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HomeMy WebLinkAbout0955 IYANNOUGH ROAD/RTE132 (4) GI,S,S .1-yaaorus�i l�G�. �� - \_ - -- r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ; Map Parcel Application _ A -Health Division Date Issued '. ? Conservation Division Application Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Addresses Yyno �J Ville age�—*4�-f Q h n j S OVWVV-n---er -Address 35"�,JYSIey PAW.9ani M o-VZg Telephones Per timPer Request! C,) C)W S sidf�� - ru Al - Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation OOO� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family '❑ Two Family ❑ Multi-Family (# units) 1 Age of Existing Structure Historic House: ❑Yes ❑ No On Old King'6'$ighway::.-0 Yes ❑ No t -n 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, � `'w 0 m Number of Bedrooms: existing _new 1-0 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 ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name_ i , a. �J %/J� `C� !Telephone-Numberi' [Address• d)AA0 e Lice! nseVA"00", . � Home Improvement Contractor# Worker's Compensation # AL CQNSTRllC_T.ION DEBRISTRESULTING FR THIS_P_RQJECT1WIL`- BETAKEN TO_- 14 !d aSIB GNATUR DATE 6 /. 4 FOR OFFICIAL USE ONLY ,i APPLICATION # t DATE ISSUED t MAP/ PARCEL NO. ADDRESS VILLAGE OWNER f DATE OF INSPECTION: t' FOUNDATION r FRAME - ;f _ INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r - PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING s . y., DATE CLOSED OUT i r _ ASSOCIATION PLAN NO. I .77xe Commorripealth,of MassacInuetts Departrrre?rt oflfrrtiusft ial Acciderrts - - of-ce of rmw-stigations 600 Washin - • gtort Street ....... Boston,MA 02111 4. n-,Yvi4v masmg4av1dia "[Turkers' Campensation Insurance Affidavit:Builders/Crontractars/EIe ifticians/Plumbers Applicant Iufhnnatign Please Pxint_LeLrih1v Name(Httsmess�Organizatioaflndittidnal} � � c e- Address: City/stattlzip C - I one Are yo-u an een over?Checl€the ap apriate box: T . of project(required),_ L a employer with � 4. ❑I am a general con 6. Netractor and I YP� ew consfrnactiota J employees(full audforpart-timed* have hired.the sub-contractors 2.❑ I am a sale proprietor orpartner listed ou the attached sheet 7. EJ159,odeling ship and have no employees. 'These smb-contractors have g_,❑Demolition wotizing for me in any capacity_ employees and have workers' ti-arl�etx' Comp.;n�,�„re COMP-ine�trane_# 9. ❑Building addition [No r • . required-] 5. ❑ We.are a corporation and its 10 El Electrical repairs or additions' 3.❑ I am.a h,omeoum-er doing all work ofTicers have e ercised their 11.❑Plumbing repairs or additions myself [No workers'comg- right of exemption per MGL.. 2 1� ❑Ro f •� insurance required-]7 c.152,§1(41 and we have no BlZ / • employees-[No,workers' ' , 13.. (7tht (a e� comp-insurance required.) V`/,7 c •tiny WHcaed dwtcbedsbox;Wl roast also fMoutthe sectionbeiowshawiug theirvmteW campensatinupolicyinformaaoe_ l-amem a ers who submit this dfidatdi indicating they are dniag alIwan}aR�tFieahire autsideromtractorsamst submit a new a�dayst indicating rnrTi TCanuWtM. 'ffMt cbea ibis boa must attached sa additional sheet shoo-kg the nameof the sub-corurrctmx and suo whether arnot ibose eadtieslwe employees.Ifthesub-contractoeslave mnplayees,theyxmsstpmvide their workers'comp.palicg number. I acre an eneploy�er flsatis pratadutg iuork¢rs'caeerp¢resrrii�re insnrarrce f or any=¢nrpfny�ees �Beloty is th¢pflticp arrd job site information. Insurance Company Name: Policy if'or Self-inns.Lie. :' Ekpiiation Bate: Job Site Address: City/State/Zip: Attach a copy of the corkers'coanpensationpolicy declaration page:(showing the policy number and respiration date.). Failure to secure coverage as required.under Section 25A of MGL c� 152 can lead to the imposition of criminal penalties of a fine up to$1,50D_OD and for one-year imprisostmeuta as well as civil peualties.in the farm of a STOP WORK ORDERand a EW of up to WO-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 vrerificatioa I rho kereby c utdor d ' s a dpenaTtczs nfp¢tjury fJeatflTta infarflzn#imaptm2r dabm ' bars id correct' Sr Date �u / Phone ik v� a a g to Official use only. Do nat write in this.area,to bi'ctrinpTeted by city artoom officiaL City or Taws: PerrmtUcense 4 Issuing A.nthority(circle One): ` 1.Board of Health 2.BuRding Department 3.City town.Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other. Contact Person- Ph-one#- Information and Mstructions Massachusetts CT r-heral Laws chapter 152 reqaires all employers to provide workers'compensation for their employees. Pam this statatc,an anp&5yw is defined as.",.every person in the service of another under any contract ofhire, express or implied,oral or wtitteu." An employer is defined as."an individual,partnership,associaaficrn,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 apartmeots and who resides therein,or the occupant of the - diwelling house of another who employs persons to do maintemnce,construction or repair work on such dweIling house or on the grounds or building appudtenanf thereto shallnotbecanse of such employmentbe deemedt o be an employer." MGL chapter 152,§25C(6)also states brat"every stale or local licensing agency shall withhold the issuance or renewal of a ficeise or permit to operate a business or to construct buildings in the commonwealth for any applica. twho has notproduced acceptable evidence of compliance with the insurauce.covexagerequired_" Addi[ionaHY,MGL ahaptrr 152, §2SdM states"Neither the commgnwealth nor airy of its political subdivisions shall eater into any contract for the performance ofpublic work until acceptable evidence of compliance with the insura ce.. requurem ents of this chapter have been presented to the contracting arrthozityf Applicants Please fill out the workers'compensation affidavit completely,by checl®g ih. boxes that apply to your situation and,if necessary,supply sob-contractors)name(s), address(m)and phone number(s)along with their certificates)of insurance. Lbnit,-d Liability Companies(LLC)or Limited LiabilityPartnmzHps(LLP)withno employees other than the members or partners,are not rz uired to cant'workers' compensation insruance. If an LLC or LLP does have employees a policy is required.. Be advised that this affidavit maybe submitted to the Departmmt of Industrial Accidents for confsmation ofmsiir�ance coverage. Also be sure to sign and date the affidavit. The affidavit should be retcnmed to the city or town that the application for the peunit or license is being requested,not the Department of TnrhTcfrial Accidents. Shouldyou have any questions regarding the law or ifyou are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-fimued companies should enter their s elf-m sura ce license nainber on the appropriate line. City or Town Officials f Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of thr,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 pennit/license applications in any given year,need only submit one affidavit indiriig current policy infbn natiou(if necessary)and under"Job Site Ad 1drms"the applicant should write"all locations in (cit or town)__"A copy of the-affidavit that has been officially stamped or marked by tht city or town may be provided to the applicant as rnof " that a valid affidavit is oa file for firtnre'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 v6ntim (ie. a dog license or permit to bun 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 nunberr 'he COMMMt tar Of Mas chusetls Dtpar[ment cuff 1udustza1 AOCZeuta Off ce of lnvesf tio= � � �QQ�ashingtan S'tz�t ' Boston.,M G2111 T(,-L A 617 727-4900 Cxt 406 or 14 MASSAFE Fax#617-727-7749 Revised 4-24-07 mas,-gavIdi'et Massachusetts Department of Public Safety w Board of Building Regulations and Standards License: CS-058441 I C,pnstruction,Supervisor } �. .e { MICHAEL J DIN61A, 32 OUTPOST LN- ZZ,CENTERVILLE MA 02 "1,; lam. Expiration E .Commissioner 16115/2017 C rcpainn7�ricueal�i o��Jac�zcca - O'fSce of Consumer Affairs 8c Business Regulation Lrcertse or.registration valid for individul use only r before the.ex�pir'ation date:_If found return to: OME IMPROVEMENT CONTRACTCSR . y egistration: ,182287 '� Type: Office of Consumer Affairs and Business Regulation p on z 6f_ Corp ration 0 Park Plaza-Su 17 x irati 1 Suite 5 0 Q Boston,MA 02116 y R ACMD INC. i MICHAE.L DINOIA 32 OUTPOST LANE CENTERVILLE, MA 02632 � ' Undersgei-et ry Not v id4signature 01/20/2^016 WED 11: 19 FAX 508 94.7 6844 GAMMONS INSURANCE 19001/002 ACOR" CERTIFICATE OF LIABILITY INSURANCE' E' (M'°""YY) `� 1/20/16 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 endorsemenks). PRODUCER CONTACT NAME: Gammons Insurance Agency PHONE FAx (506) 947-6844 IA F�d) (508) 947-3460 No: 328 Bedford Street E-MAIL PO Box 1235 ADDRESS: info@ ammonsinsurance.com _ INSURERS)AFFORDING COVERAGE NAIC N Lakeville, MA 02347 INSURERA:Main Street America INSURED INSURER B:AIM Mutual Insurance ACMD Inc INSURER C 32 Outpost Lane INSURERD: Centerville, MA 02632 INSURER I INSURER F: I COVERAGES CERTIFICATE NUMBER: 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,TERM 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 ADDLISUBRPOLICY EFF POLICY DIP LTR TYPE OF INSURANCE POUCYNUMBER MMlOD/Y MMIDO(YYYY LIMITS �-GENERALUABILITY MPTTO�I'TQ �2/r6/ —T2�r6/16 EACH OCCURRENCE $ 1.000.0�0 }{ COMMERCIAL GENE RAL LIAB ILITY DAMAGE TO RENTED $ 500 OOO CLAIMS-MADE F1 OCCUR I ME EXP(Anyone person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LLMITAPPLIESPER PRODUCTS-COMP/OPAGG S 2,000,000 E CT I POLICY I PRO- I LOC - - - -. _ i - i$ - AUTOMOBILELIABIUTY COMBINED SINGLELIMIT I$ a accident ANYAUTO 1 BODILY INJURY(Per person) ;S ALLOWNED SCHEDULED d P BODILY INJURY(Per accident)AUTOS AUTOS ( ) $ NON-OWNED w PROPERTY DAMAGE - HIRED AUTOS _AUTOS Per accident $ UMBRELLA LIAR a OCCUR I EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B VYORKERS COMPENSATION VWC10060197762014A 12/17/15 12/17/16 WCRYLIMII STATU- I OTH-I AND EMPLOYERS'LIABILITY, .Y!N ' ANY PROPRIETORIPARTNERIEXECUTIVE EL.EACH ACCIDENT 100,000 OFFICERIMEMBER EXCLUDED' N T A (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 100,000 IF yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 50O,00O DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Renarks Schedule,If more space is requ red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF 7HE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE' EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town-of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS." 1146 Route 28 - South yarmouth MA'02 601 AUTHORIZED REPRESENTATIVE Robyn McCarthy ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2D10106) ^ The ACORD name and logo are registered marks of ACORD Phone: Fax: (508) 398-0836 E-Mail: jfoley@yarmouth.ma.us i WE Town of Barnstable Regulatory Services g rY Richard V.Scali,Director MASIL39.�' Building Division Paul Roma,Building Commissioner 1 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner-Must Complete.and Sign This-Section If,-Using A-Builder : -e-g; as Owner of the subject property hereby authorize / ✓G . -;- -- j NO c C2 to act on mybehalf, in all matters relative to work authorized by this building permit application for. (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. - tp Sigkatureo Owner Signature of Ap lic t �eL Print Name. Print Name Date Q10kMS:OWNERPERMISSIONPOOLS Mass. Corporations, external master page Page 1 of 2 u L7-AM-9.1 11 It K LWJ 6 C Corporations Division Business Entity Summary - ' ID Number: 001027322 !Request certificate New search Summary for: 955 IYANNOUGH RD, LLC The exact name of the Domestic Limited Liability Company (LLC): . 955 IYANNOUGH RD, LLC Entity type: Domestic Limited Liability Company (LLC) Identification Number: 001027322 Date of Organization in Massachusetts: 04-29-2010 Last date certain: The location or address where the records are maintained (A PO box is not a valid location or address): - Address: 955 IYANNOUGH ROAD. City or town, State, Zip code, HYANNIS, MA 02601 USA Country: The name and address of the Resident Agent: Name: NELLY SHEEHAN Address: 35 BURSLEY PATH City or town, State, Zip code, WEST BARNSTABLE, MA 02668 USA Country: The name and business address of each Manager: Title Individual name Address MANAGER NELLY SHEEHAN 35 BURSEY PATH WEST BARNSTABLE, MA 02668 USA In addition to the manager(s), the name and business address of the person(s) authorized to execute documents to be filed with the Corporations Division: Title Individual name Address The name and business address of the person(s) authorized to execute, acknowledge, deliver, and record any recordable instrument purporting to affect an interest in real property: s Title Individual name Address http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary,aspx?FEIN=001027322&... '10/7/2016 f z TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map act r( Parcel 0 2- %�r 76 � 6 / Permit# ci Health Division .!km ''7�P� 1 LE Date Issued "bonservation Division 1114 MAY 28 AM 9 37 Application Fee _ Tax Collector J Permit Fee Treasurer Dill Planning Dept. APMCAMMM OBTAIN AWE y '" CONNECTION Paw n= TIIB Date Definitive Plan Approved by Planning Board RONUMING DIVISION PBtON TO COM MCTION. Historic-OKH Preservation/Hyannis Project Street Address `l<5ZS_ Village � � S 1 o Z c e,f.,J 2 Owner '�i o-c o'ct.y R� L4 2`�-� Address C -tea-i-Cr V L I,� I`7 A— a a-e.3 Z, Telephone L�"y G1 - 7 7 I ct 2. `{ IL- Permit Request 2 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay j Project Valuation P Construction Type Lot Size Grandfathered: O Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes O No On Old King's Highway: 0 Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout O 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:0 existing ❑new size Barn:0 existing ❑new size Attached garage:0 existing ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded 0 .Commercial ❑Yes ❑ No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION - '�. Telephone Number Name �. �ec 2 ec2�( V��>5 T 7 �- �� Address C I `� ® � dcc PQ License# LALL �..Z'zw� I le MA 1b 2c,3 `L Home Improvement Contractor# ' - r Worker's Compensation# ONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ATURE / DATES 2-8 —0 y FOR OFFICIAL USE ONLY HERMIT NO. - -� DATE ISSUED MAP/PARCEL NO. I t ADDRESS VILLAGE F^ { OWNER DATE OF INSPECTION: FOUNDATION FRAME f INSULATION h FIREPLACE ELECTRICAL: ROUGH c o o FINAL PLUMBING: ROUGH FINAL GAS: ROUGH �. ' FINAL c FINAL BUILDING S `- ✓ '} DATE CLOSED OUT ASSOCIATION PLAN NO. + The Commonwealth of Massachusetts _ -- Department of Industrial Accidents 600.Washington Street Boston,Mass. 02111 Workers'.CZZ:om ensation.snsnrance Affidavit-General Businesses / ,• J3 i�gCSSiiiv� +Wa.. ," `S.'3• '':T�a l. �r`••y,. 7. ..a'�.. .•'.'fir: . •.:, � / namet't'cy�( address e# ai Awork site location fat address E ' crvr A-y�r-� ems/ G L ❑ I am.a sole proprietor and have no one Business e: 0 ❑Re Retail staurant/Bar/Eating Establishment working in any capacity. [l Of Sales(including Real Estate,Antos etc.) ❑I am an on 310 er with . em'to ees(full&bart time)'. �Other I a>ii an employer providing workers' compensation for my employees Working on this job. "8II •Ilea1 .. r Y' 5•' 1: •:ir :�;. • • hone..#.:�"�,:•_ i• InsuranCe.ca: ii :e•, -i�:.4 fit::. .:k:',•. / T am a sole rietor and'have hired ired the independent contractors listed below'who have'the following workers' P P , compensation polices: . :r.Y •t` '' �; ,.�.•. ..f • ••�y• :J S,��tve.��•.'.� -,,P�7 Y.,,tY.�N•.4J1• :J; .:t.•. c6lupen Dam Y. � . address:. sir r ::.• - A It 2llsIIr8IICe - ?•'icom 'r.: r.s.�i, .i;. :(: •.,�,. •{' :'n'�a •ter:•), st.•� p4':J 7. address: .- • msuranci-c +: Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that p copy of this statement maybe forwarded to the Office of Investigations of the DTAfor coverage verification I do hereby certify er the pains and pen of perjury that the information provided above is true and correct '' Signa Date Print name Phone# official use only do not write in this area to be completed by city or town official city or town:— permit/license# ❑Building Department []Licensing Board ❑check if immediate response is required []Selectmen's Office C]Heahh Department contact person: phone#; ❑Other (revived Sept 7003) Information'and Instructions Massachusetts ..General Laws chapter�152 section 25.requires all employers to provide workers' compensation for'the' . employees: As quoted from the law', an employee is.defined as every person in the service`'"of another under arty contract of hire; express or implied; oral or written. f An employer is defined as an individual,partnership, association, corporation or other legal entity, or,any two or mare 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' 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 bf th. .dwelling house of another who.emplogspersons to do.maiuteuance, construction or repair work on such dwelling house or on the grounds or a urtenant thereto shall not because of such employment be deemed to be an employer. :. : .... : ... building. pp . MGL chapter 152 section 25 also'sWes that"every. state'or local licensing agency shall ivithhold 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 eviderice-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. Applicants Please fW in the worrkers' eompensafM affidavit completely,by checking the box that applies to your situation..Please supply company name, address and phone numbers along with a certificate of insurance 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 regasdinjf the�"law"or if you ale required to obtain a:workert!compensatioapolicy,please call the Department at the number listed below. City or Towns . Please be sure that the affidavit is complete and.printed legibly. The Department has provided a space at the bottoni 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. The.affidavits may returned to. the Department by.mail or FAX.uriless other•ariangements have been made. The Office of Investigations would like to thank ybu in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. ; The Department's address,telephone and fax number: The Commonwealth Of Massachusetts- Department.of Industrial Accidents BMW of Wesfwwns 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 nhnna#- 1617) 777-490 ext:ao6