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HomeMy WebLinkAbout0034 HAMDEN CIRCLE 3 �� Nam en Cir, ,, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street t Boston,AM 02111' ww'mmass.gov/dia Workers'Compensation Iusurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print' Name(Business/Organization/Individual): L bJ( ,4�- _424 a)'r C C - Address: 7,1 P �j` l� ►^'l lJ ,�� Gi City/State/Zip: fit r & J�, . 4&621f7r» Phone.#: Are you an employer? Check the appropriate bog: .Type of project(required):: 1.❑ I am a employer with 4. [] I am a general contractor and I * • have hired the sub-contractors 6• ❑New construction . employees (hill and/or part-time). Remodeling 2.❑ I am a'sole proprietor or partner- listed on the•attached sheet. 7• ❑ g ' ship and have no employees These sub-contractors have g,�❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition comp. insurance.$' [No workers comp.insurance 10.❑Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.© I am a homeowner doing all work . officers have exercised their 11.[]Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance,required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' 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 sbowing the name of the sub-contractors and state whether ornot 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.#: 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 c. n lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK,ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the 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. Signature: P � Q. Date• i Z 3 6 _ Phone# U I —7 27 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/Towu Clerk 4.Electrical Inspector 5,Plumbing Inspector 6. Other Contact Person: Phone#: I 1 .t®r° atio l ana instt"llcl ouni 1 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 hue, 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 ehapter.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-contiactor(s)name(s),address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members*or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate1ne. 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 bum 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:. e CoMMQUW aJ.th of Massachusetts Departmont of hndwt ai A.ccideuts Office of Invest gafteas 60 Washington Street Boston,.MA G2111 TO.#617-727-4900 ext 406 or 1-877-MASSAFB Fax##617-727-7749 Revised 11-22-06 www.Inamgov/dia t� 'op TOWN OF BARNSTABLE Permit No. __2018 ________________ yb�O I\ I IIA"STAU ; Building Inspector cash t460 OCCUPANCY PERMIT Bond ----_______________ No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Cedar Acres Realty Trust AddressGraat Pond Drive, S.Yarmouth, MA lot #82 ,,34 Hamden Circle, Hyannis Wiring Inspector Inspection date Plumbing Inspector��DP' Inspection date Gas Inspector JN f ?%J Inspection date Engineering DepartmentL , - ��,�,�, �,� Inspection date 77 THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. . 10e ............................................................... Building Inspector r J ou•og V? b t t, Fjlq ` K �• ,4 Ilk rb -Pico t1 A ' v e C� / APsesso=_;s map' and lot number / ��S d �� �� 7 SEPTIC SYSTEM MUST SE ` r INSTALLED IN COMPLIANCE• Sevvage 'P.,ermit number ....................:......... ... ................ .... WITH FANITrA yICLE r^ ; `I STATE TOWN. s °*7 �r° TOWN OF �BARN�STA�B�LE '" 3 (n' Z H9HBSTODLS; .9 BTU I.LDING ' INSPECTOR r, 900 i63q. 0 MAN m APPLICATION'S FOR PERMIT TO .... . .. ...................................... ..................... t•. TYPE OF CONSTRUCTION ... ... .... . ............... a.> ................/.. ..:.�..........19..��_ . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit acyo7din �o tie f (lowing information: LL 9 Location ........ .... . . .... 1 . .... .... .. ............ ......... Proposed Use ........I .e t/ ..............................................- .......... ZoningDistrict ........................................................................Fire District ........., ......................................:............................ Name of Owner / ' �2�� .. ddress ..... .. Name of Builder ..:... . . ...`.. ..: . . Address ...................... 2 .................................... Nameof Architect ....... .--.......................................Address ....................................... ............................................ Number of Rooms ........... .../...). .................. .....................Foundation lCi� � .............. Exterior .... f' 1..�.. ...Roofing ....��.... . .. ....... . ...... ....... Floors ................... .... .... ...Z� �'v'..............................Interior ............/ �. ..I�,� Heating ...... J ..Plumbing ....................�,�.. ............ Fireplace .. ..r....................................Approximate Cost ....... Definitive Plan Approved by Planning Board -------------------------- ------�9--------. Area .......... .. .. . . Diagram of Lot and Building with Dimensions Fee ................. ?..................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 6, Q 1 'r • r � t f h I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. T . Name . ..... ....... Cedar �raa Realty Trust ' � � � . . . . ` \ ^ '` ..2�l��_. - hf�r _. mo�`.��mr� . . i . _' . . ------. ' r' o�oole ��m�l1�m -----.~-----...^-----._------. Hamden . Location -- ' . -------.. - - ^ ` ------- P_________'____ ^ ^ - Owner ---.��4AK.A;T.e*;..���l9y.,�KMAt.. Type of Construction ---..f rnm»e--.�---.. . ` . -----'^-------------'r------ ' � ^ � . � �B� ' � Plot ----._---.� Lot -----._---- .~ ^ . , . May 8 78 ` Permit Granted -----'�-------]P ' + . � ^ ' � Date of Inspection ....................................lV . ^ Dote Completed ' l� � _ c . _ . - PERMIT REFUSED .—.---_----..—.------- lq ' --------...---^-------~----. - - ' . —.~---.—.-------------------. ' ` --------.'�-----..------.~.-- . ----.----------.--...------.. - Approved ................................................ lg ^^ --------------------------. . . ------------------------..—.. � -' | Assessor's map and .lot number ........!..........'.:'...............:...... Sewage,Permit number ...........................:............................. °fT"ET° TOWN ^ OF BARNSTABLE �P o i NAPS:rSHLE. i 9� 1639. IVILDING .INSPECTOR APPLICATION- FOR PERMIT TO ......................... r}' ? TYPE OF CONSTRUCTION ....!s'�/ *.. ... . .? , A���........... ,�r� �� r.�!............... ................................................" 19. ', . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies'for a permit according^to -the following information: Location ........... .." .... ` .�`.......... �..`f?...- ? ` .::r•�......... .............. ........................................................... ProposedUse ....... .... _ _ r ..... ....................................................................................................................... '" ........................Fire District .................................................................... Zoning .District ................................................. .. - f ) Name of Owner (`.. " 4 / .� �(�.� �1�.� i,.�.:Adc1ress 2 n >.�.�i.7;��c � ! � !'►� l� , Name of Builder .�' �,» A19 ..�`....`.r......Address ................................ ' ' ......................... f. .... . Name of Architect ...........Address ................:....:....:............................ ...........................................................:........................ Number of Rooms Foundation °r !..................... . ..... `.._"' ....................... ......... ..x ............. ...... �. r . / srI� j% Roofing �.�' � ` ............ .... . .....Exie for . /I/ c l iYl�" i ......... .. < ... .:: :. ... .,�./ ..... ........ ........ ter/ Floors / /'� .r 7 i ,f� /; f .Interior / . ' i! ..f./ f .. �.................... .................. .. ......... ..... Heating -1 f N tl ng ................... ...... `..�{ . f!..... ........ ... ............. ... _. ................. .._.......... Iumbi .... ..... /Fireplace ........ ....... _ .. .I....... .............../......................Approximate Cost ............. .......�....+ ........................................... Definitive Plan Approved by Planning Board -- ---- - 19 ----. Area �.. : .(' .. J Diagram of Lot and Building with Dimensions Fee ` .............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH I I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name : �. .... ' ` .' ...... ................ rV............ Cedar Acres Realty Trust A=20.1-185 20133. 'one story No ..................Permit for ................................... single family dwelling ...............t......................................................... ..... story g Location ...........3.4..Haopden...C.irc. e....... .......... . .. .... ........ . ...... ... ..........................H.. ... ......nnis................. ..... ............... Owner C...e....ar Acres Rea V t ..................... Type of i7/Constructon ......... ...came............................... ................................................................................ #82 Plot ................ ... ...... Lot .... ............................ 8 78 Permit Granted .........................................19 Date of Inspection ...........I ...................19 Date Completed- ............................9 �ERMIT �E,�U,SED ................ ........... ... .. ............... 19 .......................... .............. ........................ .................................................................. ................................................................................ Approved ................................................ 19 ............................................................................... ................................................................ .............. 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