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Home My WebLink About0006 ESTEY AVENUE F7 r �- i �� Town of Barnstable Building � "'.�,..:•,; f,.;a" �.-�.s .�,'tt "�` '. "',s .. .�'; ,;.:� v' ,'�,%' ' f z" ", ,�.. `� .,..,.z V •. PAost Th�sGar,,d So;That r �s Uisibie.From`the#Street A roved�Plans Must beRetained on Job andthis CardMust�`be Kept . BA1tNfiTAt33.6. ,L. x. ,firt '� • PP, l 6 PostedUntil Final Inspection Has Been Matle _ y Where a Certificateof-Occu anc is Re aired ,such Bu�ldm shall 1Votbe Occu led untllra;Final•,Inspectionhas beenJmad,e ' Permit l Applicant Name: Michael McMahon Permit No., B-19-1181 Approvals Date issued: 04/11/2019 Current Use: Structure Permit Type: Building-insulation-Residential Expiration Date: 10/11/2019 Foundation: Location: 6 ESTEY AVENUE;HYANNIS Map/Lot. 324 085 Zoning District: RB Sheathing: Name -.MICHAEL T MCMAHON Framing-: � Contracto�rw 1 Owner on Record: WENTWORTH,PERI S �: Address: 44 PRINCE ROAD 4� r: Contractorlicense' CS 068111 2 WEST YARMOUTH, MA 02673S Est Project Cost: $3,803.00 Chimney: Description: Weatherization,weather striping,air sealing,„blown cellulose Permit Fee: $85.00 � t Insulation: Project Review Re f 1 Fee Paid � $85.00 q Date 4/11/2019 Final Plumbing/Gas Rough Plumbing: '. .. Buildin Official ' g Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after•issuance. All work authorized by this permit shall conform to the approved application-and the;approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning b -laws: laws and codes. This permit shall be displayed in a location clearly visible from access street or'roacl and shall be maintained open for public,inspection for the entire duration of the Final.Gas: Work until the completion of the same. .. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and fire Officials are provided on this.permit. Minimum of Five Call Inspections Required for All Construction Work:: a-` Service: 1.Foundation or Footing '' Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 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 All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: �J 3 P : od/30� � �lime, Town of Barnstable *Permit# - $ k%jires 6 months firm issue date Regulatory Services Fee: 3SMASS , ---- ■ARNNS[ABI�, ' Thomas'F Geller,Director �-PREeS � 1'11M1d1IT I � V 111 -..Buildin'Div6i6n Tom:Per`ry;CBO,:Building'Commissioner, SEP 10 2013 200 Main Street,Hyannis,'IMA'02601 wwwaown:barnstable:ma.us. TOWN„ Office: 508-862 4038 i r�BLE EXPRESS.PERMIT-APPLICATION' '-s RESIDENTIAL ONLY Not Valid without Red X-Press Imprint -Map/parcel Number 3d / 015 Property Address(X F_s4� V. t*Ya�nd•tS Residential Value of Work 3�tXT.° r Minimum fee of$35.00 for work under`$6000.00 .,. Owner's Name&Address rtS Me Sprinkle, ome-improvement. = Contractor's Name 199 Barnstable Road, Hyannis-MA'02601 - Telephone Number 508 10 Home Improvement.Contractor.License#(if applicable) ` `;�037,57 F C8-006643 Construction Supervisor's License#(if applicable) &Workman's Compensation Insurance Check one: , I am a sole proprietor ❑ I am the Homeowner ® I have Worker's Compensation Insurance Insurance Company Naive A:I:M Mutual;Insurance Co`: Workman's Comp.Policy# 7004943012013 Copy,of Insurance Compliance Certificate must_accompany each permit. Permit Request(check box) Yarmouth Transfer Station El Re-roof(hurricane nailed)(stripping old shingles) All constiuctton debris will be taken to ❑Re-roof(hurricane nailed not stripping. Goin over. ,extstin la ers of roo ❑ Re-side #of doors 'Replacement Windows/doors/sliders.U.:-Value (in& um'.35)#of windows, a Smoke/Carbon Monox,de detectors -floor plans marked with,red Sr and inspections required.` Separate Electrical&Fire Permits'required 'Where required: Issuance of this permit does not exempt compliance with othertown departrnent:regulations;i.e.Historic,Conservation;etc. *.