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HomeMy WebLinkAbout0118 CENTER STREET //S � ,z�r Sf- - �- - - -- - r id t„E Town of Barnstable * ermit# Expires 6 months issue d Regulatory Services Fee . anrtiMABLE. • MASS. Thomas F.Geiler,Director i6g9 ♦0 Building Division Toni Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 r www.town.barnstable:ma:us . Office: 508-862-4038 Fax:'508-790-6230 EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Q S7—, N�� e of Property.Address 0 [,Residential Value of Work 4 000- - Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address � .. , Telephone Numbe � Z 7 Contractor's Name - Home Improvement Contractor License#(if applicable). Construction Supervisor's License#(if applicable) ao P...E o.S a.�,^■T y ❑Workman's Compensation Insurance Check one: DEC 4 4 2012 I am a sole proprietor ❑ I am the Homeowner r' ❑ I have Worker's Compensation Insurance TOWN:OF BARIVSTABLE Insurance Company Name r . Workman's Comp.Policy# w Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) .?K Re-roof(hurricane nailed)(stripping old_shingles) All construction debris will be taken to Re-roof(hurricane nailed)(not stripping: Going over existing layers of roo f) IV_ ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value c, (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License.&Construction Supervisors.License is required. SIGNATURE: Q\W MESWORMSIbuilding permit forns�MRESS.doc .. ��. �z �_ - � '« .. Y T .e- . ' � � _ - ,, s v P� 11 The CommonWealth a,f Massachuset#s Dig 7ariment of Industrial Accidenis Office of Invesfigations 600 Washing-ton Street _ Boston,AL4 02111 wrc�rv.>Rnago+��'dia Workers' Compensation Insurance davit: Bugders/C-on&actors/Eledt c -anslPhimbers Apphcant Information Please Print IAybl Name(Busiuess/Orgauizat4nfhttrvidnal): ��� v w lb CiWSta&7 p: Phme 4 r1Ce you as employer?Check the aglxrapriste box: Type of project.(required): . .0 I am a employer with 4. ❑ I am a general contractor and I 6. 0 New constrwtion employees(full atad/ur part^#im,e)-* haine.hired the sub con#ra+closs 7_ Remodelin 2<i am a sole proprietor or partner.- listed an the attached sheet ❑ g . ship.and have no employees These sub-contractors have g_ Demolition- woiking for mein any capacity- employees 1 .and have woorkers' _ Q Building addition [No wodcers' comp.insurance camp-umacance_1 required.] 5..E] We area corporation and its IO.O Electrical repairs or additions. I❑ I am a homeowner doing all work officers have exercised their 1 I,0 Plumbing repairs or additions right of exemption per MGL ' myself [No workers'romp. 12.E Roo€zep insurance required.]T c. 152, §1(4),and vie have no employees.[No workers' 13.0 Other coirrp_insurance required:] 'tiny apphcaw thst checks bog Al must also fill oat the section belay showing their workers'compemsatum policy inforiastion T Homeowne m wbo submit this affidavit indicating they are doing aR weak iud the¢bire outside carr=wrs mast submit anew affidwit indicating such- tCaatractors thst check this box mast attached am additanmal street showing the name of the sub c aiwacum and state wbether at not those entities have . - euplayees. If the sob-contmaors have employees,they n ustp=vide thmr Workers'saiap.poliep'aumber. I air alt eMpinyer t1lat is providing workers comparnadon insuramce for my emptayee& Below is the policy and jab site iafornaat�sn - ,. .,: Insurance Company Dame: Policy#car.Self,ins.Lic.#: Expiration Date: city Jab Site Address: t3` zip- d tion date). ember an 'on a e(showing the 1i � } ileers compensation policy declara� �4ing policy e1p� . Attach a-copy of the wo p p � P g { Failure to secure coverage as required under Section 25A of)!v GL c_ 152 can lead to the impasitton of criminal penalties of a fine up to$1,500_00 and/or one-year impnsonrnent,as well as civil putties in the form of a STOP WORK ORDER and a fine . o€up.to$250.00.a day against the vihlatur. Be advised that a copy of this statement may be forwarded t0 the Office of Investigati=of the DJA fort insurance coverage veriffration I dv hereby cetWfy apbf Wir s a k4ffS o.fPedM7 A&the in orinatirrn provided above is Grua and correct, Si Lure: Date: Phone#: ©dial use only. Do not mite inthis ax�a,to be coea City or by C or Mini offieiat". City or Town: Permitilicense# Issuing Authority{circle one}: 1.,Board.of Health 2.Buddi ig Departmeat 3:City/f'owu Clerk 4.Electrical Inspector 5. ' for Phun bmg 6.Other.. _ . ..