Loading...
HomeMy WebLinkAbout0054 FRANKLIN AVENUE ,� — _ �. �a Town of BarnstableBuilding t PostThis* �AIW3CA[iL.6, a 3�R> CardSTh;%a t,^rti 'V�s�ble>From the,Street °App \n6sMuse u. ., yob bada, s .. M < Keso ro �usbept • M` Posted Until'F�nallnspectron Has Been Made wk . : ` 6sA . ;•. • Where�a Certificate`of Occupancy is,Required,such Building shall Not beOccupiedntil a Final Inspection has been made e�n11� ._iris .... a. �.... Permit No. B-19-71 Applicant Name: YARMALOVICH,ANDREI &GLEASON,ANASTASIA Approvals Date Issued: 01/17/2019 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 07/17/2019 Foundation: Residential Map/Lot: 292-045 Zoning District: RB Sheathing: Location: 54 FRANKLIN AVENUE, HYANNIS �r , i Contrattor Name Framing: 1 Owner on Record: YARMALOVICH,ANDREI&GLEASON, t cense Contractor Li 2 I Address: 29 MILL POND ROAD I w Est Project Cost: $9,000.00 ! a Chimney: WEST YARMOUTH, MA 02673 , Permit Fee: $95.90 Description: Adding one more bathroom on the second floors Pa Fee id $95.90 Insulation: Project Review Req: Date, 1/17/2019 Final: R - wl um mg/Gas PI b' ( 3R, Rough Plumbing: Building Official 1 Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorzed by this permit is commenced within six'f nths'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. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws acid codes. This permit shall be displayed in a location clearly visible from access street ororo6&5nd shall be maintained open for'public mspectio%n for the entire duration of the ; - Electrical work until the completion of the same. Service: The Certificate of Occupancy will not be issued until all applicable signatures by the,Building and Fire Officials are provided onahis permit. Minimum of Five Call Inspections Required for All Construction Work: ' §. „ Rough: 1.Foundation or Footing 2.Sheathing Inspection Final' 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 Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. "Persoktracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Final: Building plans are to be available on site\ All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT p Application Number...... ............................. .... ... nsnee Permit Fee............✓,...„I 1..........Other Fee........................ 1639. Total Fee Paid: ....... ................................ ......... ...... TOWN OF BARNSTABLE Permit Approval by....... .........on..... lviap....... BUILDING PERNUT of....... ........Pa=l........�J-�....................... ................. . APPLICATION Section 1 — Owner's Information and Project Location i Project Address -5 F Village Owners Name /-7-1,97-bo ylfCA Owners Legal Address -� City, r2 state_ �Zlp d<2 -1 Owners Cell# E-mail f� s Se tion-2—Use-of-Structure Use Group Commercial Structure over 35,000 cubic feet � ❑ .0 rro V mmercial Structure under 35,000 cubic feet gle/Two Family Dwelling Section.3-Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement . ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ® Sprinkler System ❑ ddition ❑ Retaining wall ❑ Solar Renovation ❑ Pool ❑ Insulation Other-Specify Section 4 Work Description Last updated: 11/152018 Application Number................................................... Section 5—Detail Cost of Proposed Cobstraction Square Footage of Project Age of\Structure Dig Safe Number #Of Bedrooms Existing Total#Of Bedrooms(proposed) 110 MPH Wind Zone Compliance method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics Wiring ❑ Oil Tank Storage EY'S moke Detectors Plumbing ❑ Gas ire Suppression ;"HeatingS stem ❑ Maso Chimne ❑Add/r 1 y my y e ocate bedroom i Water Supply ❑ Public ❑ Private Sewage Disposal ❑ municipal ❑ On Site � P P Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage # of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed , Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No a Last updated. 11/15/2018 ,. TJL _ u —T jI — i _if 1 �T .,' _ a t a r _ , _1 r�'!�:_J. �1 j1 . ,_j1 I , l� — - ( 7 1 � IF_ ;S Ire TVu 1 A'n 1 V_ I i 9 , � S , 4 +� a �� �1._ _ I J � I +_ r� lrL_ 1L , r I ff a I — ! I _j IL itL._1 .1 ! i _ _ _ _ a , � I � ' a -— - -___J !j_. 