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HomeMy WebLinkAbout0188 HINCKLEY ROAD i�� i� ' ����_ i A [ . ` �, Town of Barnstable 9 .... �.. _. . . _.� ... . _ _ �. M Buildi ng ,° A !Post This Card So That it is Visible From the Street-Approved Plans Must be.Retained on Job and this Card Must be Kept 1MAH& ,Posted Until Final Inspection Has Been Made. er ' ya Where a Certificate of Occupancy,is Required,such Building"shall Not be Occupied until a Final Inspection has been made. I m it Permit No. B-19-793 Applicant Name: Wojciech Piwowarczyk Approvals Date issued: 03/15/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 09/15/2019 Foundation: Location: 188 HINCKLEY ROAD, HYANNIS Map/Lot 310-093 Zoning District: ' RB Sheathing: Owner on Record: BARNSTABLE HOUSING AUTHORITY Contractor*Name: WOJCIECH J PIWOWARCZYK Framing: 1 Address: 146 SOUTH STREET Contractor License: CS-076146 2 HYANNIS, MA 02601 I Est. Project Cost: $ 15,500.00 Chimney: Description: Roof replacement at Scattered sites Permit Fee: $ 79.05 { Insulation: Project Review Req: Fee Paid:` $79.05 " Date 3/15/2019 Final: i Plumbing/Gas Rough Plumbing: ".Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within'six'months 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. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open fo public inspection for the entire duration of the Final Gas: r work until the completion of the same. V �` Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: " Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT r Cape Save Inc. 7-D Huntington Avenue - South Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 ,f 3/23/16 f Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permit#B-16-579 . r TO: Building Inspector(s), This affidavit is to certify that all work completed for 188 Hinckley Road,Hyannis has been inspected by a third party Certified Building Performance Institute (BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely,' William McCluskey • �' 1p�y 4A r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map O Parcel O 9 3 O, , 5j8LE Application # '✓ 15-T Health Division Date Issued20 ton ;,;, Conservation Division Application Fee ` Planning Dept. Permit Fee. Date Definitive Plan Approved by Planning Board , ;, g r) � O , Historic - OKH _ Preservation/ Hyannis Project Street Address nr Village vox a n 1, Owner 1 Address J q 6So o j� Otn n i f Telephone LoreEAJnA Qara atilt 40IkSI� RLkAkdr, = Permit Request � cet Sf +o Sect R C. fan sem en wS Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 33 0 0 Construction Type 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 ❑ 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 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 ❑ 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 )4"No If yes, site plan review# Current Use - _ - - -- . Use Proposed - - - ---- p - - - - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name VN'-(1 ' c ��iaM �C�a Y e �C-,, J��c-���. Telephone Number sd8 3 9 8 03 Address �'""+ ^f�'^ Pf rC License # _:L_L S. Y Fr"`o K+( , M A- O M6 q Home Improvement Contractor# �� D Email Worker's Compensation # WW C 713 U 77 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3 L ( b —_ 1 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED 4' z' MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING P DATE CLOSED OUT ASSOCIATION PLAN NO. 14. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement: Property Owner's Signature`. 1 sir - Date Phone: `ail Address: tf � VY S Tenant Signature Date i Agency Approved Weatherization Company Adam T. Incorporated / All Cape Energy / Alternative Weatherization Cape Cod Insulation I Cape.Save / Cazeault Frontier Energy Solutions / Lohr Home Improvement / Tupper Construction Agency Signature Date _ N.4: .Y,tt 1 a i c4 r ,• 14. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a.right of enforcement Property Owner's Signature: Date Phone: Address: ' r Tenant Signature ,,_. %t Date ' s Agency Approved Weatherization Company Adam T. Incorporated All Cape Energy Alternative Weather'zati n Cape Cod Insulation / Cape Save / Cazeault Frontier Energy Solutions / Lohr Home.Improvement / Tupper Construction Agency Signature Date t I r, .,, ,p _ . - - 7t 1�s�:� �•,t t •�� � �` .i�'u,��C,� � .,r # .,�.d tI.j 7 ..,The Commonwealth of Massachusetts _ ""+ "Aj "� , DepartmentoflndustrialAccidents, �;,rt.s�, a �"�p'� I t . .