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0037 FRANKLIN AVENUE
�'7 F�gNKG !iy fl v c r 25 10 08:30a p,1 Barnstable Leased Housina'Dept: 508.771.7292 e�ar+sne�eTelephone 508.771.7222 Housing Autho' rity FAX: �os.77s.9;12 146 South Street Hyannis MA 02601 ZONING VERIFICATION TO: Linda/Robin l FROM: Kim Gomez, Leased Housing Coordinator _ _ M PHONE NO#: 508 771-7292 FAX 508 778 9312 RE: LEGAL RENTAL UNIT VERIFICATION ' DATE: / -7?_� ADDRESS: VILLAGE: UNIT TYPE BEDROOM-SIZE. MAP & PARCEL NO: The owner,of the above listed property is entering'into a dontract with us for rental of the property listed above. Please verify by,signing below that the unit is:legal and meets all zoning requirements for a rental in the town of Barnstable. If.it,does not, please list-'the reason below: ;,ank.yo r your ass' e in this matter: a e Print natne Date: D VIA FAX: 508-790-6230 } ;Equal Housing Opportunity Agency 40 �ranrl �r +�� a 3-9- l� e,,O�owl F VE Town of Barnstable *Permit# Erpires 6 months front ksue date Regulatory Services Fee MASS. Richard V.Scali,Director S25 0 Building l s aft Tom Perry,CBO,Building Comm.sston - 200 Main Street,Hyannis, 26D www.town. f�mya.us 2011 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIW U ONLY A D / Not valid without Red X-Press Ineprint Map/parcel Number Property Address /v ko Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address1 Z Contractor's Name W1 010 WoPI �/GFF S ie FL Telephone Number 791 p3L - z/S-01 or- r3 � Home Improvement Contractor License#(if applicable) /66 OZ.,6' Email: Construction Supervisor's License#(if applicable) 67 2_7 7 Z. - YNorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner (� I have Worker's Compensation Insurance Insurance"Company NamerD '}'II�,� �NSee M k / Workman's Comp.Policy# 22 W�.CI--T Z6 3,5 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ 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 roof) ❑ Re-side ?,6— ReplacementWindows/doors/sliders.U-Value t O (maximum.32)#of windo #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 equired. SIGNATURE: C:\Users\Deco)I 4tajcari�M�0.smdows\Temporary Internet Files\COntent.Outlook\2PIOI DHR\EXPRESS.doc Revised 040215 r _ `Window World of Boston,LLC MA HIC Registration AffiCos&ShowrOOMS Number. {A�LddG t4A Cummings Park 0 295 OJd Oak Street 166025 Woburn,MA 01801 Pembroke,MA M59 Federal ID# P (781)932-4805 (781)826-6281 27-1461665 : "Simply the ElestjbagS3 www.WindovAUorldci8oston.com hii Customer: f Phone(h) Install Address' Phone(w) cnv State:MA Zip Q1(2G` 6mali WINDOW WORLD GLASS OPTIONS _1000 Series Single-hung AIWMd $189 Solar2one Elite 2000 Series DH MechlWelded Sash $195 [Triple Glazed TG2- $176 :K:40D0 Series DH All-Weld fsseries s000or _6000 Series DH A JhWeld $240 WINDOW OPTIONS _2LJtsSlider $334 _Glass Breakage Warranty $151NCLUQED 3Liteisfider arA,a,,ral (Imutim $525 ____.1/2Screens $slNfxuDi:D _Picture/Fixed Lite $334 _Foam insulation on Jambs and Head $11 INCWDED Awning g280 _Double Strength Glass $t5 INCLUDED ---Casement $29D Double Locks(>26') $5 INGLUDED 2 Lite Casement $,575 TFull Screens $22 3 bite Casement l,n,+a,nr nr+,k9 van $860Colonial Grids(Contoured/Flat) $45 _Prahie Grids $51 _Basement Hopper $334 _Diarnorai Grids $- _Bay Window-Soffih Mount I INS Seat$2660 Simulated Divided Lite $182 _Bow%ndow-Soffit Mount I INS Seat$2765 —Tempered DH Sash(BSO)(TSO) $85 _Garden Vindow $188D Obscure Glass(BSO)(TSO) $35 ,Spec"Window—$— Oelet Stfle(40/50 or 60140) $3Q Beige/Almond $4C _Foam Enhanced Frame $35 wood Grak,Interior(Series 40001 b'000 only)$100 PRE 1978 BUILT HOMES(Federal Lead Contain nl t Lat4 &kjWCekl Dark 0*CherryI Far Wood Lead Safe Practices Required p� $25 -Rjcl7AA Are) MY HOME WAS BUILT IN THE YEAR`� '!�k•Rtiti _Brain Exterior(Arch.Bronze l AunericenTerra)$100 MISCELLANEOUS _Designer Color Exterior g155 custom Exterlor Aluminum Cladding W'mdax Color _l F Textured$75 ❑SmoothG-B$75 $ Facing Color lralde oufs;ab _Metal Window Removal $50 NON CUSTOM DOORS _Now Cmiskurtion Vinyl Removal $175 !�Vinyt Racbtg Patio Door lift.or eit SS95 —Speciality Window Exterior Trim $ Anyi Boiling Patio Door an. $1o95 Mull to Form Mufti Unit $sq __ ddtobasepdraforGustornRo8iit9PatioDoor$1ISO Install Interlorif3rtermrStops $50 — Freneh Rail Sibling Patio Door 50.or aft $1295 __Install Interior Casing Starts At $95—J—� French Rail Sliding Polio Door eft. $1396 _Insulate Weight Boxes $20 bait J _French Rail Sliding Patio Door 911t. $1496 _Roof for SaylBow Windows $500 Custom Exterior Cladding $150 Existing New Const.Ent.Beira,Fit $150 =SdarZone Elite or ETC Casa $17911C Removal of Existing BayylBaw $250 _Grids Patio Coor S129 _Repair Sol,Jamb or replace sill nosing $50 Weadgrain Interiors $2 B _Full Sub-Sill(Single)replacement $15C �FxtedcrDesigner Colors Munion Removal $30 _L_iMer o.Casing 219 - $175 _ Say/Bow Conversion lid,Retro Fit $850 liandt6set options $ (New Siding Will Not Match) $ ____Building Permit Door Color N1__-�� t$QtIN�-�p:FOiE $tWQW 1NOACt7.�� • rrsrde °"tom r du'd>C1D�dceq ASI k: �"�",•` Customer declines exterior wrap and understands A rt�g and/or repo$may be required Initia Customer deol'mes rids on 2 wIndow9ldoors Initial OB A :Ctdtamerisrespundble for ttxfob t Inconsecuei vim ifisM*mtPa'nOtg,swam Atemnsystemdacermit ntonneet&000parmitleEsin eaeesa of;25.00,Homecwnwar d ar Ca do Assceiatlen Apivoval,Nlsimic olstddApproM.CRY of Boston puff&sidewalk Parma fees in correction with Insfav Ok. NO EXTRA 4YORK IF NOT IN WRITING! Extra agrees tot the terms of payment a9 foll ows, 6dra Labor&Materiels $ Site Sat up,Disposal&Delivery Fee $ $195.00 Total Amount $ Custom Order Deposit W% $ fit# Balance Paid to Installer upon Completion $ Amo" iawed $ 1Nrndow Worts of Baslonahbcipates stoning this wank oAAQ�ZkR131/3%-aru3 being substanlally completed in T. s.SeaaiM Interest�s N Any depot required in advance of Ire gait et UR want of!M toil contract price art a IcW cast of any material or equifored of a special order or custom made nature,whish must be ordered to advance of rife start of the tvotkto assure that the project will proceed an schedule.Nodna payment shelf be demanded land)de contract is oampletmto the satisfaction of both part. - Ail home improvement earlrecim and subcontractors shall be registered and that any Inoldres about a coital or subcordiesla r refining to a regishalOn should he directed to:office of CasamerAffairs and gasmess Regutatmn,Ten Park Vim,Suite 9170 Boston,fAA a2116.Phone:(617)973-0700 Rework shall begin piorto Itur abiolag o1 the contract and hansm'Mal to the amf Oda copy of such CGM'n6 Window WWd of Easton underpravisko of Chapter 142A ofthe general taws Is requhel to zpplyte and pble`.n all tonsWdiawelated permits.WildodMiki of 8aston shall not be deemed responsible for delays In1w work desctdrad in the agreement caused byragt4alory,pamdl granting agencies,autheitles or individuals. Rouse:Bthe PURCHASERS)olttsias his moo cwrabueiion related perralls tarthe work descdbed under Ibts agreement ordeals with erreglskred contractors, the pURCHASER(S)is bereby adclsed Bnal to the event of a dispde,jtMgsrnent sod nenpaymeol,tire PURCHASIRM win not be en4Red to Bloke a claim or cdledien[ram the exam*fund established by chapter 142A,MALL 1 buyer may cancel is trehsabdo at any lace Pict ig 01 [Bird htrsness gay alter Unadate ,this ealNsatian. Notice 01 eaneetlalion must be in WritingpasUaarked no lain than nedaigitt tii the bitoiweg third buaiResa da"y FOR RES This ih5n.World,RancRseisbM ends owed and Operated b Window thtdaofBo tLC.under Bcadso from ftdowvvmld Inc. • -:mar: not a�n a ny btar k spaces. Date i salasm nets N there are any blank spaces. Date owner.oe nor srgn if theta are any Wank apaM. Data easrcneru Wh?te Copy-Original Yellow Copy-Flle Pink Copy.Customer Hares Pdrsmaeew-able Niassachuserts Department of Pubiic Safely Board of Building Reguia;ions and Standards License:CS-072772 JEFF C STEELEg ` 24 SHERWOOD AVE r S� .