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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
:Map ��� Parcel Zy Permit# 7� 940
Health vision Date Issued
Conservation Division y 00, Fee c>". D 9
Tax Collector
Treasurer
Planning Dept. N' PC'
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address S1 416iV- 'C-C. DX-- "A'O S
Village
CA-_r"VQC Ed IsRvr err— CA"VIM
Owner S"f, rRC.1.S )6"Im tmisg Address PO 6T AS'7'7, 14u h1J4, WX 8 2 743
Telephone "V51,6MAS1W -JU q'11-'12 oa
Permit Request �f �n�Tlrl� +(,`� TD ?AAISu 61l`t"9f SftiA- HpVJYUC
,4C9466 44MtA?tb !�K USST A t. RYJ .
Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new
Estimated Project Cost D8WA11!AJ Zoning District Flood Plain Groundwater Overlay -
Construction Type 15
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes Wl�o On Old King's Highway: ❑Yes RNo
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
Number of Bedrooms: existing new
Total Room Count(not including baths):existing new First Floor Room Count
'Tieat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other
-Central Air: ❑Yes ❑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:❑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 1, rG ' ice- P40 S�,� Proposed Use FA 94,54 > Ll.
BUILDER INFORMATION
NameL,A7Jn l��1�>JJ 1 Telephone Number �� Y-to ASS^
Address (4an Biel r.-.J iD�1 VtF License# CS C)a 51 S1
6Ase-/ST -Aue; MA II Home Improvement Contractor# 156 l I D
Worker's Compensation# 54R F
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL-BE TAKEN TO
SIGNATURE DATE _ �/ 9 /In
461.
FOR OFFICIAL USE ONLY
µ• ��
�ERMIT NO.
DATE ISSUED
` MAP/PARCEL NO.
t ADDRESS r `'r' VILLAGE ?
OWNER
F DATE OF INSPECTION:
w
FOUNDATION
FRAME i
INSULATION
` FIREPLACE =
ELECTRICAL: ROUGH FINAL d .
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL `
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
�ti 11
The Commonwealth of Massachusetts
Department of Industrial Accidents
r w Sl/ 8t/OQ.S
___ — 011lceollDPe 9 •
— 600 Washington Street
Boston,Mass 02111
Workers' Com ensation Insurance davit
22
RAWNM
name:
location
city
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❑ I am a homeowner Performing all work mysel
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v.
e as mmder Sedim►Z5A of MQ.1S2 can lead to the impoadfion of erhumal penalties of a Sae nP to 51,500.00 and/or
Failure to secure coveag malt"is the form of a STOP wORS ORDER and a Sae of S100.00 a day against me- I understand that s
one years,imprisonment as well as d12 p of the DMA for coverage vetillestim
copy of this statement may be forwarded to the OIDoe oflnvestit
I do hereby a the paka qd-potawff"of penury t the information provided above is •mid correct
-
Si�ature
phone#
Print name �2d1+�.rd P, t "T16�w eta!1
official use only do not write in this area to be eompkted by city or town omchd
permdt/liceme# [3Bunding Department
city or town: ❑Licensing Board
❑Selectmen's Ofte
❑checkif immediate response is required ❑Health Department
phone#• _ ❑Other
contact person:
(tented 9/95 P1N
Information and Instructions
Provide workers' compensation for their
Massachusetts General Laws chapter 152 section 25 requires all employers top P
employees. As quo
ted fim the"law",an employee is defined as every pion 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'oth&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
g p association or other legal entity, employing employees. However the owner,of a
trustee of an individual,partnership, or the oc ant'of the dwelling house of
dwelling house having not more than three apartments and who resides grounds or
to persons to do maims c or repair work on such dwelling house or on the
another who employs p emp�oymeat be deemed to be an employer.
building appurtenant thereto shall not because of such
L 152 section 25 also states that every state or local licensing agent'shall withhold the issuance or renewal
MG chapter applicant who has
of a license or permit to operate a business or to construct buildings in the commonwealth for any app
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,bhn c wo until
the
commonwealth nor any of its political subdivisions shall enter into any performance
ce w�the fiWU = of this chapter have been presented to the coatracang
acceptable evidence of camp .
authority.
Applicants
compensation affidavit c�PletelN by chwicing the box that applies to your situation and
Please fill in the workers' camp numbers alMg with a�fi�of msmw=as all affidavits may be
supplying company names,address P of ins�nce coverage. Also be sure to sign and
submitted to the Department of Industrial Accidents for for the permit or license is
date the affidavit. The affidavit should be remmed to the city or town that the applicationP
questions regarding the"law"or if you
being requested,not the Department of Industrial Accidents. Should you have any at the number.listed below.
workers'are required to obtain a work ' compeusatiati policy,P the Department
City or Towns
e be sure that the affidavit is complac and p lily Ile Department has provided a space at the bottom of the
Pleas has to contact you regarding the applicarrt. Please
affidavit for you to fill out in the event the Office of number. The affidavits may be retunid t^
be sure to fill in the pe>midliceose number which will,be used as a reference
the Department by mail or FAX unless other atrang®ems pave been made.
The office of Investigations would Inca to thank you in advance for You cooperation and should you have any questions.
please do not hesitate to give us a call.
go
���e.
The Department s address,telephone
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Me of lmesugations
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 7274900 eat. 406, 409 or 375 .
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ON3931 MOVE E ddW 80 O 0
Existing Building to be converted
for 5t. Francis Xavier Prep. School ,
Gift 5hop i
a'a'
3/Ox6/8
exist.dr.
re-uae exist.fence —� -
i ...-.---.-.------ o
J
existing support a z
tl- � post new atepa i
2'� existing deck and railings i
X s remove Otero
new =
i
— i
newiwalk
o P p IT� RO 05ED S E WORK
FOR
Z a s T a' 2T a' i X �
handicap ramp sloped to exist. -MA i � FROPERTY LOCATED AT
deck which i6 24"above grade
See Dwga. No. 2 and 3 for details i 81 HIGH SCHOOL ROAD
new i grabs area grabs area HYANNIS, MA
planting i new conc. walk a
\ remove exist.fence
- ............ -- - - --- - - 5cale: 10, _ 1,_0��
Date: Aug. 8, 2000
exiatin tree and hed es
to remain L DWg. NO. 1
line of exiting paving
CHURCH PARKING L07
i
Flan of ramp for
5t. Francio Xavier Gift Shop
5aale 3/8" = 1 -0" foot and balluster detail
/ to match ramp, see dwg.2
Aug . 8, 2000 f
- Note:
New steps to have
12"tread and 6" risers
3' 0" L<3
1' 0"
' 0" -5' 0" 5' 0" 5' 0"
- 11 :El
0
-R
L CV
0 3 i
� d-
tQ
_N
b r s
5, Dwo . No. 2
I o
i
Foot cap to be oelected
1x6 rails
NOTE: Note:
trim 4x4 Pt post use Same post and balluoter detail
N with 1x5 pine for existing deck. Railo not required
1x4 backing
1x6 rail
� p
N
0' 2 1/2° 2x2 balluotero =
@ 5"O.C.
2x4
0
1x4 deck boards
1x4 trir7 2x framing anchored to
4x4 preooure treated post
1x6 trim
approx. grade
Conc. filled oonotube
4' below grade
Detail Section of ramp for
5t. Francio Xavier Gift oho
Scale 1-1/2" = 1' 0"
fug. 8, 2000 Drawing No. 3
• :. ✓/ee TOam�novuaea� o�,./�aaaac/ucoelta
I .
BOARD OF BUILDING REGULATIONS
a License: CONSTRUCTION SUPERVISOR
t: Number: CS 005157
f
Erpires:05/232002 Tr.no: 22818
Restricted To• 00
ROLAND B CATIGNANI `
60 GEMINI DR
W BARNSTABLE, MA 02668 Administrator
,3
I
a t 7b 2��
Engineering Dept.(3rd door) Map ParcelG, �� Permit# �
House# o 1 . J_S. Date IssuedJ�-
PC,c3 4fJ_A Fee ,
dft (3rd floor)(8:15 -9:30]1:00-4:30) OCc�
Conservation Office (4th floor)(8:30- 9:30/1:00-2:00)
Planning Dept. (1st floor/School Admin.,Bldg.) QFIHE
De ' 'five Plan Approved by Planning Board 19
BARNSTABLE,
U _ En Nar
TOWN OF BARNSTABLE
/ Building Permit Application
Project Street Address 01 dd
Village P1/1 i S'
Owner r �P�- S Address
Telephone ,o kf 011 /14 Ch�A 1-9 e is
17 C C/
Permit Request c4t i'Oq 0 )-1 FAO �' s-®)-L 14.
t
n First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
NIPXI Dwelling Type: Single Family 5 Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House g g ❑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
NkN�, No.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 ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
j ❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
�p
❑Other(size) 7X 3 2
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use_/ ���ry�-/& Proposed Use 5r__ r
Builder Information
Name I 5-7.Z
( �.P D/-Q t� / /�c�-1 11il Telephone Number
Address !/ �S'.1 :1 ��/�. (,- License# 19 2 f 9
�` lr �t r-P a �li 3 Home Improvement Contractor#
Worker's Compensation# 6R14UB-997K277 397.
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
'SIGNATUR2MIT
DATE
BUILDING DENIE FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY
PERMIT NO. 1
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
.l
DATE OF INSPECTION:
FOUNDATION , y
FRAME ,
INSULATION
1
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
' FINAL BUILDING
}
DATE CLOSED OUT'
ASSOCIATION PLAN NO.
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The Town of Barnstable
• saaxsTnsM -
9e� 1' Department of Health Safety and Environmental Services
ArFDMF►'�A Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only ,
r
Permit no.
r
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: 4=l P C Est.Cost
Address of Work: 1 Gc, A (;- Ckoo
Owner's Name al� l /f P1, 1) / 12 L mo S' -e
Date of Permit Application: l
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 the agent of the owner:
Z/
Datd Contra r Name Registration No.
OR
Date Owner's Name
r
The Commonwealth of Massachusetts
Dcpartnunt of ludustrial.4cculcnts
I
OficeollnyestI9211ans
fill(! N'a.vhinl;ton Street
•;w••• ., '.. Boston.Alau. (12111
Workers' Compensation Insurance Affidavit
se�11�pltc•tnt information• Plea PRINT
name*
location-
city Chong#
1 am a homeowner performing all work myself.
1 am a sole proprietor and have no one working_ in any capacity
I am an employer providing workers' compensation for my empioyees working on this job.
gout tangy• narne: d^ S c�l� � c PC- C
address:
gin: �� L1 ����//�/1 'P' Z4, /4. ��L�J�� Ithonc
r `` 6 14UB-997K277-397
insurance co. �! �/ c� iicv# I
[i I am a sole proprietor, general contractor, or homeowner(circle one) and have`hired the contractors listed below who have
the followin_ workers compensation polices:
comonrn• natnc•
address:
phone#!:
incur"re co. Polio•#
.t.::•+... yam.^.•_ — '�•S t'...::•`.�:'_— __ —?f'_-'^'.:�:. —��iT'•r�ww � .:.� •.—��...w._�...i�—i�..
contnnn,%• nnine•
address'
gin phone#•
insurance co noiicy#
Attach additional sheet if necessary-• -,+� "' '^'�:'�•.�'-� "' _�'` '+^
i�--►...a�rYr.�f-' ...i eu y.�` •�,i.�;���_�. ..,.. �.. "' it W �.�a....� :i1Y!'�.L—i6••1N•w:!L
Failure tti secure ctiverat:e as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a tine up to 51.500.00 andiur
unc t cars'imprisonment as tt•ell as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a
cope of this%tatcment may be furN•arded to the Office of investigations of the DIA for coverage verification.
1 do hereby certift• r tier rite pains a,td p t hie njperjuty that the information provided above is true and correct
Si_nature �" Date
Print name •e D La/ Phone# 3L0�-� 5 5 72_
'official use univ_ do not write in this area to be completed by city or town official - Y�
cite or tntvo; permit/license ft nlluildin�Department I
C3Liccnsing Board
1]check if immediate response is required C3Scicetmcn's Office
'.` C3I1c2ith Department EE
F:.
contact person: phone tl; r IOthcr s.
.i
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' ccnnpensation for t.
employees. As quoted tom the "law". an etnphoree is defined as every person in the service of another under any
contract of hire, express or implied. oral or written.
An einplt rer is defined as an individual,partnership, association. corporation or other legal entity, or any two or in
the foregoing_ enLa,_ed 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
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dw-clling house of another who employs persons to do maintenance , construction or repair work on such dwelling_ !
or on the ;srounds or building appurtenant thereto shall not because of such employment be deemed to be an emplo:
MGL chapter 152 section 25 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 leas 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 contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapte:
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation an(
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 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 requir
to obtain a workers' compensation policy. please call the Department at the number listed below.
Citv or'rowns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returner
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have am• questi.
please do not hesitate to give us a call. -
The Department's address. telephone and fax number.
The Commonwealth Of Massachusetts T
Department of Industrial Accidents -,
Office of investigations
600 Washington Street
Boston,Ma. 02111
fax #: (617) 727-7749
ow
WARTHENI OF PUBLIC SAFETY
CONSTRUCIION SUPERVISOR LICENSE
Nu�her�� Expires:
.
Restrrcted` QO
G E 0 R G E J ALLAIN
338 PLEASANT PINES AYE -
CENTERYILLE, NA' 02632
ON
.ROVE COl11RACtOR
h � t
iatica<<3105 �,
ii.atioe � 3104
Mean RJR!
!. y
,yy`OFtHE TQ,,� The Town of Barnstable
BARNSTABLE. De• He
alth alth Safetyand Environmental Services
Department Building Division
367 Main Street,Hyannis,MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Inspection Correction Notice
Type of Inspection b.i
Location k-�C4k, fCL-jj_ 7jD-. Permit Number 1 6 T �L C
Owner �,� Z �� � ,�,� � Builder
One notice to remain on jobsite, one notice on file in Building Department.
The following items need correcting:
�t vL, a
r ,
Please call: 508-790-6227 for re-inspection.
Inspected by 2
Y '
Date
M j
Engineering Dept. 3rd floor Ma ce ear nit# -7 �
House# Date Issu d _-7 oZ 1
Board of Health(3rd floor)(8:15 -9:30/1:00- .3f rb _
Conservation Office(4th floor)(8:30-9:30/1:00-2:00) JBV I �,C1 'ISOW3fYlIZS�(0�
01 Rolm ISOISIAIQ DolaMON51
ZHL WOU i �izaa�
ef' 19
BARNSTABLE,
MASS
�j rFO 39..N,
U TOWN OF BARNSTABLE
Building Pe it Ap licat*p
tree Address
Village
Owner �Kdd&ss� �L
Telephone -- /�
Permit Request s
First Floor square feet Second Floor square feet
Construction Type
t.. Estimated Project Cost $� j
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure ,istoric House ❑Yes LSO On Old King's Highway ❑Yes 24,0
11
Basement Type: ❑Full rawl Walkout ❑Others
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 1- r
Number of Baths: Full: Existing a;Z_ New Half: Existing New
No.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 LSO Fireplaces: Existing New Existing wood/coal stove ❑Yes UO
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
one ❑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 7 7 S
Add re License# ( CF
Oa /cam O 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
SIGNATURE DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
r R
ia•
• s
y q
,w
S 1
a ,
. � ✓fie -�dhvrizonu�ea/� ���aaac�ucaeC�s
DEP..ARiNENT OF PUBLIC SAFETY _
CONSiRUCIION SUPERVISOR LICENSE
tfd�ber = u Expires:
Fi.• Res# icted�'10 00 j.i
�IN RICtfARD J PECKMAN SR
� HYANNIS, MA 02601 �"
OFtl1E Tp�
The Town of Barnstable
MAWL ��� 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 o r re uir ents.
�• f�I?J
Type of Work: Est.Cost
Address of Work: /
Owner's Name
Date of Permit Application: `7 f —
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 51PROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby ply f a permit as the agent o he owner:
e
C ntractor Name Registration No.
OR
Date Owner's Name
t " The Conttnonwealth of.4husachuseas
" •+.i� -:__-.7� Department ojlndustria/,9ccidents
;� :i
�K
Office of/nYestigat/ons
Boston, Muss. 02111
Workers' Compensation Insurance Affidavit
Applicantmfrmation:... _. likasePRINTlebjbl�z
name•
locition•
city nhonc#
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an emplo er providing workers' co nsation for my ployees working on this•job.
om nv name:
Address:
cit• ^ a G Q on #• —7 7 — .
insurance o. lice# 30
-. .:-. , :,...,�., .-......,.. .,,.,.•,•...,r,:,�.,...... _•r---^=-«......:,ter...,.«:.... ...,.,„ +,-.-^.,t,+.*.•.,,,.•........_..-..r,.w. . .
I am a sole proprietor, general contractor, or h6fieowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
comnanv name-
address:
city: nhonc#•
insurance co. Policy#
..,,_-':•.- KFff« ':T1�'09_ ':"T!R';^•f^T'9T"'`_i��u ��'`'�� 'i�ir��a•�' a.ir.x.us
company name-
address-
phone#•
insurance co policy# _
,Attach additional sheet if necessa
_.._._ =—
Failure to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or
oneyears'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereby cerli,f under Nye pains and enatties of Jerjun•drat the information provided above is true and correct.
— / S _
Signature Date 7 �
Print name Phone# -7-7 6 !q
/ f
official use u Iv do not write in this area to be completed by city or town official r + Ml
city or town: permitAicense# riBuilding Department
QLicensing hoard
Q check if immediate response is required Q
Selectmen's Office
Qlicalth Department
contact person: phone#; Mother ,
'>Y-.wY•`. -., ._.•t+:s,y'ce!_Y.�Y!�M�4..!ww• .. ..... .... ,. _ �t�.T,+'1.."y....�••n::--ti^+.l.++r".
(revised RQ;P1A)
information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted loom the "lacy", an empl(�vee is defined as every person in the service of another under ail,,,
contract of hire, express or implied, oral or written.
An empinper 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
dwcllin, house of another who employs persons to do maintenance , construction or repair work on such dwelling house
or on the urounds 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 of-
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant ,vvho has 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 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.
� _-.__..._.. __. ... ..-. - •. .'....ter--. _ t.�--�..�....�.�_`
, «s. �r �-
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 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.
., 77
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. Please
be sure to fill in the permit/license number which will be used as a reference number. Tile affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The 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. 4
r.y.,,•!:.�r..•. M"^.`w.!1wq:+�'J"�+'f1L1JC7'" -!'ta.VTv...y
Tile Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 NVashington Street _
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
c. J i l -18-96 11�0:5//7A American Property Ser•v i ce 1 P.01
"`� ✓lt6 L/'Q�i3'L�I2(J'!2C(fe'lL(.CfZ 4�✓��dd�CC�24tdP.�d
k'
HOME=. IMPROVEMENT CONTRACT OIRS REGISTRATION
r Board. of Bu.i tding IRequlati.,ons an(.1 Standards
OIle Ashburton Place Room 1.301
Boston, Massachuse.t: .s 02108
HOME IMPROVEMENT CON'i'RAC TOR
Re(:)i 12040:3 Expirat.i.on, 1.2/07/97
Tyr.) - PRIVATE .CORPORAITION � ;%T,k (�-#„o,,,� /rd
HOME IMPROVEMENT CONTRACT
Registrati0 120403
AMERICAN PROPERTY & CONST SVCS INC Type - PRIVATE CORPORATI
RICHARD J . PECKHAM Expiration 12/07/97
64 ENTERPRISE RD/PO BOX E '
HYANNIS MA 02601 t.AMERiCAN-PROPERTY 3 COAST
RICHARD J. PECKHAM
G�u�re.o-if 6 8Ew 64 ENTERPRISE RD/PO 8Ox E
AUMMfSTRATOA HYANNIS MA 02601
I
t
l
1 I
. 77.
� A
J60--2Z-96 11 : 27A American Property Service 1 P.01
AMERICAN PROPERTY & CONSTRUCTION SERVICES INC. 64 ENTERPRISE ItD,HYANNIS
FAX Date: 7"-39
Number of pages including cover sheet:
Fro
To: � ',os
i
Phone: _ Phone: 508-775-9191
_FaxLne: ' �o�3� Fax phone: 508-771-5064 _
CC_
REMARKS: ❑e_ �Urgeentt ❑ For your review ❑ Reply ASAP ❑ Please commcnt
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