**Note: Property Owner must sign Property:.Owner Letter.of Permission. p�copy-o a Improvement Contractors License&Construction Supervisors Licenseis in SIGNATURE: h. C:\Users\decollikWppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\QRBZUBN\EXPRESS.doc Revised 053012 The Commonwealth of Massachusetts Department of Industrial Accidents ru Office of Investigations 600 Washington Street - ` Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers Aaalicant Information Please Print Legibly Name(Business/Organization/Individual): Sprinkle Home Improvement Address: 199 Barnstable Road City/State'/Zip: Hyannis, MA 02601 ' :- Phone #: 508 775-1778 Ext.10 Are you an employer?Check the appropriate box: Type of project(required): 1.[�[am a employer with 10-12 4. E] Lam a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6: ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the.attached.sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have,; g_ ❑ Demolition workingfor me in an ca acit employees and have workers' Y capacity. 9. ❑ Building addition r [No workers' comp. insurance comp.insurance.+ required.] 5.e❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I LE] 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' 1c4.UtPjj 2f comp. insurance.required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. '*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for tnv employees. Below is Cite policy and job site information. Insurance Company Name: A.I.M Mutual Insurance Co. Policy#or Self.-ins. Lic.#: 7004943012013 Expiration Date: 1/01/2014 Job Site Address: Cd City/State/Zip: mn/I(S 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 insu a coverage verification: I do hereby c t ains and penalties of perjyry didt the information provided above is true and correct. Si nature: Dater Phone#: 508 775-1778 Ext. 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): I.Board of Health 2.Building Department `3.City/Town Clerk •4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ztokti Town of Barnstable ° Regulatory Services • uxxsusr.E, • Mass Thomas F.Geller,Director 16 Bniiaing Division Tom Perry,Building Commissioner 200 Main Strcet,Hyannis,MA 02601 www.to wn.b arnstab l eana.us Office: 508-862-4038 Fax: 508-790=6230 Property Owner Must Complete and Sign This Section If Using ABuilder I, CX as Owner of the subject property hereby authorize' l tN - tbm, :rMb,,,,0ZMt to act on my behalf, in all tatters relative to work authorized by this binding g Per nut for. Le � - -(AddAss of Job SipaArf4f Owner Date P Q. Print Name If property Owner is applying for permit please.complete the Homeowners License Exemption Form on the reverse side. Q:FO RM S:O WNERPERMISSION L r SPRIN-1" OP ID: DS ACORO" DATE(MM/DD/WYY) CERTIFICATE OF LIABILITY INSURANCE; " 12r21/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS.UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE'COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.' IMPORTANT: if the certificate holder is an ADDITIONAL INSURED;the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the* certificate holder in lieu of such endorsement(s). PRODUCER Phone:608-775-6060 CONTACT Bryden&Sullivan Ins AgencyE FAX NAME' 88 Falmouth Road Fax:508-790-1414 AUCONN Ert: me No): Hyannis,MA 02601 E-MAIL Kelley A.Sullivan ADDRESS: INSURERS)AFFORDING COVERAGE NAIC If INSURER A:Associated Industries of MA INSURED Sprinkle Home Improvement Inc. - INSURER B i ^ - - 199 Barnstable Rd Hyannis,MA 02601 wsuRERc: 4 INSURER D: INSURER E INSURER F - - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR RODL SUEIR - POLICY EFF POLICY EXP - - LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MMIDD/YYYY LIMITS GENERAL LIABILITY :-. -. - - _.EACH 0CCURRENCE COM $ MERCIAL GENERAL LIABILITY PREMISES Ea occurrence CLAIMS-MADE OCCUR - i MED EXP(Any one person), $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $� - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ s AUTOMOBILE LIABILITY - ' � COMBINED SINGLE LIMIT' Ea accident $ ANY AUTO BODILY INJURY(Per person), $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY O accident)PERT DAMAGE° $ HIRED AUTOS AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE- $ DED RETENTION$ $ WORKERS COMPENSATION RY LA IT JI ER AND EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N AWC7004943012013 01/01/13 01/01/14 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? NIA. (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ "500y00 If yyes,describe under DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ - 500,00 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION ' SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. THE.,EXPIRATION 'DATE. THEREOF, NOTICE WILL BE'DELIVERED IN Sprinkle Home Improvement,Inc ACCORDANCE WITH THE POLICY PROVISIONS. Margo Mack - 199 Barnstable Rd. AUTHORIZED REPRESENTATIVE Hyannis,MA 02601 Kelley ASullivan 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD' " - y `y ;Unrestricted Buildings of any use group which contain less than 35.000 cubic feet (991m)of 1�assacnuser•.s )eparirner ol �, oiic enclosed s `pace. - Boarc vi -Bu,ia:ng Peguiacsons ar.0 s-anaaras. CS4)W643 is BRAD K SPRINKLE I"LOTHROPS LANE g� Failure to possess a current edition of the Massachusetts W BARNSTAEILE MA State Building Code is cause for revocation of this-license. ' F-DP i Licensing information visit: www.Mass.Gov/OPS ;110111s„:>{, 10/08/2043 Office of Consumer Affairs&Bustoess Regulation License or registration valid for individul use only ,.=KOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ` v�egistration: 103757 Type:, Office of Consumer Affairs and Business Regulation ',_ - Expiration: 7/9/2014 Private Corporatior,' 10 Park Plaza-Suite 5170 Boston.MA 02116 SPRINKLE HOME IMPROVEMENT,INC Brad Sprinkle ' 199 Barnstable Rd « 4` Hyannis.MA 02601 Undersecretary Not valid witho signature �oFrrurow Town of Barnstable *Perm it#o?dl L 2 Regulatory Services Errpires6,rontlrsfroirisrue(late 1619- 10� Thomas I', Geiler, Director Building Division - RESS PERMIT Tom Perry, CBO, Building Commissioner 200 Main Street,-l-Iyannis, MA 02601 SEP ;2 O 2010 www.town.barns table.ma.us Office: 508 862-4038 TOWN OF PA`.'90 �9D�'60 EXPRESS PERMIT APPLICATION` - RESIDENTIAL ONLY Not Vaiid withorU Red X-Prevs Inrpriiil _ Map/parcel Number S. 79rj Property Address Residential Value of Work °'� �(� Minimu4m fee of$35,00"for work under S6000.00 Owner's Name & Address � Contractor's Narne �j �— 3 ' ��/� Telephone Number. ` _77 Home Improvement Contractor License#(if applicable) . .. - r Construction Supervisor's License#(ifapplicab.le) Dworkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I m the Homeowner: ave Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request (check box) Re-roof(hurricane :nailed) (stripping old•shingles) All construction debt-is"will b.e 1 taken to V�d1,T/��✓� , ❑ Re-roof(hurricane nailed) (not stripping. Goring over- existing layers,ofroo•fl ❑ Re-side ' #of doors' El Replacement Windows/doors/sliders.U-Value (maximum :-35) #of windows. *Where required: Issuance orthis permit does not exemol compliance with other town department regulations;ire.Historic,Conservation,etc, **.*Note Property Owner must sign Property Owner Letter of Permission. A copy of the ome Improvement Contractors License & Construction Supervisors License Is j req s SIGNATURE: ✓^ Q:4PPILHS rORMSlbuilding permit fonnskCXPRGSS.doc . Revised 072110 r J, cense,or reg�stiationand-fo ,tndrv�duCuse only before the expiration dafe If tfound return to - Office of Consumer Affairs,and'Busmess'.Regulation F' t F10 Park;Plaza Smte 5170 I ;Boston;>MA02116 rs f �Al f , i Not valid without natiure ;I { i n Ogee of Consumer fairs Bc+ H ;`c BMQEM nsmessRe gnlaEMENT hpn ,;CONTRACTORRegistrtiao Oy14286 ExpiratrqLt. 