___ .__Caatact_I=ersan; .._: - Phone#: ., 1 i EVE Tp� � f i A STABLK ,�� Town Nof Barnstabk'QW Regulatory Services. -M Thomas K.Geiler,Director, Building Division Thomas Perry,CBO Building Commissioner - 200 Main Street;-jHyannis;;MA 02601 www.town.barnstable.nii.us Office: 508-862f-4038 'Fax: 508-790-6230" Property Owner Must Complete-and Sign This Section I'f.Using A Builder—, I, as Owner of the subJ*ect property .. ., ���a�:^,'t'%r' .:� -tee} .•s*. r�=,. _ i. : '! w. h l to act on my behalf, hereby authorizeC F in all matters relative to work authorized by-this Building permit-application for Iff (Address of Job) of Ovine u, . Signature r� � �Date Cc /�//�11,y: '/{/ /J/I F` _ � ��Ito�J///wjj'a ° �.*• :c:r� tl r. �+, < J�i�..�/ � ������ ` : /�f/, /! `�,,i .N „4F. �i1:1.1 , ✓R� [ {. Y . �i q = 3 �r Print Name' "j-. .... ,g i. If Property Owner is applying for permit,please complete the Homeowners License Exemption Form{on,the reverse side.,.' k. u4 t �IKKE , Town of Barnstable Regulatory Services ' r MUMST"M ' Thomas K Geiler,Director .. Y., 9 MJUS& .:.a 39. Building Division - r Tom Perry;Building Commissioner.= 200 Main Street,`Hyannis,i MA VOL www.town:barnstable.ma.us.• 1 Office:. 508-862-4038 ry s .s• Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# ,_:, f; e, .a i work phone# CURRENT MAILING ADDRESS: . s. r r t' •�.•. ' city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs,more than one home in a two-year period shall not be considered a homeowner, Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, . bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official , Note: Three-family dwellings containing 15,000 cubic feet or larger will be required to comply with the State Building Code-- Section 127.0 Construction Control. - �£ HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which.a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors),provided that if the homeowner engages a person(s),for hire to do such work,that such Homeowner shall act as . supervisor." : . _._�._..- _ _. :,.. . _ Many homeowners who use this exemption are unaware that they are assuming the responsbilities of a supei;sor;(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. JI" a r �. ! ,• „' i; .• ;.i ;.>i, •, a ;< "ram ;. ° - 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. . �/e �onv�noruueirlll ✓l/laaa ��-_'-�"_'-r�..,,-..,.�._..�,.., .�_... ,..... _ _ _ ... .. _ o� acluceelta Ofr"O in& License,or registration valid for lndividul use"only " TOME.1�1! ? ANT COTITRAC?OR before the expiration date, If found'return to: ; Registration, ;lT!$22 , . ►A . Office.of Consumer Affairs and Business Regulation Expiration: 412 14 DBA „ 10 Park Plaza-Suite 5170 DE RROS CONSTRbJ -j'+FFN ; ° Boston;MA 02116 y, EULER DEBARRO$ � Y 7 2 SPINNING.BROOKRD.} , SOUTH YARMOUTH;`hAA 13266 ' t Underseeretary Not alid without signature .; bLOZ/S6/ti0. _ uollendx� Jauolsslwiuo ti99Z0 �'I�I ql ouuai.tiano S0,2Iii4'ffffQ 2I�'Il1� a £6brsB0-S3 :asuaolq _IO.",U">;IhS U()1]JIl]�SUO� - spjepuOs pue suolteIP6a8 6uippm8;o P��oB �ilgnd 1o.luawedaq- sas'nyoessew "'l-o mmonwealth of �a 'husetts 4 Ma. t beet Metal T mit Map�2(:;� Parcel G Date: aLo 4errm t•60 Estimated Job Cost: $ �©o o . Permit ee: $ :4' Plans Submitted: YES NO Plans Reviewed: YES NO f Business License Applicant License# Business Information: Property Owner/Job Location Information: Name: �. t� ��'� C�e�L� Name: d _. � i7 AALT1 7� Street: 3 0 Lk s� X2rt✓c Street: City/Town: XILD►., City/Town: a_i_V% C _ O A Telephone: S O Q- S10 b rc3. t� Telephone: 5000 Photo I.D. required/.Copy of Photo I.D. attached: YES NO 1 sta ;tiar J-1/M-1-unrestricted license - J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Fire Dept. Approval Institutional_ Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of bories: o- Sheet metal work to be completed: New Work: Renovation iz­ � L HVAC Metal Watershed Roofing Kitchen Exhaust System - Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: . T. INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112_ Yes ip No ❑ If you have checked)Yjj,indicate the type of