No workers'comp.insurance comp.insurance.$
5. We are a corporation and its 10.❑Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions '
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]
t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp,insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
xContractors 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 is providing workers'compensation insurance for my employees. Below is.the policy and job site
information. 0
Insurance Company Name: -
Policy#or Self-ins.Lic.#: --)I AAA 6(5 1 Expiration Date:
Job Site Address: `t$ (13✓1 O� City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date):
Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DU for insurance covers a verification.
I do hereb un er -and a perjury that the information provided above 's true and correct.
Z
Si pa e: Datig
e:
Phone#:
70ffflcialnly. Do not write in this area, to be completed by city or town official
: 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 hiie,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
Teceiyer.or-tcus-tee-of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any
applicant who has not produced�acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither.the commonwealth nor any of its political subdivisions shall
enter into any contract for.the performance of public work until-acceptable evidence of compgaiiee with the insurance
requirements of this chapter have been presented'to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-conttactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit,or license is being requested,not the.Department of
Industrial Accidents.. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom
�'�.. of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding.the applicant.
�--,,.Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
thatmust submit multiple permit/license applications in.any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all-locations in (city or
�tovn)."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 fo 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 like to thank you in advance for your cooperation and should you have any questions,.
please do not hesitate to give us a call.
The Department's address,telephone.and fax number;
The Commoiawedth Q£Massachwetts
Deparnent of Lidustrzal Aceldents
Office of In-Vesligat ons
600'Washingtoii Street
Bostm,MA 0.2111
Tel. #617-727-4900 ext 406 or 1-977-MASSAF
Fax 617-727-7749
Revised 11-22-06
VVWW.mass.gov/dig
j; l UFM No. mi r. j
FRAUR CONS ON: Carries Workman's Compensation and Public
L-iOWRY Inoumri�__�_ee on the OQW varlC,oeAif e M uv$ile bk ujon toquos .
DATE OF ACCEPTANCE: �'°_ �� t� -7
Homeowner Fraser Construction
74
Assessor's map and lot number ......................................
V�MbSYSTEM MUBT° BE. !
°,� T s:,�ED Y'�9 M LI ;NCE
Sewage Permit number ..... II STATE..
�
/� E,',. I r A:^y CODE AND TOM
THE?0 TOWN
1TN O�j Br1 N riLLE
°
BJHB9TADLS, i
NAM
BUILDING INSPECTOR
O�G MPY Ar
a•
APPLICATION FOR PERMIT TO ..
TYPEOF CONSTRUCTION .............�iV.D�.........................................................................................................
.....-1;el .`......... .'.�.....19...7.
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit accordi 'g to the following information:
Location yy�
Proposed Use / r-<.Y �` �`�� ��R t
63
Zoning District ........ 00/
......................................................Fire District ......1N............................................
Name of Owner /// '/Sd/VAddress .....�....�GG/9�/�`'r ...�/��!.....
....................................................... .......... ....
Name of Builder S...... ...........................Address .... 4.4?..... .!..�..........�7.r�N.....!?...........
Nameof Architect ................. ................................................Address ....................................................................................
Number of Rooms ....... ®®
...........i...............................................Foundation .417607-...4.1..............
`
................
Roofing �e►J
Exterior ...........r.................... .✓ ........................................ g ............................../rf ........................... ......� ...........
Floors Interior .... � ` Sh �e �i� ........................
Heating ........................ 0..................................................Plumbing .............../v.�.. .................v...
Fireplace ...................9.V.4.......................................................Approximate Cost ............../BU..... ................................
�® /.I/� s.
Definitive Plan Approved by Planning Board --------------------------_------19________. Area . ... .... ........... . -
Diagram of Lot and Building with Dimensions
Fee .............................. ..........
SUBJECT TO APPROVAL OF BOARD OF HEALTH
90 ,
C Pts
M 0n°' t •
�7
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding he above
construction.
NaCe >/,� � .... .........................t�...........
~
Drew, Harrison Constance
'
16845 add to 1rq�le `
Perm - '
family onmullzmg
--------`^---------`-- '
8 Road
Location �. ---...........-------.. --' '
Hyannis
^-------...`...........--.--.------.--. .
ILarri000 8/ C~~~taz��� Irn*�� � !
Owner ---------^------------'
Type of Construction ..........Pranmy ______.. e
�
-----.--------------------..
\
(
/ .
Plot ............................ Lot ................................ |
Permit GrantedGranted --.Janua -2l�� -----]V ' '�� i
Dote of Inspection Date �
Completed .... ' ^ ^
'
} �
PERMIT REFUSED �
-----_.----_--------.. lV �
/
/
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.--------------.—..---------. '
^
. �
' .
~._.---.--------.----------.. .
^^^—`---------^~------~—~---'
.----------.------.--.—.---..
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. �
Approved ................................................. 19 .
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--------^------------^^^^—^''^ � |
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