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0091 KENNEDY CIRCLE
9/ _ _� __ �, �� 1 � `M'CCARTHY �y- C: RUCTIQN CO. e4�4 sid oaf and Commercial Builder s t 3f s, R U - ZATION SPECIALIST:- � QUA�' Li�Ws'1�Cf MCCARTHYC October 21, 2014 :S Town of Barnstable Thomas Perry CBO a Building Commissioner 200 Main Stret Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, This affidavit is to certify that all work completed for permit application#0 at 91 KENNEDY CIRCLE has been inspected by a certified Building Performance Institute(BPI) inspector.All work performed meets or exceed Federal and State requirements Sincerely, Michael McCarthy McCarthy Construction s TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division Date Issued Op Conservation Division Application Fee Planning Dept. Permit Fee APA Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address mc `e., Aqw__ Village Owner 0.Y� S Address /l `2 l d Telephone Permit Request AiY b TYt �' / Ike d C � Iki ;4- A ?!- � Pquare feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation)C4 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'sdJi;hway: Yes No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' y.r�' j G7 Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft 71,13 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 ount 0� 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 'rG�� ^�� APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name " Telephone Number C/79-41FU `934 Address ?"D. D License # Home Improvement Contractor# l�I Worker's Compensation # ay—Iy00 l31?7L ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO MW-4ked, SIGNATUF DATE u FOR OFFICIAL USE ONLY I APPLICATION# DATE ISSUED f MAP/PARCEL NO. r r ADDRESS VILLAGE OWNER y DATE OF INSPECTION: ;,.,!FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL 4 c PLUMBING: ROUGH FINAL GAS: ROUGH FINAL n t FINAL BUILDING w - DATE CLOSED OUT r ASSOCIATION PLAN NO. t ' r t'� ' 1 I OWNER AUTHORIZATION FORM I, Ct r (Owner's Name) owner of the property located at ke, '(c/e (Property Address) Q►'1 Y? f roperty Address) � l hereby authorize 6 V 1 I Fc—) 4we-A G�- (Subcontractor)' an authorized subcontractor for RISE Engi Lring,-to act on my behalf to obtain a building permit and to perform work on my property. er's Si lure 33) � J` Date r 06/18/2014 22:59 9787778415 PAGE 03 CERTIFICATE OF LIABILITY INSURANCE16/19/2014 THIS CZXMCA79 15 AS A MATTER OF INFORMTION ONLY AND COMPERS NO RWITS UPON THE CERTMATE-HOLGM THIS CwnmATE DOE NOr AF�RIpATl1/ELY OR weA1i ay mwe, ornm ON ALTER THE COVERAOIS AFFORDED BY Tim Poums BELM INN CERTIFICATE OF WSURANCE DOES NOT CONSTITUTE A'CONTRACT QETWEIN THE lSStM R@!. MMORM iREPRES WTATTVE OR PRODUCEi,MIA THE CER?1FICAW HOLDER. IttPORTANT! a the emfl8ede holder to an ADDITIONAL INSURED,dW pollgypa)must Be wWom a. 8 SUBROOATEN IS WNVED,s e the bnn0.OW C Mdi6om Of 90 DOW.argin DONOW BW MWAM 0a*RdmmwnmvL A etslereerd an Ihb eeM ub dos net am In fthb to Brs eodNleeb holder In Ilse of such onlayawnwWaL PRoauCER COOMM INSIMMC9 AMUCY INC (979)774-2463 o c978)777-8a15 123 Sylvan St Denvers, MR 01923 rMl epeapwo oore,aoE rraee WWRMA:Commerce ins. Co. INBWRW Building Performance Contracting, LLC ,1QSa ZW;Ltgrg dba IfTayset Insulation ,NSA C:AtJAMtla i h-t*C P.O. Boa 633 1ttSURM D.RB Jones Truro, Ma 02666 , RER . Imam F; COVERAGES CERTIFICATE -NUMBER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE IBM BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. M07WITHSTANO NG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICN THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS S.UlUEI:T TO ALL THE TERMS. EXCLUSIONS AND CONDRIONS OF SUCH POLI W.LIMIT$SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. L Im OR Mkok NOE P—MMY WJ MR - u wM . cENEwu LUIBLJTY 6414 OCCURRBrCE 0 1 000 00 R COMME WLAL OENERAL LW*Wff ine asMeeorrw�em s SO 000 aA*"UMM FZJ.occua RVED Exp(AIW on pww) 0 1,000 B MF0020002000041 S/1/14 5/1/15 PE7mm&*ADvmmw s 1,000 000 cilI ew ABBnow 0 2,000 000 cowl.AccFMrAM LIMIT APPLIES ISM PRooucra-coNPAPAeH a 1,000,000 noucr . 29 Loc i AVTONOBILE LIABIL N 1,000,000 ALL OWNWA AMO s e !2/14 /2/15 BODILY AWWar maw s WRIMI auras Affurti"TICIPJAME 0 t A UM RBIA LAS vault EAa1 OCCUM CE s 2,000,00F D EXCESS Lae CLANSAUM COBW3904112 5/1/14 S/1/15 A ►TE tf 2,000,000 pool I RS COMPENBA ON 0 AND EMPi DYERS'UASUN via C 0"4 WELUDWIF ® WA NCV00S39400 Y/Zs/i3 u/23/14 ILLEACRACCIDW t a00 000 oNIEILaE-EA Ewt a 00,000 ro�R' unaDO"b°wN OF OPWATI01115 We. ILL mBEA01T•POLICY uw $ 500,000 DESCRWMU of 0MATIONs I LOCATIONS I VENUM (Alt t ACM 101.AWPorW Rwwft 890mts.a more specs Is nNp*W) CERTIFICATE HOLDER CANCeLLATION TOTQ!! OP Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Barnstable, No THE EXPIRATION DATE THEREOF, NOTICE JMLL BE DELIVERED IN ACCORDANCE WITH 3P70LICY PROVISIONS. A MORM REPREB C 0`198"010ACOROCOWOM710N. Al1 rigt rued. AGORD25(2010" The ACORD name and�ale►eBi hmW melt oTACORD The Commonwealth of Massachusetts F'riitt F°r`z' �f Department of Industrial Accidents ' - - - Offlce©flnvestiortions I Congress Street,Suite 100 '.. Boston,PM 02114--201 T %ww.masSaovIdia Workers' Compensation Insurance Affidavit: Builders/Con_ tractors/E_lectricians/P'lumbers �-- A plicant Information Please Print Legibiv Name;{Busiaess/Oni�tionlludividuat): Utz! s, 4Y4iTr,*_ laxy-t. Address: Q rJ3 City/State/Zip: f u o Q L-reb Phone W': Are on an employer?CheFk the appropriate box: Type of project(required): I. I am a employer with �I e 4. 0-I am a general cunt zctor and I 1 fall and/or lame * have hired the sub-contractors 6. 0 New construction employees(, Part: ). 2.El I am a sole proprietorrn partner- fisted on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have - 8. ❑Demolition working for me in any opacity. employees and have workers' [Ate worlt m'comp.insurance comp.insurance t 9. Building addition . required:] S. Q We are-a corporation and ifs 10_[]*Electdcal repairs or additions 3.❑ I.am a homeowner doing all work officers have exercised their_ I LF]Phimbia;repairs or additions my.elf. right of-exemption per MGL o workers co msm-an��.]+ �_ 7 c- 152,§1(4),and we have n I2'Q.I f reps employees.[No workers'' - comp.insurance required_] - *Any applicant that dtecs box#1 must also fill out thesection belowowiag their workers'compensvtion policy information. t Homeowm�s who submit this affidavit Mca&g theyare doing an work and they hire outside corim ours must submit-anew affidavit indicating such. ZContractorsthat check tins lox must attached an additional sheet showing the name of the su6-contt c and saoe whether or not those entities;:have employees. Vthe sub-conttacoots have employem they must provide their wotitms'comp policy number. I am an empioyerthatisprmugha�workers'compensation insraanceformry employees Below is thepoliry andJob site information. /J l Insurance'CompanyName: f7T�C(�? E✓ if • Policy#or Self-ins.Lip.#: 26b Expiration Date; nov Job Site Address: C11 Le-nnejs4 CCi-c� City/State/TaP: is t OZd o� Attach a copy of the workers'compensation policy declaration page(showhig the policy n and e8pirabion date). Failure to:secure coverage as required under Section,25A of MGL c.152:ran lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$.250.00 a day against the violator..Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby —under the gins and enal�s o Mat Ike --rmaliioa provided above is true and comwt _._ _ _ Phone Official use only. Do not write in this-area,.to be completed by city or town official City or Town- PermWLicense# Issaiug.Atit3vority(ctirle one L Board of Deal* X Building 3Deparbuent 3.Cityfretwn Clerk 4.Electrical Inspector 5 Phm*ft Inspector 6.Othe:r 6"nntent Dnrcnas• �i......,8. I JW QAassacpusetts-Department of Public Safety Board of Building Regulaffonvand Standards - - _ Construction Snpei-rkor License: VI z"7a_93_ JOSH EMOND - POBOX633 - .