011 TYPe>r! Tr# 293257 RLT GONST. 1;INell 1 S DING&RO i. RONNIE TAYLO� � TJ' OFIN I. 31 u MAN NI CIRCLE'` CENT�RVILLE �e s MA :IJnders'ecretsry J 7: - e Na. 1 E •� t/2 p g, \J .. 07 p .n..0 C . , :Q w N. - - o NCD . N J r. O _ '22/2010 09: 05 5084204,4.74 PALUMBO INS COTUIT PAGE 01 CERTIFICATE OF LIABILITY INSURANCE DA/TE DOZY a2121/j2o10 PRODUCER (508) 429-1943 FAX: (508)420-4474 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION William Palumbo Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, .EXTEND OR 4527 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Cotuit MA 02635 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A;Travelers 393s7. RLT CONSTRUCTION INC. irvsuRERB;GuaTd Insurance Co 31 MANNI CIRCLE INSURER C: _.......--•--..... --.__..--..__.-_..... INSURER D: , CENTERVI LLE MA, 02632 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 'IMAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCR18ED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OFSUCH (POLICIES.AGGREGATE LIMITS SHOWN.MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADD`L POLICY EFFECTIVE POLICY EXPIRATION LIMITS OF INSUjiQN�E POLICY NUMBER DAr5IMM/rpWYY1 I DATE IMM/DD/YYYY) GENERAL LIABILITY •EACH OCCURRENCE ._S ......._1 ,000,000 - 'trAMAGE TO RENTS �1 X1COMMERCIAL GENERAL LIABILITY PREMISES(Eeoccurrence) _a -300,.boo - - ,CLAIMSMADE XIOCCUR:68D8475N705 8I1I20.09 8/1/2010 MEDEXP(Any oneperson)• •.3-:;_- 5,000 PERSONAL&ADVINJURY S• � ,000,000 1 GENERAL AGGREGATE S, 2,,000,000 r _ _ _ LGE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS;COMP/OP-AO© Er 12. QQQr000 POLICY PRO- I LOC ----- - - -- AUIOMOBILE LIABILITY COMBINED SINGLE LIMIT . 5 ANY AUTO '(Ea accident) _ � ---- --... -•--• -- --ALL OWNED AUTOS BODILY INJURY B SCHEDULED AUTOS .' - j...(Par Parton) HIRED AUTOS - - BODILY INJURY - -- (Paro=ldonl) $ L_ NON-OWNED AUTOS PROPERTY DAMAGE $ i - —-----— ---- (Per accldanl) GARAGE LIABILITY AUTO ONLY-FA ACCIDENT $ -- --ANY AUTO OTHER THAN EAACC - - AUTO ONLY: A00 :$ EXCESS/UMBRELLA LIABILITY " 3 - + FACMIOCCURRENCE $ _ �.D OCCUR CLAIMS MADE AGGREGATE.--••-----.�___,.: ,., DEDUCTIBLE RETENTION $ S WORKERS COMPENSATION WC STATU- 0TH- B __IJORYLIMITB 1. ...�_ER.____,_.--___-_—_._.. AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE�YJN E.L EACH ACCIDENT $ SOO,000 OFFICER/MEMBER EXCLUDIE I " I _ (MgndgtoryInNH) V 019737 12/24/2009 12/29/2010 6,L 015EASE EAEMPLOYEE 8 500,000- IFyea,deacrIbeunder SPECIAL PROVISIONS Below E,L.OISEASE•POLICY LIMIT S 500,000 OTHER DESCRIPTION OF OPBRATION81 LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Bob: .100 Eatey Avenue, Hyannis MA 02601 r CERTIFICATE HOLDER . CANCELLATION SHOULD ANY OFTHU ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION • Town Of BarnstElble• DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL'10- DAYS WRITTEN 367 Main Street NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis, MA 02601 '. . , - . IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE � � - {�—� (`�• �- j LaRocca, 9r/SROGER c! ACORD 25(2009101) 19e8-2009 ACORD CORPORATION. All rights reserved. IN5026(200s01) The ACORD name and logo are registered.'marks gfACORD ls&nd Siding and l ofing a division of Pf-T Construction,-Inc. 31 511anni CircCe Centerviffe, 'WA 02632 Hans Engels September 13,,2010 , 6 Estey Avenue Hyannis, Ma. We are pleased to submit the following specifications and estimates for reroofing: :Remove existing asphalt shingles and flashings. Install 5/8" cdx plywood to fill in gap of existing gutter detail. Install aluminum drip edge and pipe flashirigs. Install 3 ft. ice and water shield to eaves,valleys and interwoven with step flashing. Install 30 yr..CertainTeed Landmark architectural grade shingles. CS Install ridge vent to all ridges. „ J �T Clean up and haul away all debris.to landfill. We hereby propose to furnish material and-labor.' coniplete in.accordance with the above' specification, for the sum of. Main house...:$6,840.00 Garage..... . .