coverage by checking the appropriate box below: A liability insurance policy Other type.of indemnity ❑ Bond ❑ 't. OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement.. f Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's AgentF_ F By checking this box[],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that'all'sheO metal work and installations performed underlhe permit issued'for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. ' Duct inspection required prior to insulation installation:YES NO Proeress-Inspections Date Comments FinalInsnection Date Comments Type of License: 3y ` Master, r . title ❑ Master-Restricted ;; E 'ity/Town ;. ❑Journeyperson Signature of Licensee 'ermit# ❑Journeyperson-Restricted License Number: l a� :ee$ ❑ Check at www.mass.gov/dnl nspector Signature of Permit Approval n� f - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I-Fi. ' 600 Washington Street• Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLribly Name(Business/Orgmizatian/Individud):. S L-- •Address: City/State/Zip: w_ A Phone.#: 5 6 3�a 83�a Are you an employer?Check the appropriate box: Type of project(required):; 1.❑ I am a employer with -4. I am a general contractor and I employees(frfil and/or part-time).* have hired the sub-contractors 6. ❑New construction . listed on the-attached sheet. 7. �Remodeling 2.� I am a'sole proprietor or partner- ' I ` These sub-contractors have._ ship and have no employees 8. ❑Demolition working for me m any capacity, employees and have workers' [No workers' comb.insurance comp..mcnrance.$ 9. Building addition re� ]ed 5. 0 We area corporation and its 10.❑Electrical repairs or additions 3.El I am a homeownerofficers have exercised their doing all work 11.❑Plumbing repairs at additions myself. ' comp. right of exemption per MGL Y �o workers 12. Roof repairs . insurance required.]t c.152, §1(4), and we have no employees. [No workers' 13,D Other comp.insurance required.] *Any applicant that checks box#1 most also fill out the section below showing thew workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outsid--contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they mostpravide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company.Name: Policy#or Self-ins.Lic.A 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 tore: Date: :z0 Phone#: — �I Official use only. Do not write in this area, tb 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#: � . .�-, E '.� Lc'. t '. a . � a �� . � , � .r, �. �T Town of,Barnstable * Regulatory ul Services g ' * sA[exsTesLE, • r- MAB& Thomas F.Geiler,Director~ s639. o " Building Division Tom Perry,Building Commissioner, 200 Main Street,Hyannis,'MA 02601 www.town.ba rnsta ble.m a.us Office: 508-862-4038 CFax: 508-790-6230 Property Owner Must Complete•and Sign This .Section { If Using A Builder">' I,---4 It 7261���&ll( /0// ,as Owner of the sub' ect roe ' p p rty hereby authorize .' �,N . Q/ '4�&41A14, to act on my behalf, in all matters relative to work authorized by*his building pertnit. (Address of Job) n { *Pool fences and,alarms are the responsibility of,the applicant. Pools are not to be filled before fence is installed and pools are not to,be utilized until all final inspections are performed,and accepted. Signature'of Owner Signature of Applicant Print Name Print Name 5- Date Q:FORM&OWNERPERMISSIONPOOLS �1HE Town of Barnstable Regulatory Services BAMSTABLE, * Thomas F.Geiler,Director y MASS. 1659• .0� Building Division ADD MA't A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 P. HOMEOWNER LICENSE EXEMPTION Please Print DATE: J d t JOB LOCATION: L/ CZ:NnF ST- number �^�� ,o /� street` village „HOMEOWNER": rt ori?� C��G�Dp/Lh/% �TL *77 name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION.OF HOMEOWNER Person(s)who owns a parcel of land on which.he/s}e>`rr sides or in, tn'reside,on which there is,or is intended to be,a one or two-family dwelling, attached or detaciied structures accessory tAuch 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 l09.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will 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 person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt � :UMMIJNVVItAL A li Uh NIF►�3H1:.1 iU�t f.1 J '? --� �- �� f • . . . . .. aw, a ,. i , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# I7s�1 Health Division Date Issued Conservation Division Fee Tax Collecr, Treasurer: Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address V « 4 Village 12 Owner it t f Address ?�D, w a 5-1— ©St cfmwz Telephone 420 o G 4�( Permit Request Akcf® --,A Q_ -- w r�a�G c✓ 4ctciz, — ' r- v✓� T C� Square feet: 1 st floor: existing Jdb proposed 2nd floor: existing prop zed Total new Estimated Project Cost 2W�b `'�'— Zoning District Flood Plain Groundwater Overlay Construction Type OW) f R-ap-e Lot Size a i 3 Grandfathered: 2—es ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ICY Two Family ❑ Multi-Family(#units) Age of Existing Structure -16\►�C Historic House: ❑Yes UN-10 On Old King's Highway: ❑Yes U41rol F Basement Type: ❑Full Q'Crawl ❑Walkout ❑Other asement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: • existing_ ^ new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas O'Oil ❑ Electric ❑Other Central Air: ❑Yesr 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# Cgrrent Use 96"(M g�, Proposed Use 'II BUILDER INFORMATION Name- IL J�(r K Telephone Number 4b29 463 ' Address laU OS f Id ems[.t License# 6 OKS fib 43 al ILLS A( 4 151. Home Improvement Contractor# Worker's Compensation# JC)6 f° i}v ('1( l ALL CONSTRUCTION'DEBRI I G FROM THIS PROJECT WILL BE TAKEN TO 4j t SIGNATURE DATE - I .} FOR'OFFICIAL USE ONLY • _ PI`RMIT NO. - 2� DATE ISSUED MAP/PARCEL NO. VILLAGE • .{ ^' .. . ADDRESS , OWNER DATE OF INSPECTION: " FOUNDATION FRAME t.. INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL - - PLUMBING: ROUGH FINAL r t r GAS: - ROUGH FINAL - 1 FINAL BUILDING+ DATE CLOSED OUT .. - • r -� ASSOCIATION PLAN NO. +� W; D6PARf.NENf OF PUBLIC SAH-17 CONSTRUCTIbi SUPERVISOR LICENSE Nu�6er = Expires: —--- ResG€rated4re� y 00 walw x TERKELSEN ___< Y25I 05T/W/BARN RD HARSTONS HILLS, HA 12648 .` i Registration . 126638 Type - INDIVIDUAL Expiration 06/29/00 NEIL TERKELSEN NEIL A. TERKELSEN 12`5,,� DST W BARN RD : 1xRSTONS MILLS MA 02648 ADMINISTRATOR 1HE The Town of Barnstable • 1AMSTA13 ' MASS. Department of Health Safety and Environmental Services A,E p 59. N,or a Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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: Estimated Estimated Cost Address of Work: �� Owner's Name: G'l�'/ l �I�C�� d IC.t,ll �c tJ®� V`TY IIC. r- - Date of Application: F` I 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. /ase D R PENALTIES OF PERJURY I hereb appl for a permiof owner: Dat Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav — _ _ e Commonweaun • � .......- .y- Department of Industrial Accidents -�_°-•- • � OfBc�of/aYestigatians =_-s F 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit TI- named �� �Y ` location: city rm vhone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one workin in airy achy workers' ensation for my employees working on this job. I am an employer providing :.:.::..:..:::::::::.; ?.;:;;.: ComA an v name s ad fires S e �,, ahon c tw I . ... .... ..... insurance co- // general contractor, or homeowner(circle one)and have hired the contractors listed below who ❑ I am a sole proprietor, have llowin workers.co ensa on Polices:..........:. .: . .:.::::::.::::::.::::::::..... . .:::::..,..:.:........... :...: .............:....... ... the fo .......?� ..... nv n am e m a ' Co D address. i n him CrIY .. f l� ci tv , // cumanv name— ess: - to- :::................... n ............. . g� to secure coverage as reqwell BreNO,d under Section 15A of MGL 152 an lead to the imp°sU°n of erhnmd penalties of a Zhu up to 51.500.00 and/or o�yam,imprisonment es weII as dvII penalties in the form of a STOP WORK ORDER and a line of 5100.00 a day against law. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verincatiom 1 do hereby certify under the pains mid penalties of pedury fh°t the lnjormaOn provided above is and c rred ��-�— Date Sigaature— — Print name._� —,-1�e9 t rc 1�� Phone# L42�6 6 Q�g - official use only do not write in this area to be completed by city or town official permit/license# ❑B»flding Department city or town: L jLicensing Board ❑Selectmen's Office ❑check if immediate response is required ❑Health Department • — ❑Other contact person: phone#: