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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map of Parcel_y � ". - Tl i� fv i1f= I3 Permit# 2 7 1
HN 1 A B L E
Health Division -5 Date Issued 2 Ale
Conservation Division / 7 �i 20 11 MAY 1 � p�tcAn Fe 42zol �
Tax Collector Permit Fee6?Ll I Uloq 1 _________ F"�
•c�
Treasurer �„ _ fsIVISION SEPTIC SYSTEM MUST BE
Planning Dept. INSTALLED IN COMPLIANCE
WITH TITLE 5
Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND
Historic-OKH Preservation/Hyannis ,
TOWN REGULATIONS
Project Street Address
91
Village l
Owner �� Qhvu - (�� � Da ina-I dcoh,Address �� �G y" T sA,,—t aV-c
Telephone
Permit Request eb o v Q;G e Y ` 1
Square feet: 1 st floor: existing lag proposed 2nd floor: existing proposed d Total new 0
Zoning District Flood Plain Groundwater Overlay
Project Valuation o00 Construction Type (. 00i
Lot Size 4 a3 Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family C" Two Family ❑ Multi-Family(#units)
V
Age of Existing Structure Historic House: ❑Yes pi-No On Old King's Highway: ❑Yes �lo
Basement Type: 0-F-ull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing 3 new
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes &kf16_
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:.❑existing ❑new size
Attached garage:❑existing ❑new size Shed:Erexisting ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes E o If yes,site plan review#
- -Current-Use--- - r - Proposed Use
'/� BUILDER INFORMATION
J
Name Dow I tom' ocmd Telephone Number ,>0t-S-6 q-7 6 7 c�
Address 1A Etkr6c.k R b �, R,d License#
N, r rn00 14 D-)-YA1, Home Improvement Contractor# 1 3 I
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE
„ - a
FOR OFFICIAL USE ONLY
PERMIT NO. `
DATE ISSUED
t -
' MAP/PARCEL`NO. J
r
ADDRESS 's t ' VILLAGE
OWNER,
DATE OF INSPECTION: r�,I
FOUNDATION ,� /�✓C.. - a -
a: FRAME A7�Y!
INSULATION /w
FIREPLACE
} ELECTRICAL: ROUGH FINAL ti .
PLUMBING: ROUGH FINAL '
GAS: ROUGH ._,”. FINAL "
FINAL BUILDING-
1 m
t DATE CLOSED OUT .
i, ASSOCIATION PLAN NO. ,:
RESIDENTIAL BUILDING PERMIT FEES
APPLI ION FEE
New Buildings,Additions $50.00
Alterations/Renovations $25.00 S r a
Building Permit Amendment $25.00
FEE VALUE WORKSHEET
NEW LIVING SPACE
square feet x$96/sq.foot= x.0031=
plus from below(if applicable)
ALTERATIONS/RENOVATIONS OF EXISTING SPACE
r 7• �' square feet x$64/sq.foot= 1 7 v2 o x.0031= S• 3 s
plus from below(if applicable)
GARAGES(attached&detached)
square feet x$32/sq.ft.= x.0031=
ACCESSORY STRUCTURE>120 sq.ft.
>120 sf-500 sf $35.00
>500 sf-750 sf 50.00
>750 sf- 1000 sf 75.00
>1000 sf-1500 sf 100.00
>1500 sf-Same as new building permit:
square feet x$96/sq.foot= x.0031=
STAND ALONE PERMITS
Open Porch x$30.00=
(number)
Deck x$30.00=
(number)
Fireplace/Chimney x$25.00=
(number)
Inground Swimming Pool- $60.00
Above Ground Swimming Pool $25.00
Relocation/Moving $150.00
(plus above if applicable)
Permit Fee
pmjco'st
.... . :.,'�� '•t S'CC�li1St?ttS• .
c •ea th
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•� L'011y)71pri f .
• The
• Department of lndustriuT.Aceidents' .
- 600 Washington Street _
• Boston;Mass. .02111
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oo,00 an or
fnstli$riG179{ enaYties of a fine tsp to$1,5
e as re aired under Section 23A of MGL 152 can lead to the SmposiHoa of of$100.p a �t me, I unaerstand that
Failure to secure coverst 9 eualtles in the fdim of a STOP WORK O>;DF!R and a Elmo of at o0.00 scaly g
one years'impris onment as well as chdl p .
be forwarded to the Office of Invrstigations of the DlAfor coverage verification.
copy ofthis statement may .
cle e s an a alties afPe that the inform above iss c and c�t e
I do here6 ert un y Dats --1---- .
Si�atuz$ •t � ' .--.�hona# � ., .'+ ,
Dint name ,
de not write in this area to be completed by city or toga oMcis�
a{fcialWeonlY perm3t(license# [�Buiidingl5epard. L
. ❑Licensing Board
city or toww, ❑Selectmen's Office
once is required (]HealthDeparbnent .
[}chcckif immediate reap oOther_
phone's;
contact person: '
(nvisad Sept 2w3) __ _
.. . .. .. ..by. .. i ... n • �..: ..• , .. ,~ : , ,
• ' . nfoz•zriaf�oin and Znstxuctions
chapter 152 section 25 requires all employers to pYovid rworkexs' eompensatidn for tlrear.
Massachiisett�, person in the service of ano$ier under any contract
�P10yees; ,As quoted'from the f`lsw", an employe.a is.defined as every p
d f hire;express or irn d�oral or written,
' partner,
' , association, corporation or other legal entity, or any iwo or more of
.An�rcpioyer is defined as an inNduak,p �p
the foregoing�gaged•in ajoint enferprise,and including the legal representatives of a deceased,employer,or the-receiver or
artnershi association or other legal entity, emplo�+mg employees. 'Howevei•.the owl er of a
trustee,of an individ ,p . p; occ ant bf the,dwe .house bf
owe house having noftaore than three aparbnents and who resides therein, or the:' up , .
k' spexsbzis to do maintenanc; con,strptibn or repair work on such dwelling hou�e car on the grounds or
another wbo emp•o3' thereto shall sf
tb'ecauo o such employmentbe deemecitobe a�i ernployer� ,.,
building.app�enant •L - .
cha ter 152 secd' 25 also-slates that'every s°tate'or lbcal licensing-ageney shalt withhold the issuancb or renewal
rIGL PY pp. ,.
of a license or perno?f to operate a businesspantie "with the Ins'urancesc� age re ulz ed: AAditi ally;nbitlier'the o bas
not produced acceptable evidence of comp
of it's olideal subdivisions shall enter into any eoWact for the performance of public work unf '
cozranonwbalth.nor.an3�. P � .
acceptable evidence of compliavde with�e insurance xequiz•ements of this chapter have been presented:to the contra
authority. •
,,,• _ _
Applicants
please the W�rkGOrS'.eompensafm affidavit completely,by checking the box that applies to your situation,,Please
su ky company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted
PP
to the Depar�ent•of industrial Accidents•for confirmation of insurance coverage, Also-be sure to sign and date the
affadah ghe affidavit should be returnedto the city or town that the application for the permit or license is being
re uested, not the pepaztment of Industrial AccideAts. Should you have any questions xegardiri the'"Iat '.or if'you ale
g fain a•workeW•compensationpplicy,please call the Depart ent at the ninnber Iiste�l�elow. .
required to o� , , • . . '
jai 'o
City or Towns .
fleas e be sure that the affidavit is complete and printed legibly. The.Department has provided a space at the bottom.of the
a ff yit far you to 5 o-at k the event the Office of Investigations has to contact you xegardv�g the applicant Please
errrutnicens a numlier which will ti a us eel as a reference number, The.affidayits may.b a returned tq.
be;Blue,to fill in e geiments havebeenmade. • ` ` '
the D epartment by, or 1x A unless oth&'arran • .
., y • �
The Office of Ivvestigah0�v''° d lie to thank yw in advance for you cooperation and s4iould you have any questions,
please do notbesitate to give u8 a•ca17—
/ �{ment's address,telephone and:fax number: .
The Dep
The Commonwealth Of Massachusetts .
Department.of Industrial Accidents
• . B1'�ce Di[HSteStella .
600 Washington Street
Boston,Ma. CZ111
fax#; (617)727-7749
(HEf To" of Barnstable
o� R.egulatou Services
next '
Thomas F,Geiler,Director
ST
0,59• ��� Building Division
Tom Perry,Building Commissioner
• 200 Main Street, Hyannis,MA 02601 ,
Fax: 508-790-6230
office: 508.862-4038
Pmmit no.
Data
,AFMAVITCOMM ENgpOVFmjNT CONTRACTOR
SUPPLFNMNT T ERMpp APP CATION
O
MGL a lAZA requires that th°'�?econstrunve
ctiou,alterations,xenovation,repair,Modernization,�Cu ied ion,
improveraeat zemovaal,demolition,ibut not more tllhan four d�t'elling units or ton of on addition to any wo structures which are adjacent to
bu7ding containing
.. registered contractors,with certain exceptions,along with Other
such residence or building b e done by .
requirements,
Estimated Cost
Type of Work• ,°'
Address of Work:
Owner's Names Q
Date of Application: SaZ
I hereby certify that:
Registration is not requued for the following reason(s):
[]Work excluded by law
[]1ob Under$1,000 ,
[]Building not owner-occupied
[]Owner pulling own permit
Notice is hereby given that'.
Oy�yERS PULLING THEIR OWN PERM[T OR DEALING WIT11 UNREGISTERED
IMTROYEMENT WORKDO NOT HA.YE
CONTR-►CTORS FOR APPLICABLE TfOME
ACCESS TO THE NITRATION PROGRAM OR GUARANTY k UND DERMGL c.1�2A�
SIGNED UNDERkENALTM9 OF PERJURY
Thereby apply foi a pernsit as the agent of the owner:
Contractor a RegisErationNo.
Date
OR
Owner's Name
FSHE T Town of Barnstable
Regulatory Services
rrsznst.E. Thomas F.Geller,Director
BA
9 s63;9• .��a Building Division
�pTfD MA'S
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma-us
Fax: 508-790-6230
Office: 508-862-4038
Property Owner Must
Complete and Sign This Section
If Using ABuilder
T ,as Owner of the subject property
c� I to act on my behalf,
hereby authorize
in all matters relative to work authorized by this building permit application for:
�Job()
(Addy s o
Signature of er
Date
Print Name
I
Q,FORMS:oWNERPERMISSI0N
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'• D I. CONSTRUC710N SUPERVISOR'
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DAVID A GARROLL
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aPROPOSED ADDITION/RENOVATIONS )PE5 1?E 51(N
E '+ DONALSON RESIDENCE RESIDENTIAL DESIGN,DRAFfING,
3 e 85 HAMPSHIRE AVE. &CONSULTING /
D HYANNIS,MA. P.O-BOX 981 r S
1 POCASSET,MA. P
«,tea
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—— I HALL N \ r
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a
faG SY'91RREA
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n O p 1 O V
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FIRST FLOOR PROPOSED m°"°w" ' o
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MR BVi6 aMetE6>.a II6 MaB[R
hr rePPUTE .
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PROPOSED ADDITION/RENOVATIONS
w DONALSONRESIDENCE RESIDEJNTIrALVDESIG�N,^D`Rf'A,FTING, \
e 4 &CONSULTING c
BS HAMPSHIRE AVE. P.O.BOX 981
�D & HVANNIS,MA.43 POCASSEr,MA. S P
(508)564 4448
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map l ( Parcel / TO INN OF tARNSTABLE Permit#
Health'-Division Date Issued
Conservation Division .5's
.. 29B MAY —3 FM 12: 28 Application Fee Tax Collector Permit Fee ( W
Treasurer DIVISION
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address
bGL/rl h/✓L /�L
Village III a oois
Owner &,Om . b0 oalsyl Address ,�� �`� S�� ;ram, �nnu
Telephone 77/ 211.3
Permit Request 9" eC
JJ
Square feet: 1st floor:existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
i
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family 1 Two Family O Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes" XNo On Old King's Highway: ❑Yes )�N o
Basement Type:XFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
Number.of Bedrooms: existing_ new
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑Gas Oil ❑ Electric ❑Other
Central Air: ❑Yes )<No Fireplaces: Existing New Existing wood/coal stove: ❑Yes XNo
Detached garage:❑existing O new size Pool: Cl existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization' ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No , If yes;site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name ���� �� C� (/0° Telephone Number o 77/ 3d'l�j
`Address 01a"lG bd o wsdY) License#
j(d=,oiblrG /NL Home Improvement Contractor#
4,4-)r.S trA- va"I-U 1 Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE ��� /07
f�
y
FOR OFFICIAL USE ONLY
PERMIT NO.
w DATE ISSUED
x MAP/PARCEL NO.
s ADDRESS VILLAGE f
" OWNER "
DATE OF INSPECTION:
FOUNDATION '
FRAME
INSULATION
z
FIREPLACE
p
ELECTRICAL: ROUGH FINAL
`r PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL'
FINAL BUILDING
f
rs
DATE CLOSED OUT
ASSOCIATION PLAN NO.
L1
r+ _
L
MAP 2 1..
291
85
1 P'*
7
r,
.. .................
AP 2 1
OconservationAgn 5/3/2004 11:24:41 AM
FENCE 00.
OF CAPE COD
o>at. a �
Narne
Address �-
Town
Phone JGv 221 �� r
11-3
l
,���� � a a as -� ��«•�cs' � �� «P7rr�.c� ,
�Jv� CL7 s icJ i T
123 FALMOUTH RD.RTE.28 How did Customer hear about RFC?
HYANNIS,MA 02601
(508)776.4124• 1.800.582.6020 v
,w
�FIKE ram, Town of Barnstable
Regulatory Services
sAtuasrABLE, : Thomas F.Geiler,Director
Muss.
1639. 0. Building Division
rEn wtA�
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: �/� /
JOB LOCATION: O Pf/79/��/�Ci /7VC a n�/S ''I .4Q 1,01
number street
village
"HOMEOwNER": 6G�e bOl)a/,sv� 5PY 77/3d/3 ,Q36-? _503
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_permit (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Al�M-1k-„L
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:forms:homeexempt
. .The Cominon"',ajth of.?Massachusetts
- s'
ent'd
.tt
at
Accidents
u shz
nd
nt
oI
e
Departm f
6at7'yjrasfcington street _
Boston;mass. . 02111
''' ✓ it
ion Com ion.Insuranee Affidavit-General Businesses
t� �,
low
0.
address: " m 09s yi i rG •��G �,?6 O l �y -7
•pin�i1 Y state,
' g F✓stablisl�meAt
work site locatiolt full address e; []Retail D�RestaurantBarlEat'iu
�] a sole proprietor and have no one $psiness 0�ce[�S 1'�s('including Real Frstate,Antos etc.)'
I a '
w.orking in any capacity.
[l I am an em 10 er with• esn'lo'ees full&' art time: �
//////%/ /%%/% %//% %%% � orl� on this job. +..
%%/%%% keys' cbmveusation for znyem�loyees w
z loyer providing v,�r ;• ; f':`.. `;;' . ::::' ..
an ,•.t.;;•s
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dtli�re$s:` v' ;. •�^, i i".,r+,;, •+:' •i}I'.{„JL: ;%t�"v7':h •�:{'� . L ':' +"�: . �t•
51•'•:s`�'1•+eJ,'is•';1.'•.t': r .�,•� l al•Y:::�.'•''�' '1 hone. t - �,l l;} r q,t t•''� , .tr .
.: :;f'::i�•.'+• .."!� r �i��:a y. ;L{': ,3 '4 ;::" •s�`�•:''�.i�i'1 il:''.d'• 1 `5,'t�•t.:' ,134°,:4' I JI':,tj•,'� •t
�� 'i' ` t' •_ .I . •,y7,.,•.a, .:�.; '•.J t;i,£ •.;'' ,'a`e,'•i :' ! '' •'7S'C t '�••�^•1'• t•,•�.It.,.^,Jw,.: r it
L '''+t'' '' .3• 't'•1''F•aY `' e;.. •',�,i,i.f��4.'�.' k�.ri•5a3w 1:::.. �' .r •oil •w.• E221MZ ,%////,
ATisuiat ce.co5+r,•:,: 1voriers'
endent contractors listed below•who have the following ;
Y'am a sole proprietor and hired the indep H
peasation polices: `.. '.•,;y' ' �;' r;.ir{IF;n' ';�: �d
:..Uv�,�,: "I ''{; L• '\SP:t'�.",S`'•:,�•r�:t t4y1:'a+.3:r ;'i°''tr,iS•'. .i •. .' •'�' '� 11..r .•� 1 P.Y�'''Y•L••t1 J;.•i• T.l.��t�,•• ..
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L:' , ! •'4,LSu;,..r, '1�.t••.•r..r:t•' +J i�a.t• 1 _L� ;'!'' n.'. .r. 'C�: ai .'�.•. ...
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,T,.r'L:" 't''1'e7r'1'et'J"%'•�+Yl'•'y�R'.• ,v,.tr'.,x:•..M1•.S. . .a.," J••" .' ., ••
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WERE a: .i3r-+t,.R •.C•} +.tt:t✓� yr", PM: I r'.;,. ;Y•
Ir :'�•'• .a:•:. "+ "''r:4,.::.• r':;3' :(..'�,n•,ti� .4t y+Nf. .i'� ;?; '',... ''':/:,va�3 "A'.
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tom ail. pauie.»�.I' "'t ::i _ ,'I. .,•� '' I" , :•... '•` '`.
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• L' ,,"i', e• ,•' t„', f�l� ••,'•i• �,1' . •',ra= :,,', :..La• `, •jl.��' Lr.•.rJ•Y�',t,T4`,ajV �''„w'•••• '.1.;;5„t:�.,��',.'S.a�::71 .i,'
'�t:'�. ..•.' •.{,�,,•r:1;L,`:,�'Cy' •`4 s}7„y J .�,�7•� a •�.•t. s. _p,•:+� i• ;�' ';�, t" r.�
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' 1+ ,V.,':.•r ;t:4••,'•, t,•a ,'�,,' 3\•,y'.,3, t':' a,,,a.:: {,.��, F/m.J.3. '<SU •. ���
f•. 1, 1, " it,.rJ a
fnsiirsn
vera a as required under Section 25A of MGL 152 can lead to the imposition of crimfnal l0 a'alLy of a fine lip to der3t a00 an or
"ahure"Seenrco t enalties in the form of a STOP WORK ORDER and a Sint of$100.00 a'day against ma X understand that
one years'imprisonment as well as ctvilp '
copy of this statement maybe forvrardtd to the Office of Investigations of the DTAfor eoverage treriiication
do hereby certify under the pains and penalties bf perjury that the info above is frA 43co
49
r ,--y Date
siatlua ll hone* 71' �i3 ,
g A '6Orix/s
rant name �
ofiicLal use only do not write in this area to be completed by city or town cmciaf permit/iicense# []Building Department
❑Licensing Board
city or town: []Selectmen's Omce
❑•checkif inmediatc response is required OHealthDeparinent ,
[]Other
Phone#;
,
contact person:
(mused Styt 2M3) —
' Informatioin and Instructions'
f Gezieral Laws'•chapter 152 section 25 requires all employers to pxovi&c tWorkexs' comp ens tidia for'their.
Ivlassachusett$ r 6
ennp'loyees: As quoted'from the f°Isw"., an employee ig.defined as every person xa the service o another under any contract
Of hire;express or it p 64; oral or written, .
emp oy : artners , association, corporation or other legal entity, or any fwo or mare of
An Z er is defined as an individual,p� �p rp •
the foregoing enga Q.in a'jomt cnferpnse,and including the-legal'rep'resentatives of a deceased,employer, or the•receiver or
artaershi association or other legal entity, emplgying employees- 'However.the owner of a
.trustee of an individual,P . p;
a�,�en g house having not'fnora than three apartments,and who resides therein, or the:occupantsbf the:dwelling House bf
another who emploi'sp bris to do maintenance, construction or repair work on such&.welling house.6r on the grounds or
budg appurtenant thereto shall not because of such:ernployment.be deeaneci to be ari employer.,..t
' ;, ;• ,
I1riGL chapter 152 section 25 also'states that'every state or local Ucensing•agency shall•,ithhbld the issuance or renewal
to operate a business or to construct buildings in the.ibnunonwealth for any applicant who has
of a license or permit
not produced accepfable*evidence•orcompliance with the insurance coverage rei uiz'ed.' Additionally;nbither'the' '
coi-a onwbalth nor.any.of it's political subdivisions shall enter into any contract for the performance of public work unto
acceptable evidence of compliance with t�e insurance requirements of this chapter have been presented to the contracting.•
authority.. _..... .
Applicants
Please $re s' cojVensa�x a�davit completely,by checking the box fhat applies to your situation..Please
e
address and hone numbers along with a certificate of insurance as all affidavits may be submitted
supply company nam P
erit•of Indust
rial A6cidents•for confir nation of insurance coverage. A.Lso'be sure to sign and'date the
arfm
to the Aep• t the a lication for the ermit or license is being •
city or town that P
affidavit. The affidavit should be xeturnedto thety FF
requested, not the Dept offti��cc.`d�ts' Should you have any questions regardi the'"Iav�'or ifyou are
ea to obtain a•vYorkert'•compensationpplicyl?epartment at the nitznber listr�l;lielow. .
requir 'please call the
City or Towns • ,
pleasebe sure that the affidavit is cbmplete andprinted 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 xegarduig the applicant Please
befsure to r you
the perrnitllicense ni=ber which will be used as a refereneb number. ne.affidavits maybe returned to•
the D epartrnent by.
maii TAX unless othe'r'aii ngemen have been made.•
The Office of Investigations would like to thank y'on in advance for you cooperation and should you have any questions,
othesitate to give us a•call. _
please do n
The Department's address,telephone and fax number: . ,
The Commonwealth Of Massachusetts
Deparbnent-of Industrial Accidents
. Bike of taStesii�ena '
600 Washington Street
Boston,MR. 02111
fax#: (617)727-7749
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post Ra 190 1
SCOTCH HIGHLANDER
This style of post and rail fencing blends with
both contemporary and traditional homes.
The full round posts and rails are skillfully
joined with a mortise and tenon construction
for a finished appearance.
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AMERICAN (LAP RAIL)
" Most suitable for country and suburban
settings the American rail fence utilizes full ---
` round rails wedged thru half round posts for a
more rugged display.
We are especially proud of our collection of
Post & Rail Fences. This distinctive line
WESTERN RED CEDAR serves as the perfect property divider and
adds a special charm to any landscape.
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EARLY AMERICAN (SPLIT RAIL)
fencing
Hand crafted Virginia Chestnut railg
for an authentic early American setting.
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SCREEN
PICKET
#1 PANEL#1 Cedar Pickets 3/4"x 2 7/8",are double-nailed using galvanized nails,to
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Cedar Backrails or 2 x 4 Pressure Treated Backrails.
l #2 PANEL#2 Cedar Pickets are single nailed on 2 x 3 backing rails
Unmatched for privacy yet charming in its I
own light this cedar screen fencing will mate
with a flaring curve to open-fence areas of I
your property. $Cleetl
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Scalloped 1 ,
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The scalloped picket offers not only pro-
tection but also a pleasing frame for your
I ( I ;i i { front yard"picture".
Spaced Picket I ; '
! I Available in all heights.
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1 i L Scalloped
COD
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123 FALMOUTH RD. RTE. 28 FENCE CO. OF 562 WAREHAM ST.
HYANNIS, MA 02601 call toll free MIDDLEBORO, MA 02346
775-4124 1-800-582-5020 947-1653
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GUAFIC
" The Reliable Fence Co. SOUTHEASTERN/CAPE COD,
INC. hereby guarantees to its customers that all materials
used in the construction of our wooden and metal fences
shall be of the specific grade stated in your written contract
with absolutely no substitutions. ;,
We further guaranty the installation of all fences, erected
by our experienced and qualified crews,to be in accordance
with usual high fence contracting practices and that our
fences will maintain their full use in winds, at least up to
hurricane force, as determined by the standards set by the
United States Weather Bureau.
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AVAIL BOX STAND-
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.LANTERN POST 100% CEDAR
PRESSURE TREATED Attractive mail box standard con-
Uniform 511diameter post, 8'6" structed with either 4"x 4"or 5"
long. All posts are center bored x 5" square treated stock. All
and treated with C.C.A. standards come fully assembled �
with our exclusive"Boston"top
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and ready for Installation.
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