1 ten• } _- -�:� --_ ':, 1 0 LT F { { CD 1-7 � 1� f�� ' �� �� �1 ,� ��'�Is ���'��l�i'-/+�o�i � r `��' � i,•-^tp�� - ►�`� ���' I �. LDr J_ ,k A V, N f — {7JL _ J" J_ t , �t-'--��-,f I r..-�II�,.`r�r -�I r i 1,11 _ r , _ G i I AL I fi ,'{ � _ ! ' ���.y�� L L _J L , JI. , 1L y J� , if IL a I 16 r �. _. _,._ ., .,-,,...r.r ., —r-- •--_--m> .._...f:--_ ,ram---„ ---.. „ '..- '9- -_ - r of A i a I� l__'._ i� L �- ____� if "IF ir I ! , f$ I Y .r , al k e' I 1 , j I . J y r I � r 1 ' r I r�. r ' f , 9 I I I _ I I ! I It - ` 1 � I� - _A-�r_ �� - _ r - _ i IL IL 1 It t J a _ A r F ,t i 4 -ti II �� _.' - •�{• _ , --"j ��:-� .�. It I'. - •— ._.lam—.,— � _ _ ��'p __ a ► I i -NIS J1 � �C JjL ji .� - �,,, - e _ I � * —.r-- — - _— `— - _ j. F Il r� 4 I J i _ 1 t, 1, i, qi ��,.�„-� '�� �� � _ 1 _ �_. I , ���L �'� ��t I` I ��-�J,-�--- -J(--,'r=�J�`�r I �1 i�_ �Z J� fL _ L_J �fFJL Jb J _ {lames i� J 1rt =At �E3�tY- ' �.�� € €I ] �� 1 3 - �` �i•' - 1� �� �•- if 7 - �r -r--. - aim., ip� 1. ,• ?i. I ji r- 77 CD 1 t j � I'� _ f��L { YAM�h €�_AIL IL }f J� 1 DFL= t 7�. r { b t { ���JL.-�.i���✓�.��..���—!L r�-,� J�i _ -.J{ � _ Jl 1r .€'J 1•—•� .�I �� { , V -• I 1 {j if '6 _ r I I _ - - - - ' I .. __yr. ..11__ ::_ :.e--IS 1j--: •- ,r - _.�� �,__ __ _ __- � _. _. - I r " I , I 1 , I I i I I - 1. ir 1 � ¢ : — _ .— r_�.�r—^• --,Yr I it r II r ow A L I I • �r---:w ,� -.�-- r -i'- - - � I i If li t i Jy - � - II �r ' L „ ji If �� � V •! !� I I II 91 } el to ro `, it J r � r I • i, The Commonwealth of Massachuseffs Department of Industrial Accidents Office of Investigations_ 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): Address• r 2-,9 17 �r 'City/State/Zip• /�2 > ��� Phone#: 6 F 2 F0 / �`P t(, Are an employer?Check the appropriate box: Type of project(required): 1.Are a employer with- 4. I.am a general contractor and I 6. D New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet:. 7. E]Remodeling ship and have no employees These sub-contractors have g• Demolition working for me in any capacity employees and have workers' [N orkers'comp.insurance comp.insuran0et 9. ❑Building addition • ed] . 5. We are a corporation and its 10.E Electrical repairs or additions �3: I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions exemption myself[No workers right of comp. � p lion 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractor;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 andjob 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 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 violgor. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D or insurao coverage verification. I do hereby certify u er the p ' and penalties of pe 'ury that the information provided above is true and co ect �Si :� rDate:N Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions f Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any 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-contractors)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 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 firture 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonv Wth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington greet Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAM Fax#617-727-7749 Revised 4-24-07 www.maw.gov/dia Application Number........................................... Section 9- Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section 10—Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your I-I.C... Signature Date f., Section_11-Home_Owners License Exemption' Home Owners Name: /51PTY�l / -�i'�rLO-cl`r Telephone Number Cell or Work Number I understand my responsibilities under the sand regulations for Licensed Construction Supervisor in accordance with 780. CMR the Massachusetts State Building e. I understand the construction inspection procedures,specific inspections and documentation required 780 CMR the Town of Barnstable. Signature Date � D� APPL CANT SIGNATURE Signature Date 0l © A�5 T Print Name `' 6LCOL)lAelephone Number E-mail permit to: y2 r'G11 Last updated: 11/15/2018 Section 12 —Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review-(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval. Section 13—Owner's Authorization I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date Print Name f E Last updated. 11/152018 Assessor's map and lot number ......�..�......Z5..��Z� �� yOFTHETo� Sewage Permit number Z EAaaSTAXLE, House number .......... �..../......../L'/' ll`%/>i!.....�l ve...... 9 NAM 00s,i639. 'FO YPY a' / i TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... ..aqxl..... ............................ .............................................................. TYPE OF CONSTRUCTION .......... N5W ......:7`!'r"?/2i ......................... . ......................................................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .................45...i'�......... ` �!vrr.. .... ...........f�i 4-. ...... 1'9 <.a ...:.......................................................... Proposed Use ..... �. •P............ .... ........ d Zoning District ..............��.f.....�, .................................Fire Distrie ........ 41.......................................... r f Name of Owner / ddress .......%5.. �... r .t..a4/rd... :n�....../ .... �/. 1 Name of Builder .:.:.. ................Address ...../OO.......Jc.�,iy.�?�•........loe4f...A ....f... ri+?duf�j Name of Architect ..............lt!Qti!.....................................Address ............................a' .....................................:....... Number of Rooms ................. .........Foundation A 4 C�t! .rlAce Exierior ........Cle.P69,n...... Xf.%� /e,�..aE..s�..., ehr4*4...Roofing ..:../9rAl//.....S;f,{ Syr... / w Floors .... ��.hvo..................c ........................: Interior �r•I kr!a.... Qr4!'c!C...........: S ...... ! .......................... Heatingl .C.t'ene.S................:........................:........:...Plumbing ........ / .r:........................................................ Fireplace ........... ... I-,": ... .,`. .... ..Approximate. Cost, .... '�y� ..4700...... Definitive Plan Approved by Planning Board ________________________________19________ . Area ......�r. 'd. �s�..... Diagram of Lot and Building with Dimensions Fee tt SUBJECT TO APPROVAL OF BOARD OF HEALTH `'N' s OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..... ......��. ........ ..........�r— Construction Supervisor's license ....© - 41e— .. .... ... ............... ng No ��/��� Permit for --- ......... Sin ----.. ---. ^ 54 Franklin " ~ . LLocation -------.. ---. ' Hai ------..��...���.�---.. �^ ' Tbomaa 6 Ibeees,� ua , [�vne, ---------------..����---. ' Frame Type of Construction -------------- . -------------------------- Plot ............................ Lot ----------' ' July 22 85 ^ Permit Granted -------'�-----]P Dote of Inspection ------------lV Dote Completed -------'-----l9 ` . / ` ~~^~ . - . ^ .. . ` . ' - ' . . �U - � U - n ~ • Assessor's map and lot number v ....... . i� Sr eyes B 6* ropy THE Sewage Permit number .......:`................................... ' K r MAM House number ............... .......... � e . E A6 CODE A .o��MpY.Ar TOWN OF BARNATWTtfo"S ' UUILDING INSPECTOR i �.� " o �9oloC o.. APPLICATION FOR PERMIT TO ...::. 4?!J.tr' .6. '...................:.... ...........................................................:.. TYPE OF CONSTRUCTION .......:....41PC1a......A*C.11-e................................................................................. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to, the following information: Location C� '7� �'Ati.��ii�J /9v�.y...... %r �7tll..r....................,....................................... ......................................... .................................. Proposed 'Use ...... .. /`e .. � ........ JJ Zoning District .............. ......A......'..........................Fire District ....... yiy!1�7�J'.....................................:.... J . Name of Owner ddress ...... 3;. ....../`.t..�tle!~. ..... �ej.../.jl' h�i<r Name of Builder ...... NN ��r................Address /od ..rY !!�11.1.o .. lick �qr�riv�¢lj Nameof Architect ............../o.oe94 ..iC.....................................Address ............................a-1! ............................................. Number of Rooms .........: ......................Foundation Exterior .......-04,,4.c.... f!f. ��!...�?�?: '.. ° r...Roofing .......rlt9 .... / ......5 �:-y4.t...:..�!�.es'.. �✓ Floors ....I'711Wr'90c l............................................................Interior ......6x1,m vv.-,n....A Qm ...................................... Heating .....................................................Plumbing ........�s.Q06�oO.-C ....................,............................... Fireplace ................ .................................:......:......Approximate Cost...... oly. 010.......................................... Definitive Plan Approved by Planning Board ________________________________19________. Area .......;2 �/,o s t...... ........ i Diagram of Lot and Building with Dimensions Fee q. SUBJECT TO APPROVAL OF BOARD OF HEALTH wee A �ibc.�ty� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the 'Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... — . ..! r..... .......... Construction Supervisor's License ....®�.�r �'......................... GAGNON, THOMAS & THESESA No .... Permit for .,.Add D..to... we.1.1L.- n�;. ...... ...... . . . ingle...FamilY.....Dwelling ...................... Location .....54 Franklin Avenue ........................................................... ...................... .......................................... Owner ...Thomas. . ...&...The s.e.s.a.. ............ ........ . . .. . ...... . . .. .. Type of Construction ......,Frame........................ ............................................................................... Plot ............................. Lot ................................. Permit Granted ........July.....22......, ................19 85 't Date of Inspection 19 Date' Completed 7......... ........119j M ce - 01 CP M :S M,M r �i . LeT 'L�_ • c�r SH OF Mks 1� + �O� GEORGE yG�„ EANiDES v No.22723 sTc VL Np Su a -=-7 -47� as shar✓r�;.ors ��i� pl r� o, � � � - f�UD C'omm.vn�f/ P/or�P5Ga0o1-oo20A Propose � zG' �ti4 N, f PZ 0 L,4A/D /:v yYr4NN1.5 _T9 oxAS A. r�AG�fG/J yd 7,YERE.54 1 d,k/G Sc,4 E /'= 2 a' D c T d, J9S2 le,4/t/&///tl VZ—NUE--- .Deed. $K /327 Py 7/? 3 < Town of Barnstable *Permit# r Building Department a 6monthsfromissuedate snxxsresiE Brian Florence,CBO 1639. �� - Building Commissioner 1°rFVMpv° 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 F,ax: 508-790-6230 frokv' V.1; ate. EXPRESS PE T APPLICATION - RESIDE'1�TUAL UN/LY 5 Not Valid without Red X-Press Imprint �/Y/� Map/parcel Number /` Property Address 67 Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Ar_7 OG-r % �" �t� Iq W ✓'f C_ Contractor's Name /Y-I"z OCx-Y,s YV-� te_k" t-0 ,,,CA Telephone Number Sbg Home Improvement Contractor License#(if applicable) CS 111 30J Email: ��lw'�t o�t/�L4- Construction Supervisor's License#(if applicable) 2 `� ILI, [ Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name rg �r, �l/✓M--e^-. Workman's Comp.Policy# LAY C 3 — C� ��6 - 0/ Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ t(check box) YY rst ORe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to S 0 ❑ roof(hurricane nailed)(not stripping. Going over existing layers of roof) [ e-side ❑ Replacement Windows/doors/sliders.U-Value. (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Propert;�I' t sign Property Owner Letter of Permission. A c yme Improvement Contractors License&Construction Supervisors License is r q fire SIGNATURE: QAWPFILESTORNISM PRESS2017 The Co mxtomveakh o,f Massadhmet€s Department ofIndushialAcddewr t3,rice of-£mvs*atio= 600 Washfiegton Street _ Boston,ALA 02111 wrvnu trras&gvP1Wia Workers' Compensation Insurance Affidavit:BuilderslContractarsMectdciansd3lumbers IICant InforMat iGn Please Pkint< � T Name(Hudae Zanfim'on&&,6 �- -- !�-t ,q 40 ✓/. Address: A,// Z Aru 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- ❑New eonstnxtion employees(full andfor part-ime j.* have hired the sub-coatractaas 2.❑ I am a sole proprietor orpartuee- r listed onthe attached sheet 7. ❑Remodeling ship and have no-employees. These sob-cortractam have $_,❑Demolition wolfing far me in any capacity: =playees and have wodneerss', 9_ ❑Build addition [No i mke-rs'causp.insurance COmP-i urauc�l required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or a,ddiions officers have exercised their 3.❑ I am a luamaoveuer doing all work 1 L❑Pltimbiag repaiia or additions myseM F-o washers' right of ese 4dion per MGL i ce required-]f c.152, §1(4�andwe havens try❑I�oafrelsairs z: employes-[No Wow' 13.❑Other coup_insurance Mpired-1 *Any appYic=dtatcbecUbaa:ftl aamst also fillo�ibe set tioahe7Rrwshot0atg tIieir�aorkexs'compeasatioapaIicyiafornzafiooL t Mmemnem who submit dills affidmf huffm1mg they axe dieing all va&cud.&en hire aatd&con=tnts— submit a new affidaek indicating scale fConttact. that check this boat xnitst 2=11sd as addidwal sheet sbo=g tbmnmue of floe sab-cmttwAmx,inch state whether or not lhose endties bzm � employees.Iftbesuhrcaatactm haveemplayee%dLeynnstpmvide&eir warkeo'camp.palicynumbez I am an emplayer tijatispr4nidLrzgitorkers"compomdiaiiinnirauceformyeitzpfojwes. Ba oav is flte pvHcy and j6h site ia2fotarafian. Insurance Company Name: Policy#or Self-ius_Lic_#: G� �l S�l ��D �-f'/�F�piratroa Date: 2/�� Job Address: F� h Ls' (\,✓� cify/S#at t.tp: `t K 04 Attach a copy of the workers'comipensatio olicydeclaration page(showing the policy nuaer and expiration date). Fai3im to somm coverage as requireduuder Section 25A of MGL a 152 can lead to the imposition of cdmiiW penalties of a fine up to S 1,54t}00 aridtor ano-year imprisonment,as weu as civil penalties in the form of a STOP STORK€RDERand a fine of up to$250_00 a clay against -wlatan Be advised that a copy of this statement may,be forwarded to the Office of I�estigations of the DIAL.far" wane coverage verifitatim I4a hereby certi uder t e pains and partahMn af'petfusy thatflte uiforw afian pnni&7F abm%u/true nd�carrect Signature: Date- Phaae cq — l 7- r/ 02&fal use anly. De rust write in tlih area,to be catnpi<eted by tatp or tonm a,f j4ciat City or Town- Perimtll icense# Inning Authority(cirde one): 1.Board of$ealtfi 2.Building Department 3.City/rown Clerk 4.Elechical Inspector S.Plumbing Inspector 6.Oithe Other Contact Person Phan#: Laformation. and Instructions Masswllusetts C=,n=sl Laws chq�152 regoires all employe to provide workers'compensation for their employees. PursuaMt to thus sty,as ernj7kn is defined as.6_.every person in the service of another under any contract of Iihe, empress or implieet Dial or wrifina." An employer is defined as"an i adiyidnal,padnership,association,c:orpor�ion or other legal eottfy, or ray two or mare of the foregoing edged in.a Joint eltmprise,and inch xag the legal representatives of a deceased employer,or the receiver or trustee of an individual,partne<ship,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 occapant ofthe - dwzIlmg house of roomer who employs persons to do main m,construction or repair work on such dwelling house or oa the grounds or building appur�thereto shall mtbecanse of such employrum the deemed to be an employer." MOL chapter 152,§25g6)also stems that"every sfafe or local fib agency shalf withhold the issnance or renewal of a license or permit to operate a business or to construct buildings in the commoawealth for any applicant Who has not produced acceptable evidence of compliance with this insurance.coverage required_" Additionally,MGL chapter 152,§25C(7)states-Neither the commonwealth nor any ofits political subdivisions shall enter into aay contract for the performance ofpubho wo&u atil acceptabID evidence of comp liaAce With the ins araT,ce. regtirm3tents of this dhapter.have been presented to the confracting aoihoaty." Applic Please f01 out the worhoers'compensation affidavit completely,by checl�g the boxes that apply to your situation and,if necessary,supply sob-contractor(s)nmx�e(s), addresses)and Phone Tn— ex(s)along with their certificat*)of yimzan ce. LfinTtPd Liability Companies(LLC)or Limited Liabffity Parfn=mhips(LLP)wifh no employees other than the members or partners,are not rbqui ed to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required.. Be advised that this affidayh maybe submitted to the Department of Industrial _Accidents for conf=zfion of fimn=ce coverage: Also be sure to sign and date the affidavit. The affidavit should be retumed to!he city or town that the application for the pennit or license is being requested,not the Department of . Industrial Accidents_ M ouldyou have any questions regarding the Iaw or ifyou are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-msn-ed companies should enter their self-insurance license number an the appropriate line. City or Town.Officials Please be sore 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 Investi g Qrs has to contact you regarding the applicant Please be sure to fll in the permit/Iicrose mmber which will be used as a reference nu tuber. In addition,an applicant that must submit multiple peumit/license applitaiions in any given year,need only submit one affidavit indicating cna ent policy information(if necessary)and under"Job Site Address"the applicant should write"allIocativns in (may or town)-"A copy of the•affidavit that has been officially stamped or marked by tho city or town maybe provided to the applicant as proof that a valid affidavit is on file for future pezmits or licenses_ A new affidavit must be f Med out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le- a dog license or permit to bun leaves etc.)said person is NOT regtmmd to complete this affidavit The Office of Investigations would like to thank you is advance for your cooperation and should you have any questions, please do not heszfate to give us a call. The Departmenfs address,telephone and fax number: Corniamgieei r of 11 . Degaa�atinfi c�1>zd�ial Accidents . Office ofe�tzg�tiolas E�111 Tf,-1.14 617 727-4M�xt 4-06 car 1-977=MA RA� Fay#617 727 7M Revised 4-24-D7 °FTVHE r � Town of.Barnstable Building Department IMMSTASIX MASS. g Brian Florence,CBO 059. �� ArEo�a Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This.Section - If Using A Builder P,,f4- C­ ,as Owner of the subject property hereby authorize e �� � O(S / ` a'"tir aceon my behalf, = in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not e filled or utilized before fence is install d all final specI's are performed and accepted. S' of Owner Si e o Appli t - to A4 I, Print Name Print Name O A 7-/U/ D e Q:FORMS:OWNERPERMLSSIONPOOLS Rev:10/17 i l'own of Barnstable �oFTHE rqk� Building Department N �� c� Brian Florence CBO rxszesLF. Building Commissioner v MA g 200 Main Street, Hyannis,MA 02601 16393g6. 'OlFn a www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number - street village "HOMEOWNER": 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/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 Hermit. (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 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 to amend and adopt such a form/certification for use in your community. _-..1.. �..__. � ! , AUTHORIZ ED Et OW: THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING.INSURERS) r be endorsed. EPRES�ENTATIVE OR P provisions E74- ERI.AND THE CERONAL INSUREDICATE Ethe policy(les)must have ADDITION NSan endorse A statement on ApORTANT: If the cerUflcate holder is an ADDITI SUBRG(30ON IS WkNED,s66ject to the not, on er rights to the certificate s a holder In lieu of such ch elndorsement(s)�lcles mayrequire NS certificate dNAME: FAX mucER BRYDEN&[SULLIVAN INS PHONE 88 FALMOUTH RD 4.i. HYANNISINA 02601 ADDRESS: NAIC0 INSURE S AFFORDING COVERAGE 33600 INsuRERA: LM Insurance CO Doration INSURER B 3EL ISLANDS HOME IMPROVEMENT LLC INSURERC: ?04 CINDEREL., ERRACE INSURERD: MARSTONS MILLS MA 02648 INSURERE: INSURER F REVISION NUMBER:. OVERAGES OD CERTIFICATE NUMBER: 37252619 CERTIFY TERM OR CONDITION OF ANY CONTRACT ORE0 HER D CU S 5U6 ECT`TO ALL WHICH TERMS, THAT THE POLICIES­'OFRAN�LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEE K RESPECT TO D ABOVE FOR THE POLICY PERT THIS IS TO STANDING ANY REQUIREMENT, INDICATED.. NOTWITH CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED N T aoL POLICIES EFF PO Do EXP LIMITS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REMM oo D BY PAID rD LAB R SUBR POLICYNUMBER EACH OCCURRENCE $ TYPE OF INSURANCE T D COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS MADE OCCUR MED EXP(Any one person) $ • PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS-COMPIOPAGG $ GEN'L AGGREGATE LIMIT APPLIES PER: $ POLICY JEC LOC COMBINED SINGLE LIMIT S OTHER: Ea accident $ AUTOMOBILE LIABILITY BODILY INJURY(Per person) BODILY INJURY(Per accident) s ANY AUTO $ D DULED PROPER OWNE TY DAMAGE SCHEAUTOS per accident $ AUTOS ONLY NON.OWNED HIRED AUTOS ONLY AUTOS ONLY - EACH OCCURRENCE $ UMBRELLALJAB OCCUR AGGREGATE $ $ EXCESS LIAS CLAIMS-MADE OTH DED RETENTIONS' 2/1112017 211112018 STATUTE ER 500000 WC5-31 S-615667-017 E.L.EACH ACCIDENT $ A wORICERS cOMPENSATION 500000 AND EMPLOYERS'LIABILITY YIN E.L.DISEASE-EA EMPLOYEE $ ANYPROPRIETORIPARTNEWEXECUTIVE 7N NIA 500000 OFFICER/MEMBEREXCLUDED? E.L.DISEASE-POLICY LIMIT $ (Mandatary in NH) it yas,describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCA170NS I VEHICLES(ACORD tot,Addlfional Remarks Schedule,maybe attached COMPENSATION LAWS OF THE STATE OF MA. WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY only THE WORK This certificate cancels and supersedes all previously issued:certificates,only as they relate to workers compensation coverage. CANCELLATION CERTIFICATE HOLDER THE EXPIRATIONHDATBOVE E DESCRIBED POLICIES BE BEFORE ' TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MAIN ST SOUTH YARMOUTH MA 02664 AUTHORIZED REPRESENTATIVE I v LM Insurance Corporation CORPORATION. All rights reserved. ©1988-2015 ACORD The ACORD name and logo are registered marks of ACORD ACORD 26. (2016103) (PDT) Page 1 0£ 1 37252619 1 1-615667 1 17-18 WC n0270258 1.8/15/2017 8:38:56 PM I Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constroe66, '§upervisor CS-111305 E Tres 06L01/2021 � 1 z ANDRE YARMALOVICHi 204"CINQEREL"-LO TERRACE } MARSTONS MILLS M/1 02648 Commissioner V� �f�icanz�R9aizaact[cF ;n {��(E/wC7f31CIrPf�v office of Consumer Affairs&Bna�ess R'lktion ,FHOME IM ]PROVEMENT CONTRACTOR Registration: 'i7,2". TYPe• Expiration <31?J1018: DBA BEL I NbS HOME1APN-0. VMENT ANDREI YARMALOUICN'#x + 204 CINpERLLA TER MARSTONS MILLS MA 0264E t•= - lJndersecre'tary THE FOLLOWING IS/ARE THE BEST IMAGES FROM BOOR QUALITY ORIGINAL (S) Jill M -A- SAT E GENL,�Et"a,gTEL%/L1lTifPP/� -- ER_' ti(J` bBILELJ%{B1L�/py YA OyyIYED SCHE "I'. `n AUTOS ONLY AG/TOS�H/REp PIP NO/V-0 AUTOS ONLY AUTOS y19►�EO j ONL Y EXCESS eg CL.q//o orA E y pED RETENTjpN A �p EMpL,OVERS'LIABILITY , ' PjVpROpI?IETOR/PARTNER/E�cC Y/A/ to �FB BER E7CCLUOEp? UT/VEAt N, if es,�N O OPERATfOAtS be ��RIpTIONOFOPERATIONS/LOCATIONS/VEHICLES(AC ORD .WORKERS COMPENSATION/NSUR4NCE �t tificafe canoes and supersedes COVE TFtis a//prev/ous/A C 4.__ CEFzTFFiCATE HOLDER TOWN OF YARMOUTH SOUTH Yq MOUTH MA 02664 wCORD 25(2016103) ThA 372 2619 1-625667 1 17-28 WC A0270258 8/25/20Ze .je:56 D�and Page .— ---- -- Engineering Dept. (3rd floor) Map 2A� Parcel 'j Jf'ermit# L7Z®® -3 s ., House#. .§ s" Date Issue, Board of Health(3rd floor)(8:15 -9:30y 1:00-4:30) 7 Aor'/51 Fee Conservation Office(4th floor)(8:30- 9:30/1:00 2:00) Planning Dept.(1st floor/School Admin. Bldg.) 114E �,BE Definitive Plan Approved by Planning Board 19P i�� LIANCE INSTALL W TOWN OF, BARNSTABLftNv1R0NM oDE Building e it Application TOWN REGULATI Project Street Address L� �� u 6,7 , Village � ` Owner Pr p� Address JA, Telephone `1 y Permit Request V�\ AZ-. � `� �/j- _L X�'v w r .cj i \ CA ff\ �b First Floor C1. square feet Second Floor square feet Construction Type k-A 3 acm, Estimated Project Cost $ -1 (�® Zoning District Flood Plain Water Protection Lot Size =S7�CCU - Grandfathered XYes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: Full Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing�^ New Half-, Existing New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing S_ New First Floor Room Count hj Heat Type and Fuel: ❑Gas )kOil ❑Electric ❑Other Central Air ❑Yes )4 No • Fireplaces: Existing New Existing wood/coal stove ❑Yes �j No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) \\ ❑Attached(size) ❑Barn(size) None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number �C 6 I � '�Cyr(® P Address License# p ` A 2 2 ®9.G . --) Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO . min SIGNATURE DATE BUILDING PERMIT DENIED FOR THE F LOWING REASON(S) 6V111 or - FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. r 4 ADDRESS • ti � VILLAGE. ��, �:, ,E ~�•. -( `s � OWNER DATE OF INSPECTION: FOUNDATION :. FRAME k INSULATION ` FIREPLACE - ELECTRICAL: ROUGH } FINAL PLUMBING: ROUGH FINAL GAS: RUG FINAL FINAL BUILDIINT _ • .. %;. ems = 's "`--, DATE CLOSED 4iJ r,a 0 c �sa i ASSOCIATION ?la N( ' °F THE r°w The Town of Barnstable " � a�errsresi.E, & 9. , Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only 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: �� N,O�?A ���+, Est.Cost— Address of Work: (�\ `13 k A%,AkV \J „ Owner's Name<;�C�S A�., Date of Permit Application: 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 SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as thrff en of the ow r: "a/ I 10i al a Date Contractor Name Registration No. OR Date Owner's Name r The Commonwealth of 4tassach usctts Departntent of ladustrial Accidents ' 011iceVINIVesMaUnns 600 {i'aslringron Street Bamone Alas. (12111 Workers' Compensation Insurance Affidavit Ann li an tnf rn t m c 5 5s Vhone# 1 am a hokFowner performing all work myself. ,471 I sole proprietor and have no one working, in capacity �f am a � Y an _ :7�1e..:...rnw.«,-.+...--.a•�_-.7":^_ ..ate+,+-?.,tseasr-s1gp7;sr-'�t+T�a?. `.�".nr .. .. ...�w�eww•�"r'4"�"'A`..�t�"nr•�.'T"�..� ''• � I am an entplover providing worker compensation for my employees working on this job. -corn any name: •Iddres � `^� '� itv -Z V 1 . 11hone#• JA — 7J CP insur•Ince co policy 1 am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: comliany name- •tddress• cif phone#• c� Insurincc co _._..�_...__r_.. _._.__ .�::a:.�.+�:...�- �i.wJw T +_��._Iir Yam••. •LL-3—� company name• iddress: city- phone#• Insurance co policy# — .Attach additionsi shceE if necessary.-� �q' :Y^`}." i s sf c��+ __rc.t..� yam, =sv�tt�.Z�r.ice;. vw Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and it fine of S100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the (Tice of Investigations of the DIA for coverage verification. I do herebt•cert' r nder the it !lies of perjun•that the information provided above is true and correct. Si=nature Date Print name Phone# —�'�c1r,, �Ofcial use only do not write in this area to be completed by city or town official city or town: permit/license# r(Building Department OLicensing Board check if immediate response is required [3Sclectmen•s Office C3I1cailh Department phone#• riOthcr contact person: �,- }«sed;5rJ.a) Information and Instructions Massachusetts General Laws chapter 152 section . 5 requires all employers to provideworkcrs' compel.. sation for their employees. As quoted from the "law". an enrpinree is dcfined as every person in the service of anothcr`undci any contract of hire• express or implied. oral or written. An enyplurer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more c the foregoing enuaged in a joint enterprise, and including the legal representatives of a deceased ennpiover, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling hous: or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or rene++al of a license or permit to operate a business or to construct buildings in the common++ealth for and applicant who ltas not produced acceptable evidence of compliance with the insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contrast for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha, been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits 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 tine 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 police, please call the Department at the number listed below. 7. .7- 7777777-7 City or'towns 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. Pleas hich will be used as a reference number. The affidavits may be returned tc be sure to fill in the permit/license number w the Department by mail or FAX unless other arrangements have been made. Tine Office of Investigations would like to thank you in advance for you 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 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 I TDO�/97/IYC092Cl/C2LUL 6�✓!/GQJl2ClZllr2� DEPARTMENT OF PUBLIC SAFETY CONSTRUC 1W SUPERVISOR LICENSE Ruder Expires: Aestrlcted:To 00 DEAN F STANLEY x � 359 CAPTAIN IIJAH RD CENTERVILLE, MA 02632 :HOME IMPROVEMENT CONTRACTOR Registration 108672 `Type -. DBA Expiration 08/21/00 h3 s DEAN F. STANLEY HOME IMPROVEM Dean F. Stanley G� Capt. Li jah Rd "°""'"'srR"`T°R Centerville MA 02632