- • ` DANVERS MA 01923,. y l" Commissioner 04107/2018 1 _ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: 186025 Type: Expiration: 4112/2018 LLC WINDOW WORLD OF BOSTON,LLC. ' JEFF STEELS 24 CUMMINGS PARK SUITE 15-A j - WOBURN,MA 01801. - Undersecretary I. License or registration valid for individual use only. before the expiration date. If found return to Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 l Boston,MA 02116 7. 1Not valid without signature DevarMefi*of jndms aI Ar=idenfs Office Of ir'-peg4vadorgs Coang nss .gre4 .Rua I - L �-���= 3^✓'F'.�PJ 3t�LEt�J,§o8Q1`t�u���c R _�ada-1 .BuRder,s/CLR "�� �a`��a please Le � ,N�,::e (3saess/Cri7oi>( diVidLai}- r.UMNlstiGS A? SJl i�—r� _ • � • „ Nun 0180 i e—_78�-932-48C5 { d -o 'hype of {re �;- Jo' air rs� rate bey: I - �- 2G- an a�enetai con acza, a;,d I �{New cous: 2 enplO�' w'`S ,tca-�OFs ° on �a e 1-ee, .2 sob-coi lie odeu a C eeS and-for, -- , 'o- a -,e;. Listed oo rtie welled e2ee a sole;,��-etc-or pa- er coo g_ !7eulol=tiou am aese sub-coita �a" si„� a-d gat-e�o ez, io ees �,� -S uildingr add�on i eja ees a1f1 ave cJri_�.,za p ! LOT 1e m anv=Paclv- coup_-mar ( �t-L _Ieci_cal repat=s qr ad2itious ri - COAL_ ,_-a�Ce _ ts�0 w0._Co S �r Z Zre a cJmora`OL aand i_ l Ti_..�°bbg or a dl onS y���^, .:���� else'=� .,:•.,�_ i A. _i i Z 2�o^eo�Ater seine a� �nr,_`: s 1\�F' { 1. ---par,S I L vi C:a?—LFJ"LSQZ je , { j�-f 1 `JOi Qpy. 3 n 5- anCG '3 \ i. Other! olrP 0� i s_ _e eLnpio ees-. - co3N.LS-k�•��..c s _ the section sho�g&e"sa*ori e:3!comI3.s�orpoiic}�o�on- 4� - - must also ail ont submit a nm davit iIIdihies h such -� a�plic^�nt ..z:checis bo ..: Q outside coatracto;s must en'risues have omea�en>rs vile SllbMtt?rus z.da.i=indicaring�e�arz domes ali Karl:and then ahe saLkiu tni~_and sme whether or not those Conrlvc;o s hat chec:t[1is box,7i11SC a-aceee an additional she *shon�g the nme a_'dte +o�e iplovz _they uusc provide the .goners coma Doric..number- ;,pioye - li tie subs ohcactos ?tLob Siew t s? s�mfzes7 e , an rcc�: �j' •..off '7c'FIJ=.`-'.:zra�fl?2•i{orS EfS !?;z.� _ - _ ly ce Company Name' �. i t vt7.L� S��SIJKi-kt CL �77 2211�'=C :2E85 - i:a�onDAe:� - - � IS JG �� •:r1ZSS- cc -c`fie p4D'fic o rc' e'Y,�Sac=©�r'9. L• � q�'�65 CI� =aen a C5 %�=>�E;For_e_ c3 osi;ion o= P - r Q required under Section a e-er VvT c_ 15, cam Lead Lo the iC& � ���` ER Ene tc secLe cou e=�-e as=-i Ene r I.d�U_� a'elE'tlr3=�T1e;rem 1�1'�riScJaIDec"!i,as.Weld, as C'vLr s i=� 1e iO I of a S i©- :a the office cry G c<��p _o S25C:.? a eat 3�a;rsi pe zzoiator: a advised tea,a copy.ors s`aieneut nay 5e forwar ce coveraa eri.5ca'ou. L.'Csu�ai'O� of heDIAior ca "r c au�iried sbove - re e`` _T t off' ©ir, t�Y�E��Jl ie.'�.•fl a.•:•� .r` a� p V Sim 'Do"Of Write zi r;.2 �'elr, Or_e-.sr.•z p� cCl - 'is e { �e���yCw�3§E;1• i �ssujaaAlt L !,.--e9e 43a�i@F. ,t+ �Tfie��e-a�F E -� ceet s.C k Yf:artl"!5G C,aeFa Il = arm�_Hea` i-�" i4.17�5eWi �F„A-a$^ WINDO-2 OP to:WI ®RQ� 70T E(MMDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1/25/2017 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 CONTACT Carli Witcher CISR,CBIA,CIC Senn Dunn-GSO PHONE NAME: 3625 N.Elm St. 'VC,No,Ell:336-272-7161 FAX No): 336-346-1397 Greensboro,NC 27465 E-AJL Bess:cwitcher@senndunn.com C.Timothy Ward,CPCU,CIC INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Citizens Ins Co of America 31534 INSURED Window World of Boston,LLC INSURER B:Allmerica Financial Benefit 118 Shaver Street North Wilkesboro,NC 28659 INSURER C:Hartford Fire Insurance Co. 19682 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. I�jR TYPE OF INSURANCE IANSD WVD POLICY NUMBER MM DD/YYYY MM/DD EXP LIMITS t: A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE �OCCUR OB6790252707 04/01/2016 04/01/2017 DAMAGE RENTED 500,00 PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PRO- 11 JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 U00 00 Ea accident , 01. B X ANY AUTO AW68757615 06/16/2016 06/16/2017 BODILY INJURY(Per person) $ ALL OWNED FS CHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS UAB CLAIMS-MADE OB6790252707 04/01/2016 04/01/2017 AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 22WECU2635 01/27/2017 01/27/2018 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION FORINFO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Info Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION t_ 6 Map Parcel Application # � Health Division Date Issued l v Conservation'Division Application Fea�� Planning Dept. Permit Fee -� Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis I Project Street Address `'4 0 T-zZAiU .b-1 ,-f_,,6 Village Owner L! _Address C J}� � Telephone �� [2 Permit Request loe�",E Square feet: 1 st floor: existing g proposed 2nd floor: existing proposed Total new: Zoning District Flood Plain Groundwater Overlay o ,:3y OO Project Valuatio �o Construction Type ' Lot Size Grandfathered: ❑Yes ❑ No If yes, attache'u' porting,4pcuqp7,�ntation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes )( to On Old King's ighway".-U Yet? XNo Basement Type: `�(Eull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing ' new Z_ Half: existing new Number of Bedrooms: 21- existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes J�>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: 1existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes *No If yes, site plan review# Current Use "o JC L Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) y.! ,Name l' 6�w Telephone Number Address % License # J Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ~�'� __.ter DATE 0 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. r ADDRESS VILLAGE OWNER ' 1 . r 3 - DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING(-A D h• a DATE CLOSED OUT f}� ASSOCIATION PLAN NO. • _ t X� The Commonwealth of Massachusetts Departrnent of Industrial Accidents 1 fir' Office of Investigations _ 600 Washington Street l rz Boston, MA 02111 www.mass•gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Address: [A0 U 0 /Stateai Phone #: h Ci IL9 0 S tY p Are you an employer, Che k the appropriate b Type of project(required): 1.❑ I am a employer with 4• 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.❑ 1 am a sole proprietor or partner These sub-contractors have ship and have no employees 8. ❑❑ Demolition ees and have workers' working for me,in any capacity. employ 9 ❑ Building addition [No workers' comp. insurance comp. insurance.$ *quired.] SWe are a corporation and its 40.❑ Electrical repairs or additit 3a homeowner doing all workofficers have exercised their 11.[] Plumbing repairs or additit elf. [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' 13.00ther 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. tContractors that check this boxxmust.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, 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information: Insurance Company Name: Policy#or Self-ins. Lie.#: 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 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 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 tender the ins andpenalties ofperjury that.the informationprovided abov is true and correct. Si nature: Date: Phone.#: Lo 6� 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 Phone#: Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, andemployee 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, constriction 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 compliance 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-contractor(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 penirit 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 that must 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 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617.-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-774.9 Revised 4-24-07 www.mass.gov/dia � T i Town of Barnstable Of TrtE rye Regulatory Services uxxsr�sce Thomas F. Geiler,Director MAS � 163,p. ' Building Division arED k Tom-Perry,Building Commissioner' 200 Maid'Streetx.Hyannis,MA 026.01 " �srw�v.to�sn.barnstable.ma.us Office: 508-862-4038 Fax: 509-790-6230 HOA,EEOWNER LICENSE EXEWTION G] ?]case Print DATE: 2 1 �D JOB LOCATION: 4k umber street . 79 village ' � n -"HOMEOWNER': `///'. . n me. ome phone# workpbone# CURRFiNT MAILING ADDRESS: city wn state rip 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 lice=,'proyidcd that the owner acts as supervisor. DEFINMC>N OF HOMEOW FR Persons)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 "hameowner"shall submit to the$tulding 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) ility for compliance with the State Building Code and other The;undersigned"homeowner"assumes responsib applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/sbc understands the Town of Barastablc Building Dcpartrpcnt minimum inspection pro edures and requirements and that he/sbc will comply with said procedures and rc cmcn Signature of Homeowner Approval of Building Official Notc: Three-family dwellings containing 35,000 cubic fcct or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S ExEhfPTI ON The Code states that ".Any homeowner performing work for which a building permit is requirmd shall be exempt from the provisions' of this seeGon.(Section 1'09.1.1 -Licensing of construction Supervisors);provided that if the homeowner rngages a pnson(s)for hire to do such work Ihatsuch Homcowors shall act as supervisor." Many hoineowncrs who use this cxerrrpdDn arc unaware that they arc assun-ing the responstbi)ities oC.a supervisor(sec Appendix Q. Rules &Regulations for Licc wing Construction Supervisors,Section 2.1 S) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicarscd persons. in this case,o rn our-Board cannot proceed against the un)iescd person.as it would with a licensed Super-visor. The homeowner acting as superosor is ultimatr)y responsible. To ensure that thefiomcownci is fully aware of his/her responsibilities,many communities requiro,as part of[hc permit application, that the'homcowner ecrhfy thathdshe understands the respm vbilities of.a Supervisor. On thc'last page of this issue is a•form currently used by scycral towns. 'You may care t amcnd and adopt such a forrr)ccrtifi -anon for use in your community. . r Y ram' Town of B arnstab-Ze Regulatory Services M 4 4 Thomas F_ Geiler, Director t63¢• �.� o Building Division Torri Perry, Building Commissioner 200 Main Strcct, Hyaaais,MA 02601 www.tow n.barnstable.ma:us Office: 508-862-4038 Fax: 508-79( Property Pro er OWAer Must . Complete and Sign. This Section zf US in �Bui er I, as Owner of the subtect.property hereby authorize to act on my behalf, is all matters relative to ork authodwd. b building permit application for. (Address of job) Signature of Cr Da Print Nam-- if property owner is,applying for pest please complete theHomeowners License Exemption Form on the reverse -side. The Commonwealth of Massachusetts Department of Industrial Accidents ,. Office of Investigations I 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leiribly Name (Business/Organization/Individual): 1 V 1 l S A,--,,�z, S Address: l `` -• .\ �r����. City/State/Zip: Ik \k r\S IO Phone#: S 1 `f Y 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 6. ON eyv construction �fnployees(full and/or part-time).* have hired the sub-contractors , 2.® I am a sole proprietor or partner- listed on the attached sheet. 7. M'Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y9. ❑ Building addition [No workers' comp. insurance comp, insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 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. tContractors 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. Insurance Company Name: Policy#or Self-ins.Lic.M 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. Z-1 Si nature: ^ / �`-_-. ... Date: L Phone#• (d 1 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#: C' f f- i i�- 11 - i - i CJ i -- -- �-- - � - -- � I -_ - _ I I > - -- _ � I ---- - I _ - - ill ---- _ _-I _ _- i r f l If f , _ , : = f i I