�• ' 4 1 Congress Street,Suite 100 ;::. "Baston,MA 021144617r: www mass gov/dia V­ , w b 1A ti,� «Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Eleetrictans/Plumbers. M. TO BE FILED WITH THE PERMITTING AUTHORITY. ��•-. Applicant Information + Please Print Legibly L , Cape.Save Inc 1 F n Name (Business/Organization/Individual): , b Address:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 02664 tPhone#:508-398 0398 •• Are you an employer?Check the appropriate bog: _ Type of projeet(required): 1.❑✓ 1 am a employer with,20 '_{employees(full and/or part-time)° t' T't , .r W-a 7 a[].Neal construction, 2. I am a sole m netoi or artaersbi and have no a to ees workm for me m•. ! 1 p.P" P P mp y g - 8.'Q'Remodelm any capacity.[No workers',comp.insurance required] , " `«'•r g 3,MI am a homeowner Join all workm self., r " " F ' t 9. []Demolition t; • ' F 3 ❑ - g [No workers comp,insurance rYgProperty: I will ' 10 Q Building addition J r 4. I am a homeowner and will be hirm contractors to=conduct all work on m N r ensure that all contractors,either have'workers'coinpensation:insurance or are sole I I..n Electrical repairs or additions t proprietors with no employees. ` 12.❑Plumbing repairs.or additions 5.❑I am a general contractor and I have hired the sub=contractors listed on the attached sheet. 1.3:❑Roof:repairs These sub contractors have employees and have workers'comp.insurance; - 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther Insulation 152,§1(4),and we have no:employees.[No workers'comp.insurance required.] *An applicant checks.box#1 must also fill out the section below showing their,workers'co• y'PP g mpensation:policy information. t Homeowners who.submit this affidavit indicating;theyare doing all.work and then hire outside contractors must submit anew affidavit indicating such. 1 *Contractors that check this box must attached an additional sheet showing the name of sub-contractors and state whether or not those.entifies have employees. If the sub-contractors have employees,they must provide their workers'comp.policy t _ l I am an employer that is providing workers'compensar y- f Y p y _ P3',.and-job lion insurance or m em to ees. Below is the of site information. V Insurance Company Name:Wesco Insurance Company k r-. A. Policy#or Self.--ins.Lic:#:WWC3136274 " " '-f .:Expiration Date:04/09%2016 4 a ` Job Site Address: 188 Hinkle Road y S'" CitiylState/Zip; Hyannis Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under.MGL C. 152,§25A is a criminal violation punishable by a.fine up_to.$1,500:0.0 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:A copy of this statement maybe forwarded to-the Office.of Investigations of the.DIA,for insurance••, coverage verification. I do hereby certify under th pains'and penaltW of perjury that the information provided`above is true and'correct Signature: Date: 3/11/16 Phone#:508-398 0398 Official use only. Do not:write to this area,io be completed by city or town ofjficagL Ctty or Town, `` �, :, •', <. w. - PerinitlLicense# { Issuing Authority(circle one). o'"^ ` ',3, ..i ii_ �',� . , 1,.Board of Health..2.Building Department.3.City/Town Clerk. 4.Electric al.Inspector 5.Plamh ng Inspectort�*.;,,t w 6.Other Contact Person: ' i ; Phone:#: , _ r'i d ..lr-r i ... .. .a"�'1 'SU: .1,.t'...•r3"it�'rv`.a.dk „ . '(. =y"t f�s -�_,. DATE(MMIDDIYYYY) ACOO& CERTIFICATE OF LIABILITY INSURANCEF10/14/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT NAME: Colleen Crowley Risk Strategies Company PHONE. E : (781)986-4400 FAIL No: (781)963-4420 VC,No15 Pacella Park Drive E-MAIL :ccrowley@risk-strategies.com ADDRESS - Suite 240 INSURER(S)AFFORDING COVERAGE NAICS Randolph MA 02368 INSURERA:Selective Ins. , of America INSURED iNsuRERs:Allmerica Financial Alliance Ins Co 10212 Cape Save, Inc IrsURERC:Wesco Insurance Company 7 D Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02664 INSURERF: COVERAGES CER71FICATE NUMBER:CL15101402127 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERRA OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE P LICYIEFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEIT- A CLAIMS-MADE Fx-]OCCUR PREMISES Ee occurrence $ 100,00 61994480- 10/16/2015 10/16/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000, GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B ANY AUTO. BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED !►e®A46796600 11/6/2015 11/6/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ X UMBRELLA LIAB N OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 oil 51994480 10/16/2015 10/16/2016 $ WORKERS COMPENSATION officers Included for X I PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE Coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N❑NIA C (Mandatory in NH) UNC3136274 4/9/2015 '4/9/2016 s f nder E.L..DISEASE'-EA EMPLOYE $ 500,000 ,describe u DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) National Grid Corporate Services LLC d/b/a National Grid, Action Inc, Colonial Gas Company and NStar Electric are all included as Additional Insureds with respects to the General Liability coverage of Named Insured as required by written contract. CERTIFICATE HOLDER CANCELLA11ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 460 West Main street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Michael Christian/CLC '� G 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NS025(201401) i Office _f.Consumer Affairs and Business Regulatlori:. l 0 Park Plaza S llte.5 T 7Q Boston,_Massachusetts 02116 Horne Improvement;Contractor Reglstratloiri �"`-` •�. Registratwn �1.71380 . Type Corporation Expiration 3/1412018 Tr# 419291 } . CAPE SAVE INC:. WILLIAM MCCLUSKEY 7=D HUNTINGTON AVENUE ' "" ' SOUTH YARMOUTH MA 02664 zIIpdate Address and return card Mark reason for etiange. . " v D Address EpAenewal Employment Lost Card; SCA i 0 20M-05l11 ns mernA-mirss&Bu ihcw:lirr�ccc�u e License or re istration valid for individul use onl Office of Consumer Affairs 8 Business Regulation- g y HOME IMPROVEMENT before the expiration CONTRACTOR date If found-return to: Registration �=171380- Type: Office of Consumer Affairs and Zusiness 12egulation �* jo Rark.P.laza Suite 5170` ' Expiration 3N4/2018 Corporation. ,T Boston,MA 02116 CAPE SAVE INC. - _ WIL'LIAM McCLUSKEY_-EIR 7.o HUNTINGTON-AVEN�7E SOUT.KYARMOIJTH,MA.02664 Undersecretary `Not valid[ i signature . Massachusetts —Department of Public Safety Board of:Building'Regui:a ions and.Staridards License: CSSL 102776 AIM W ILLIAM J'MC C'tU 37`NAUSET ROAD _ Qr West Yarmouth MA Expiration Commisss�ionnor` 0612812017' FURC HME 003187 BARNSTABLE HOUSING AUTHORITY 146 SOUTH STREET ��"k HYANNIS, MA 02601 Order Date Date Required ibis No,must appear�on'a,' Cy wy (508)771-7222 TO: SHIP TO:(if other than above address) in e 1 vW 1'i 11-11-,1 IrCa�16 V1. e �p C0ti2c�� e o Requisition No. Requisitioned By Terms Ship Via F.O.B. Quantity Description Unit Price Amount r ft- �A/A/ s -s0 oo INSTRUCTIONS Authorized Signature ❑�For Resale 1 Please send copy(s)of your invoice. n )6��' ❑ Not For Resale Tax Number 2 Notify us immediately if you are unable to ship as specified. U Item#NPR73T The Drawing Board,Dallas,Texas 75266-0429 4P FOLD AT(—)TO FIT DRAWING BOARD ENVELOPE#EW9DW ©Wheeler Group,Inc.,1982 ORIGINAL Engj eering Dept. (3rd floor) Map 3 J 0 Parcel 006 Permit# I o2ZS ` House# )y� - � Date Issued of - Beard of Health(3rd floor)-(8:15 -9:30/1:00-4:30) AIN Conse co c0 ,`� l� BTAI�rAS Pi MGV E dam)--- j CipN 1yL41 Np E 19 BARNSMIU. MA eft 0 TOWN OF BARNSTABLE Building Permit Application Projec Address J T Q /l)N c.K-1_a.14 ft o ee.rX Village D-J al rid A,1J of Owner Un.NJ i cu6le lioy rwc A,,`/-1A T4 Address 1 6 S'Ov T k S'Mee-T Telephone 5oF Permit Request _ I-LE`ta..rip_� tvo�, cs�c,�,l� 53iti�:o cf F•�.l.c )as u�e� rL✓�(�[ � LI�JTT\et- btau�� �l�v.1 First Floor square feet Second Floor JU/'!Q square feet Construction Type tuou® Estimated Project Cost $ J,. Zoning District Flood Plain Water Protection Lot Size 6 D - -" Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes V No On Old King's Highway ❑Yes �4'No Basement Type:Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) N Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing 1 New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing E- _New First Floor Room Count Heat Type and Fuel: -'Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes g 10 Fireplaces: Existing J New Existing wood/coal stove ❑Yes No - Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) 73 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 ic�as-h N r r f c )J V v A I �: A u lt�vu-14 Telephone Number I Address i H 4 - ,�'oo T, ,► Si k cc 1 License# o 1 ) (� _J ►� Rota-- 13 r-%0%N r"YN 1-r 8_rJ Home Improvement Contractor# Af f eq 1 N i tiP - Worker's Compensation# QJ ) Q 3 0 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 57 ,5-7 A r, SIGNATURE moo -- DATE :;L, BUILDING PERMIT DENIED FOR THE FOLLOWING REASONS �Vyoy r � x•. r, FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED; `- MAP/PARCEL NO. ADDRESS VILLAGE. OWNER - TV DATE OF INSPECTION: $. V. FOUNDATION r�. FRAME 3` INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING:. ,A ROUGH FINAL GAS: ; r�- `:' ROUGH FINAL FINAL BUILDING , "2 2r:;L217 DATE CLOSED OUT ASSOCIATION PLAN NO. The Conttm,nivettlth of Afassachusells i -- j•::- Department of Industrial Accidents :i Olticeof1flY tfgallons h/Ill lf'asliinl;tun Street Btiswit, Mass. (12111 Workers' Compensation Insurance Affidavit Llp610;nt informafitin'• plc-se PRINT lebi@jZ name, AnN 6 V-I- V`�' � 1(1C_,LtlS1n LI Ov `'J c} rYL e r 1 61%. it R,OV,$.\-f M A. D a. 6 ZP I nhtme ❑_ I am a homeowner performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity ❑ I am an emplover providing workers' compensation for my employees working on this job. contn•tm• name, e •addreec• - city "hone#• incur•tnce en "olicy# �❑ I am a sole proprietor. general contractor• or homeowner(circle one) and have hired the contractors listed below who ha% the following workers compensation polices: com"•anv nnine• •a d d r"s: city "hone#• noiicv# incur•ancc rn _ - •...- •,-.-•.- - �•a•- _- - ;�---.::_.-��;T••,-..ems,,... ,•.. .:r.,-.. _ �:-�"-....___ comP•tm• n•atna ��� IV� V�8 d.JV►�.},ey�r (�On1 �C!`,ISwI tt� c2nov12 •addrecc- city• Phnne#� incurnnee co noiicv it 0,3 S _ Attach addict'nal sheet if necei_sad'.::::��''` _a.--+.-:.<i�y.::_= ...._; ........ ,;'?''=,�".:.... •..�+: �;;;__`.�„r`�-;= ::,:.i:::=:.;. Failure to secure ctavcracc:as required under Section 25A of 111GL 152 can lead to the imposition of criminai penalties of a tine up to 51.500.00 andior one%-ears'imprisonment:as��ell:as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the Mice of Investigations of the D1A for coverage verification. 1 do hereby cerrift•trtrtler the pains and penalties of perjure•that the information prodded above is true and corre ct. Signature J l ,rvt/a- —+ Date 1 1 / Print name 13 �•/�-0 A nn I few _Phone# '�otlicial use unly do not pyrite in this area to be completed by city or town oRicial city or town: permit/license# r'ttluildine Department • Clucensing hoard L tC3 check if iminediate response is required OSeleetmen s Ufrice t.. C31lc2ith Department contact person: phone#: nUther�— 5 information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' ccIntpensation fo; emplovecs. As quoted iron the "faw**. an emplitree is defined as every person in the service of another under an contract of hire, express or implied. oral or written. An eniplurer is defined as an individual. partnership, association. corporation or other legal entity, or any two or the foregoin`-, 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. Howeti c owner of a dwelling_ house having not more than three apartments and who resides therein, or the occupant of the d%vclling house of another who employs persons to do maintenance, construction or repair work on such dwcllin: or oil the arounds or building appurtenant thereto shall not because of such employment be deemed to be an emp. MGL chapter 152 section 25 also states that even• state or local licensing agency shall withhold the issuance c reneival of a license or permit to operate a business or to construct buildings in the commonwealth for any ;applicant who liar not produced acceptable et of compliance with the insurance coverage required. Addicionaily. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the peribrmance of public work until acceptable evidence of compliance with the insurance requirements of this chap been presented to the contracting authority. 1 Applicants Please full in the workers' compensation affidavit completely, by checking the box that applies to your situation c supplying company naives. 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 yoii'aTe rege to obtain a workers' compensation policy, please call the Department at the number listed below. City or,howns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottc the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be return 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 que., please do not hesitate to `_ive us a ca11. ►..'yl.,..�f�..�. ....�.�••..T...• .. _ .. Min. w i�.• .I. 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 fhT 9- (617) 777-7749 �k. Q - DEPARTMENT OF PUBLIC SAFETY CONSTRUC�'ION SUPERVISOR LICENSE !` BirtMate:' Number Wiies: CS. - 011035 1212611991 1212611949 Restricted T6 00 ,fir H, BRIAN D i�ARRISON 12 LELAH ROAD BREWSTER, MA 12631