- Truro MA 026a,_, Expiration Commissioner 0312512015- i i License or registration valid for in"dul use only Ogee of Consumer Atiaus&Business Regalatioa _ before the espixadon date. Xfound return to: ME IMPROVIT CONTRACTOR Office of Consomer Ailairs and Business Regufati istra6on: .474235 T •--� 10 Park Pima-Suite 5170 LLC - Boston,il3A 02116 BUILDING PERFO - G.Lm JOSH EDMOND r ` s KINNIIaNNICK RD TRURO.MA 02666 Uade�etary of vafid without sign$Em TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map arcelidn � pp Health Division Date Issued 2-9^tcy P Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address 9� Ltenh��?,� Cvr��L Village ►� Owner Address Seri. Telephone 775'-7v Permit Request .ice k!x,.-z ,,, 4- .Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation __Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach porting documation. Dwelling Type: Single Family 6K Two Family ❑ Multi-Family (# units) -cCo Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's fighway:©Yeses❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft LO ram'` ca 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 0 No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Mike McCairthy Construction Address PO Boat 52 License # West Dennis, Cell.(508) 280-6964 Home Improvement Contractor# CSL-58633 HIC-169393 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO fry ✓ SIGNATURE 4V0 DATE ���/'7 k FOR OFFICIAL USE ONLY AOPLICATION# is VATEISSUED MAP4 PARCEL NO. ADDRESS VILLAGE OWNER .. I i •h - DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL a GAS: ROUGH FINAL FINAL BUILD.ING-, QATE CLOSED OUT AS PLAN NO. The Commonwealth ofMassachusetis Department of lnduvWd Accidents Office of Investigations ' 600 Washington Street _ Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit.,Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name usiness/or Mike McCarthy Construction (B ganizafion/IndividuaI): Rnx S2 L Address: West Dennis, MA 02670 8) 284-1-6964 . CSL-58 j-!T(7- 1�;�' - City/State/Zip: �ne Are u an employer? Check the appropriate box: Type of project(required): 1.[ I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7_ ❑Remodeling ship and have no employees These subcontractors have g. Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance 9. Burldmg addition required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.0 Plumbing repairs or additions myself [No workers'comp. rat of exemption per MGL 12.0 Roof repairs insurance required-1 t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Otlier comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing aU work and then him;outside contractors must submit a new affidavit indicating such_ lContractors that check this box must attached an additional sheet showing the name of the sub—contractors and state whether or not those entities have employees. If the sub-contractors have employees,they mast provide their workers'comp.policy number, I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: G5-r; -,2d I�— - Policy#or Self-ins.Lic.9:_V UJ L or,—Ga 17— Expiration Date: 7I r7 l`/ Job Site Address: J�cv�n CQ'4 Cvm ( City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,50D.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un p and penalties ofperjury that the information provided)above is true and correct Si ature: Date: 'I�(( Phone#: Official use only. Do not write in this area to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.CitylTown Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: -Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual;partnership;association oz ethereffiI entity,employing employees. However the owner of a dwelling house having not more'than;hreeWapar[ments and who resides therein,or the occupant of the dwelling house of another who employs"persons to.,do ,construction or repair work on such dwelling house or on the grounds or building appurtenant theretorshall.not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or IocaI licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the intnranc.6 requirements of this chapter have been presented to the contracting aufhoiity." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of in.suraiice. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-in sur n ce license number on the appropriate lime. 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 the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Address"the applicant should write"all locations in (city or policy information(if necessary)and under Job Site Ad�r pp town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of 1ndustdal Accidents Office of Xnvestigatio.As 6GOashirtQn Street Bastan,MA 02111 Tel.#617-727-490Q ext 4€6 or 1-87 7-MASSAFE Fax#617-727-7749 Revised 4-24-07 vwww-mass_govfdia , l l . Massachusetts -Department of Public Safety Board of Building Regulations and Sta ndards Construction Snpervisor License: CS-058633 ' MICHAEL J MCC;1R - PO BOX 52 �,JJ xi W DENNIS MA t5267a` ` Expiration Commissioner 04/10/2016 a Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration: 6/16/2015 Tr# 238121 MICHAEL MCCARTHY MICHAEL MCCARTHY P.O. BOX 52 WEST DENNIS, MA 02670 Update Address and return card.Marls reason for change. SCA 1 20M-OS/11 Address Renewal �� Employment E] Lost Card ej °ATE`MM,°°'YYYY' CERTIFICATE OF LIABILITY INSURANCE � 10/16/2013 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 endorsement(s). PRODUCER 01962-001 ;CONTACT NAME_-- -- ----- ------ ----=--. .----------- Bryden 8r Sullivan Ins Agcy of Dennis Inc 'PH "E FAX PO Box 1497 (A/_No_Ext)_..(508)398-6060 -- - - - _(a/c_No.__(508)394-2267- - So Dennis,MA 02660 i ADDRESS: INSURERLS)AFFORDING COVERAGE i NAIC# - - ---- - -___!_ANSURER.q: -A.I.M.Mutual Insurance Company 33758 INSURED Michael McCarthy Construction Inc P 0 Box 52 — INSURER West Dennis,MA 02670 � ' INSURER E--- ------------------------ ' INSURER F, 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, EXC:.US!ONS AND CONDIT!CNS OF SUCH POUC!ES.LIMITS SHOWN MAY HAVE uEL"°J REDUCED BY PAID CL�;i.1S. LTR TYPE OF INSURANCE ,IANSPR WVB1 I POLICY NUMBER I POLICY EFp TpOLICY EXP -- --- ' - - - -- -- -- -I(MM D�T M( MIDD/YYYY)i. _ LIMITS /D GENERAL LIABILITY I i EACH OCCURRENCE E $ L COMMERCIAL GENERAL LIABILITY I I DAMAGE TO RENTED --'--- I !CLAIMS-MADE I OCCUR I MED EXP(Any one person) $ 1 _ PERSONAL&ADV INJURY $ ---- GENERAL AGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: !PRODUCTS - S POLICY PRO i._.. LOC - --- - - - --- - - COMP/OP AGG $ - - - AUTOMOBILE LIABILITY j COMBINED SINGLE LIMIT --- - _ accident $ ANY AUTO I Y INJURY (Per person) s -- -----�-�'--- BODILY INJURY(Per person) ;$ lALLOWNED !SCHEDULED i AUTOS -. AUTOS I I j BODILY INJURY(Per accident) .$ HIRED AUTOS !NON-OWNED I I PROPERTY DAMAGE - — - - AUTOS I I !Per accdent), - � UMBRELLA LIAB � _.. _-._ I OCCUR I I F1iCH OCCURRENCE $ I AGGREGATE EXCESS LIAB-- i r CLAIMS MADE AG -- -- - -- --—- -- ATE � g DED RETENTION $ --.- ---- ------- ------- -_ � $ 'WA DR KERS MPENSATION - ! - --1- - IX I TW g TLAIMTIUTS 10 ETR EMPLOERS'LIABILITY -I I_ _ ANY PROPRIEBo R EXCLUDED? Y/"i' E.L.EACH ACCIDENT $ SOO,000.00 A OFFICER/MEMBER EXCLUDED? I Y I N/A I VWC-100-6017656-2013A 17/17/2013 7/17/2014 j--- --- -•-_,_- (PAandator;in NH) -- ----------- - E.L. ISEASE EA EMPLOYEE!$_ - i�fY s ddes&nbe under I _ ,_DtCRIP I ION OF OPERATIONS below ; F i _ - _ - I E.L DISEASE POLICY LIMIT $ -- -- -- - _ 500,000.00 i I r i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLESAttach ACORD 101,Additional Remarks Schedule,. !( if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF SANDWICH Attention:BLDG DEP7 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL ANNEX THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sandwich,MA 02563 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r `. ©1988-2010 ACORD CORPORATION.All rights reserved. OR D 25(2010/05) The ACORD name and logo are registered marks of ACORD i Pm"406m) srnr7` ty Btiat ; Il A3 ISow y - n d SUbCoAtMdar r RiS=5�gln ritt9, b atfan my bSholf to �n a bulling f r f • NIALL HOPKINS BUILDERS 91 KENNEDY CIRCLE HYANNIS MA January 30, 2012 Town of Barnstable Thomas Perry, CBO 200 Main Street Hyannis, Ma 02601 RE: 91 Kennedy Circle Hyannis Ma Dear Mr. Perry, This affidavit is to certify that all work completed at 91 Kennedy Circle Hyannis Ma has been inspected by a certified Building Performance Institute(BPI) inspector. R-30 class 1 cellulose was added to the interior walls.All work performed meets or exceeds Federal and State Requirements. Sincerely, ,= Hopkins Builders Inc. iV TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION AL Map Parcel Application # Health Division Date Issued Z Conservation.Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis 1 Project Streeltt..Address N Village Owner t Address l I K4w -� Telephone 5® Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation too oa 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: ;0 Yeses❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other € Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.) Number of Baths: Full: existing new Half: existing new ZI 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 ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) 5Name Telephone Tele hone Number p L Address6 .4-1 License # V Ib��l1 �A Home Improvement Contractor# 1 Worker's Compensation # ALL CONSTRUCTION DEBRIS ffSULTkG FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ®ATE /—V� FOR OFFICIAL USE ONLY i e4 APPLICATION# ;r. 4, DATE ISSUED Y MAP/PARCEL NO.. _ ADDRESS VILLAGE OWNER i DATE OF INSPECTION: F . `-FOUNDATION T FRAME p INSULATION' ,•, F FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL :GAS ,-, -_, ROUGH .;, FINAL „FINAL BUILDING;- DATE CLOSED OUT ASSOCIATION PLAN€NO. r The Commonwealth of Massachusetts �s ( Department of Industrial Accideizts 1 Y "I: Office of Investigations U,;'� 600 Washington Street "y i• Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumb' - rs Applicant Information Please Print Legibly Name (Busincss/Organization/Individual): Address: :A City/State/Zip- c Qp� j� Q V Phone #: ' � VU i (J�6J-7 A re youemployer?Check the appropriate box: Type of project(required): employer with_ 4. ❑ I am a general contractor and I ti New ees(full and/or part-time).* have hired the sub-contractors ❑ construction ole proprietor or partner- listed on the attached sheet t �• ❑ Remodeling have no employees These sub-contractors have 8. ❑ Demolition for me in any capacity. workers' comp. insurance, 9. ❑ Building addition kers' comp.'insurance 5, ❑ We are acorporation and its .] officers have exercised their l0,❑ Electrical repairs or additions 3.❑ I am a homeowner doing,all.work 'right of exemption per MGL 1 l,❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12•❑ Roof repairs insurance required.]-t.• employees, [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks.box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating thcy are doing all work and than hire outside contractors must submit a new affidavir indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for rrry employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: b Expiration Date: 1 Z Job Site Address: City/State/Zip: Attach a copy of the workers' coma setion polic declaration page(showing the policy number and expiration 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$1,500.00 o ne-year' prisonment, as well as civil penalties in the form of a.STOP WORK ORDER and a fine of up to$250.00 a agains the tolator, Be advised that a copy of this statement may be forwarded to the Office of Investigations oft h D for ance coverage verification, I do hereby certify un ains and penaflies of perjury that the information provided abg1rue and correct Signature; Date: 1�' Phone#: FEaD only, Do not write in this area,to be completed by city or town official n: " Permit/License#. hority(circle one): Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5, Plumbing Inspector son: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner.of a dwelling house having not more than three apartments and who'resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6),also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §'25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements ofthis chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you tb fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/licease applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof-that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog Iicense or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate.to give us a call. The Department's address, telephone and fax number: The-Commonwealth of Massachusetts Department of ladustnal Accidents Office of Investigations 600 Washington Street; Bas°ton,MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77,MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.m,ass..gov/dia i� ACCW® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 09/09/2011 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 endorsement(s). PRODUCER CONTACT NAME: Mark Sylvia Insurance Agency PHONE nAic No: 508 420-9227 771 Main Street ,vC No Ext 508 428-0440 nDoRess:mark marks Iviainsurance.com Ostervllle,MA 02655 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Farm Family Casualty Insurance INSURED Niall Hopkins Builders,Inc. INSURER B: 118 Lakefield Road INSURER C: PO BOX 231 INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER F: 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 ADDL SUBR LTR TYPE OF INSURANCE N D POLICY NUMBER MMIDDY� MMIDD� LIMITS A GENERAL LIABILITY _ 20011_6275 10/30/2010 10/30/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES Ea occurrence $ 100,000 CLAIMS-MADE ❑X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL BADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 7XPRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO LOC $ A AUTOMOBILE LIABILITY 2001 C53575A 6/25/2011 6/25/2012 Ea MBINED accciden SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ 1,000,000 ALL OWNED SCHEDULED Per accident) $ 1,000,000 AUTOS X AUTOS - BODILY INJURY( NON-OWNED ED HIRED AUTOS AUTOS - PROPERTY DAMAGE Per accident $ 1,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION 2001 W6459 9/8/2011 9/8/2012 VJC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N IMIT XFR _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH)If E.L.DISEASE-EA EMPLOYE $ 500,000 as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Carpentry,Electrical CERTIFICATE HOLDER CANCELLATION (508)790-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD '-,���1:1;t�+,;rcltra�ckk� - !?tp.ta'1ntcnt Dt•i'ta#aiat `+;ti'.t`i� 13at a tt tit l3ualtltn !tt tllsatlarais gritP+1<trtdrtrtl L-iC;"ell*"e LICt*r;se= CS 84916 §F ?i ttt NIALL J HOPKINS BOX 231 SO, YARMOUTH,MA 02664 Expi;atioti: 4f,2J2013 r Trm: 14504 33 TOME IMPROVEMENT// ga�nmo� coal r, o t�aacrc�vel ., Office ofrZoa umcr f\t airs B mtss. egil a Ion License or regagtration Valid for mdividul use only C ENT CONTRACTOR before the expiration date. If found returu to r s Registration ,.161773 -tb- Type: Office of Consumer Affairs:and Business Regulation. 4 t Expiration: t 1/20/2012 Private Corporation 10 Park Plaza-Suite.5170 a> � Bostd i�,NIA 021 =6' NIk1LL HOPKINS BUIE0ERS INCY NIALL HOPKINS 21 G r RUEAN AVE i SOUTH YARMOUTH;, 02664- Un dersec rota rg _.._. dot vah without signature is E P } 3 I j 3 I AUTHORIZATION (Owner's Name) owner of the property located at (Prop Address) (Property Address) hereby authorize02H- (Subcontractor) an authorized,subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signatu ie F Date { veering Dept.(3rd floor) Map a. o::' Parcel 0 5 7 Permit# 02 j T F House# v f F-?J- ' Date Issued /0 B��rrj of�TP�lrl, 12 ,,i�r �, ) Feeo2s G •00-2:00) Planni s oor/School Ad_min. Bldg.) THE►p D oar o 19 _ BARNSTABLE. 019. MASS • �FD MAC aF TOWN OF BARNSTABLE --- Building Permit Application Project Str et dress �� /��,r%�/�> j' C 1 ec 6 �.D Eb '1,=h' Village ' Owner ef-D u,Ale D 1!P/7-e Address Q C C E .:Telephone c, - 8 -i Permit Request First Floor - square feet Second Floor square feet Construction Type Xstimated Project Cost $ -3 p p p, --,o Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family IQ Two Family ❑ Multi-Family(#units) Age of Existing Structure Soo yew Historic House ❑Yes W No On Old King's Highway ❑Yes JW No Basement Type: ❑Full ❑Crawl Rf Walkout ❑Other Basement Finished Area(sq.ft.) ' Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing 3 New Total Room Count(not including baths): Existing -5-' New First Floor Room Count Heat Type and Fuel: ®Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ElNo Fireplaces: Existing / New Existing wood/coal stove ❑Yes MNo Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) x ❑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 Address License# 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 1 6? e dam° BUILDING PERMIT DENIED R E FOLLOWIN EASON(S) l � } p` FOR OFFICIAL USE ONLY _ PERMIT NO. t DATE ISSUED. MAP/.PARCEL NO. ADDRESS - VILLAGE OWNER DATE OF•INSPECTION: FOUNDATION _ t FRAME INSULATION FIREPLACE w ELECTRICAL: ROUGH FINAL a PLUMBING:. ROUGH FINAL ' GAS: ROUGH FINAL FINAL BUILDING Alt DATE CLOSED OUT ASSOCIATION PLAN NO. t ATM! �. The Town of Barnstable XAM Departmentt3'of Health Safe and Environmental Services ram ,•` Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commission For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstrucdon, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or constriction 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: 12s;- - C—t z> Est.Cost ocs0 i Address of Work: F/ e 11CCr C Owner's Name 27 D—m `/FOP 7' Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _ Work excluded by law Job under S1,000. 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 G 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Co. it.r .�.e Registration No. OR • TOWN OF BARNSTABLE ' _ . BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please.print. s DATE _ _ - 1 JOB LOCATION ti F-6 X K c" Number Street. address Section of town- "HOMEOWNER" De Name Home phone Work phone PRESENT MAILING ADDRESS City/town State Zip code The current exemption for "homeowners" was extended to include owner-occsr)iE dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to reli side, 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 off; on a form acceptable to the Building Official, that he/she shall be resuonsi: for all such work performed under the building permit. (Section 109.1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the S-. Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands .the Town of arnstable Building Department minimum inspection procedures and requiremient-c nd that he/she will comply with said procedures and requirements. OMEOWNERIS SIGNATURE PROVAL OF BUILDING OFFICIAL Tote: Three family dwellings 35 , 000 cubic feet, or larger, will be required so comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 Home Owner engages a persons) for hire to do such work, that such Home Owre shall act as supervisor. " . Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for . licensing Construction Supervisors, Section 2. 15) . This lack of awarene often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home "Owner.' ac i. las supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, ma:: communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On t � last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. The Conrnronlrcalth of.1fassachusctty ;,;li Departine"I of Industrial.4ccidents � � r . : ;= 1_ ,.� ; � 011iceallavestigatlans us un„totr StreethfU ! Workers' Compensation Insurance Atftd:avit Iililic intintormatitin• Please PRINT iedilj , name• L,/I C 7'Y Inc�tion• �/ / ee A) N e�p C i e a e z citt. w v/ Yin/N 11 S Pa /f% e,,7— 0 6 -7 -7� nhnnc 0 ?-A 2111 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ['l I am an employer providing workers' compensation for my employees working on this job. enoman • name: addre«: citv-. nhnnc#t• incur-ioce rn nnlict 0 I am a sole proprietor. general contract - or homeowner cle one) and have hired the contractors listed below who have the following workers' compensation po t comtinny nnrne- nddresc• cits 1 nhnnc it• z. incur-inre cn nniict �- - . •'ter - Vw• - - r�i...r_Jr - - _ ..1: ,� _- - �- ___.��.i0��.�_�� cmmninv n•trnc• 'tddrecc• cin•• nhnnc it• incur•tnce co noiict• Attach additio_nal sheet ifnecessary __'._ ^_.., _^+.•'•:"�• •'.." --•...r." '�-,"":r•• '"`vs - —.' :•«��� Failure to secure cot•crai:c as required under Section:SA of n1GL 152 can lead to the imposition of criminal penalties of a lineup to 51.500.00 andiur unc s cars* impr►snnment as Wellas civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a dad•against me. I understand that a Copy of this statement mat be furtt•arded to the Office of Investigations of the DIA for coverage verification. 1 do herchv cerrift•under the pains•and penalti•s of perjun•that the information provided above is true and correct. t_natun We fog Print name g�n t.:Jr4� D 717 A-P T Phone# S D8 ofrrcinl Ilse unly do not write in this area to be completed by city or town official ` L City or tntt n permitilicense i# r 1guilding Department t ❑Licensing, Hoard t Selectmen's Office l 0 check if immediate response is required ❑ • ❑1lcatth Department contact person: phone#• MUther. r�. . Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all ern plovers to provide workers* compicnsation for employees. As quoted from the "ta��". an emplitt•ee is defined as every person in the service of anutller under any contract of hire. express or implied. oral or written. An entplurcr is defined as an individual. partnership, association. corporation or other legal entity. or ally,two or ;rc the foregoing engaged in a joint enterprise. and including the le-al representatives of a deceased employer, or the recci\,er 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 dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelIin�_ :,c or on the __rounds or buiiding appurtenant thereto shall not because of such employment be deemed to be an empio',e MGL chapter 152 section 25 also states that ever• state or local licensing agency shall withhold the issuance or _11•al of a license or permit to operate a business or to construct buildings in the commonwealth for any scant ,who has not produced acceptable evidence of compliance with the in coverage required. Adc.Jonall�•. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfornmi,ce of public work until acceptable evidence of compliance with the insurance requirements of this chapte- been presented to the contracting authoriv.,. 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 ��a%,it should be returned to the city or town that the application for the permit or license is being requested. rn ;he Department of industrial Accidents. Should you have any questions regarding the "law" or if you are recuirc- ;o obtain a workers* compensation policy please call the Department at the number listed below. 71 City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom c the for you to fill out in the event the Office of Investigations has to contact you regarding tite applicant. Pie: be _ : to fill in the permit/license number which will be used as a reference number. The affidavits may be returned -ate Department by mail or FAX unless other arrangements have been made. Tile Office of Investigations would like to thank you in advance for you cooperation and should you have any question please do not Hesitate to give us a =11. - The Department's address. telephone and fax number. The Commonwealth Of Massachusetts i .. Department of Industrial Accidents ... Office of Investigations 600 Washington Street Boston,Ma. 02111 fax (617) 727-7749 n h n n e =: (617) . 12 -1900 est. 406. 40Q or 7!