$4;730:00 To install rubber to existing gutter detail instea p ywood.Main......$7,770.00 For garage......S5,400.00 Terms: No deposit required. Payment in full is due upon completion: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviations`from the above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the"estimate. All agreements contingent upon-strikes,accidents.or delays beyond our control. Owners to carry fire,wind damage and other necessary insurance: RLT Construction, Inc. carries General Liability and Workman's Compensation Insurance. Certificates of Insurance provided upon request. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and hereby-accepted. You'•are-authorized to.'do the, 21 spe ified._ Payment will be made as outlined above. Date of Acceptance: Signature Start Date d,(O Signature The C'ornMotrwealth ofl'lfassadnisetts - ---: Department ofIndrrsirial Accidents �—�- Ogice of Investigations ( , Gt7Q Washington Stree Boston, JV4 021'Il faUIM mass govIdia 'Workers' Campensation Insurance Affidavit: Builders/+Con:ti•.-tctorsJEl:ectlicians/Pl:timbers Applicant Infoamatio:n PI ease Print Le 'blti• Name. (Business/Drgaiiization•'Individtiiall),/ Address: city/state zip: G Phone #: � Are y an employer? Check the appropriate=boa.: Type ofproject(requited): L.ffl ant a employer with 3 4., 0 I am a general contractor and I eaVloyees(fu1C and/or part-time). * have hued the sub-cantractors 6- [:].New oonstnic.tion 2..❑ I am a sole proprie cT or partner- listed on the attached sheet: T ❑.Remodeling ship and have no eni 1a rees These sub-contractors have P P ) 8. 0_Deuwltion tivorkuig :for me in any capacity. employees and have workers` [No xvorlcers' conap,insurance comp-insurance. Y p. �.Building addition 5. We are.a co•i oration.a.vd it.s 10:❑.Electrical repairs or a.ddititans required.] ❑ P 3.❑ .I am a.homemimer doing all work officers;have exercised their 11.❑P cubing repairs or additions myself. [No workno'comp. right of exemption per'NML Roof repairs insurance.required.] t c- 152, 1(4).and.'"Ie have no i_ p� employees.[No workers' 110 Other comp-:insurance requiued.] 'Any aPpticant thstchecks box#1.nust also fill out the:section betow shaving their wwken'compensation policy infonmtian- 1 Hamem mers who submit this affidavit indicating they are doing all work and then hire outside-contrRoors mast cabmit a aew.effidm,it indicating sucIL 'Contracims that check this box mirst attached an sdaioaal sheet showing the'nsmr of fbe sub-coufrsc:tnrs sad state whether or not fhose entities have employees. Ifthe sub-conUactorsuve employees,they.amstprovide their warken'comg.policy number. Iaril art eutplay r that is pro+idirrg error leers'.canrpcarsafiort ittsJrt rsrrccr for rcty eitcpla�ees. Belau is the police anal job site information. Insurance Company Name: Policy#or Self-ins-Lic..#: Expiration Date: 45 Job Site Address- / - / �'!�/`�. City/State/LP: Attach a copy of the workers'.compensation polic}'declaration page(shoxIdng fie polic3'numb r and expiration date): Failure to secure coverage as required under Section 2.5A 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.a s ci-vil penalties in the form of if STOP'[VORP°ORDER and a fine of up to$250.00 a day against the violator.-Be advised that a copy of this statement n ay be.forwarded to the Office of Investigations of the.D.IA for insurance cotii-arage verification. I do here ky certify tPt dues and rt e of p�Iajuty that the rrrforttiahott pro uteri about es truce a lit correct. Sienature: Dater Phone Official use:only. Do not wrife in this area, to be conipleted by cite or f01tilt official, Ceti or Tozi'n: PermitlLicense# ". Issuing Authority(circle one):. 1.Board of Health 2.Building Department 3.L`.ryffoivn Clerk 4,Ele.ctricnl Inspector 5.PlumbingInspector b.Other Contact Person: Phone#: