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HomeMy WebLinkAbout0009 LINDEN STREET 3/a . Town of Barnstable Building Post This=Cara So�That��t��s"Uisible�From�the�Street Approved,Plans Mus#be Retained on Job and'this�ard�Must:b�e�Kept MAW. Pos"ted Until;Final Inspection Has Been Made fiz" ib3p Cqr z ;' :, ..< ac rt � ,s s ,; . .. s '',: Permit-�• �° Where a.Certificateof�Occupancy is Required,such Bulldmg shall�Nat be Occupied:unt�l a�Final Inspection;has been made Permit NO. B-18-936 Applicant Name: Mark Mordini Approvals Date Issued: 04/02/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 10/02/2018 Foundation: Location: 9 LINDEN STREET, HYANNIS Map/Lot 310-267 Zoning District: RB Sheathing: Owner on Record: MELLO, ROBIN M �Contracor Narne MARK E MORDINI Framing: 1 ga Address: 9 LINDEN ST �� Contractor L cense CS 057645 2 HYANNIS, MA 02601 .. Est Project Cost: $ 12,555.00 Chimney: Description: strip roof shingles and re-roof per GAF specs(12 square);' a and Permit Fee: $64.03 water shield 6'from fascia and T from rake boards and in valleys, ,' Insulation: $64.03 install soffit and ridge ventilation,install gutters and downspouts Fee Paid Date. 4/2/2018 Final: Project Review Req: M _ Plumbing/Gas Rough Plumbing: . ' iq BuildingOfficial Final Plumbing: h This permit shall be deemed abandoned and invalid unless-the work authorized by this permit is commenced within si months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved appl cationa'nd thetapproved construction documents for which this permit has been granted. $ - All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or roadand shall be maintained open for public inspection for the entire duration of the f work until the completion of the same: Electrical The Certificate of Occupancy will not be issued until all applicable signatures by theBbildiiig a_nd.Fir'e Off cials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing a 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 Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy 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: "Pe}rsons 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 Town of Barnstable REE£If?T ` Aa 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit (V Application No: TB-18-936 Date Recieved: 4/2/2018 _ o C> Job Location: 9 LINDEN STREET,HYANNIS Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: MARK E MORDINI State Lic. No: CS-05 645 En Address: North Attleboro, MA 02760 Applicant Phone: (508) 80-0156� ,. (Home)Owner's Name: MELLO,ROBIN M Phone: (508)790-2904 rn (Home)Owner's Address: 9 LINDEN ST, HYANNIS,MA 02601 Work Description: strip roof shingles and re-roof per GAF specs(12 square), ice and water shield 6' from fascia and 3' from rake boards and in valleys, install soffit and ridge ventilation, install gutters and downspouts Total Value Of Work To Be Performed: $12,555.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). 1 understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Mark Mordini 4/2/2018 (508)280-0156 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $12,555.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit.Fee: $64.03 4/2/2018 $64.03 i XXXX-XXXX-XXXX- Credit Card 1 ; ...............................................................................................................................................................t............................._4147.....................................z............................................................................... ,Total Permit Fee Paid. $64.03 Aa. Town of Barnstable Regulatory Services K Thomas F.Geiler,Directors t MAWBuilding Division 0.� Tom Perry,Building Commissioner Q " 200 Main Street, Hyannis,MA 02601 ^ems www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT#K3- 0 1 FEE: $ SHED REGISTRATION 200 square feet or less Location of shed(address) Village Property owner's name Telephone number Y- y ?- -27,, , © "z;�(,,-:>-7 Size of Shed Map/Parcel# Si ature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation.Commission(signature is required) rev Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN i Q-forms-shedreg REV:05201 FLE-k MIP 31976 CENSUS TRACT# 126 CLIENT: Dunning&Kirrane, L.L.P. DEED BOOK 9913 PAGE 299 OWNER: Lisa A Aponte PLAN BOOK 71 PAGE . 43 LOT APPLICANT: Robin M. Mello ASSESSORS PLAN 310 PLOT 267 M O R T G A G E INSPECTION P L A N O F L A N LOCATED AT 9 Linden Street Barnstable, Massachusetts SCALE: V= 20' July 10, 2003 N IF WALSH i 1J I F WALSH APPLEFORD STflIZY ET UX f AVED ;DRIVE SOr+ LINDEN STREET I CERTIFY TO DUNNING & KIRRANE, L.L.P., SHERWOOD MORTGAGE GROUP, INC., AND ITS TITL INSURANCE COMPANY, THAT THERE ARE NO VISIBLE ENCROACHMENTS OR EASEMENTS EXCEPT A SHOWN AND THAT THIS PLAN WAS PREPARED UNDER MY IMMEDIATE SUPERVISION. THE LOCATION OF THE DWELLING AS SHOWN HEREON IS IN COMPLIANCE WITH THE LOCAL APPLICABLE t• A P F ZONING BY-LAWS WITH RESPECT TO HORIZONTAL DIMENSIONAL REQUIREMENTS. THE EXACT LOCATION OF THE BUILDINGS SHOWN CANNOT BE DETERMINED WITHOUT AN ACCURATE Ala t � Y• INSTRUMENT SURVEY 4 THE DWELLING SHOWN HERE DOES NOT FALL WITHIN A SPECIAL FLOOD HAZARD ZONE AS DELINEATED ON A MAP OF COMMUNITY# 250001 - 0005C DATED 8/19/85 � �`� Kenneth R. Ferreira BY THE F.I.A Engineering, Inc. P.O. Box 1903 New Bedford, MA 02741-1903 508-992-0020 Fax: 992-3374 GENERAL NOTES:(1)The declarations made above are on the basis of my knowledge,information,and belief as the result of a mortgage plot plan tape urvey inspection made to the normal standard of care of registered land surveyors practicing in Massachusetts. (2)Declarations are made to the above named client only as of this ate. (3)This plan was not made for recording purposes,for use in preparing deed descriptions or for constructions. (4)Verifications of property line dimensions,building otTsets, fences.or lot configuration may be accomplished only by an accurate instrument survey. +� I .� S r •� / � O � � a �, � � � . �, � �. J� .. �./ DATE: May 25,2011 TO: Building File FROM: R Anderson RE: 9 Linden Street, Hyannis Spoke to John(978-371-1008) concerning this property. He advised this is a bank owned property containing two structures. A former garage has been converted to a"cottage". John wanted to know id he could rent out the "cottage" as a seasonal rental or if there was any way to make the secondary unit legal. I said there was no way to make this a legal seasonal rental. I sated this is a SF zone only. This unit was not created as a legal cottage. The permit identifies it has living space/office use only. He could use as an additional bedroom, the kitchen would have to be removed, it could never be used independent of the main dwelling in any fashion— overflow bedroom only. He stated his parent might like to visit—ok if not used independent of the main house. Debi spoke to him first—he told her he lives in Concord, will move here and rent out his Concord home. He did not mention any of that to me. I got the distinct impression he wanted to buy a property with an accessory unit for the investment and to defray his expenses. Advised that we would require that the kitchen be removed at the time of conveyance. Message Page 1 of 1 Bar , , Lo' To: Taylor,-Madeline Subject: RE: 9 Linden St � �,� 1 This one is interesting. There are two Map & Parcels with the address o 9 Linden Street, 31026 and 310268. 1 imagine you are looking at 310268, which should be 9A Linden Street for an planning to go out and may give it a new address. The 2004 permit was to convert the garage to living space. The floor plan shows 2 offices, a library, and a bathroom. The owner, Randall Florence, submitted an Affidavit stating"I will be converting an existing garage to be used as personal space. It is not my intent to bypass town ordinances or bylaws in reference to rental properties or zoning regulations." Clearly, this was not to be a second living unit. -----Original Message----- From: Taylor, Madeline Sent: Wednesday, August 09, 2006 10:12 AM To: Barry, Lois Subject: 9 Linden St Hi Lois I got a call this morning from the owner of 9 Linden St,in Hyannis. He is interested in applying to the program. I just looked up his assessor's info and it says that a 2 bedroom and 1. bathroom cottage was constructed in 2004. Can you give please give me some background on this? I'm not sure he would qualify for the program if the unit has been completely finished and I'm wondering how he would have gotten a permit. Is it a single family home? Thanks for your help. Maddie 8/9/2006 Y BaNstable Assessing Search Results Page 1 of 2 . asI ON i v; Home: Departments:Assessors Division: Property Assessment Search Results New Search 5 New Interactive Maps i Owner: 2007 Assessed Values: MELLO, ROBIN M 9 LINDEN STREET Appraised Value Assessed Value Map/Parcel/Parcel Extension Building Value: $73,300 $73,300 310 /267/ Extra Features: $2,400 $2,400 Outbuildings: $300 $300 ._Mailing Address Land Value: $ 132,500 $ 132,500 MELLO, ROBIN M Totals $208,500 $208,500 9 LINDEN ST HYANNIS, MA. 02601 Tax Information: Tax information is currently not available for 2007 Construction Details Building Property SketcIPM04rtySketch & ASI Building value $73,300 Interior Floors Hardwood Style Ranch Interior Walls Drywall Model Residential Heat Fuel Gas Grade Average Minus Heat Type Hot Water , Stories 1 Story AC Type None ), Exterior Walls Wood Shingle Bedrooms 2 Bedrooms y Roof Structure Gable/Hip Bathrooms 1 Full f y� Roof Cover Asph/F GIs/Cmp living area 752 Replacement Cost $91669 Year Built 1947 � Depreciation 20 Total Rooms 5 Rooms Land http://www.town.bamstable.ma.us/assessing/assessO6/displayparcelO7map.asp?mappar=310... 4/6/2007 BaNstable Assessing Search Results Page 2 of 2 CODE 1010 Lot Size(Acres) 0.07 AsBuilt Card N/A Appraised Value $ 132,500 View Interactive Maps > Assessed Value $ 132,500 ' Sales History: Owner: Sale Date Book/Page: Sale Price: MELLO, ROBIN M Jul 23 2003 12:OOAM 17317/239 $ 199,000 APONTE, LISA A Nov 15 1995 12:OOAM 9913/299 $46,000 GUALTIERI, LAWRENCE J& Mar 15 1985 12:OOAM 4465/206 $54,000 VANBEEK, FRANCES 1626/229 $0 Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value FPL1 Fireplace 1 $2,400 $2,400 SHED Shed 48 $300 $300 Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area (Unfinished) BMT Basement Area (Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area UST Utility Area (Unfinished) (Finished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story (Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story (Unfinished) FHS Half Story (Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/assessing/assess06/displayparcelO7map.asp?mappar=310... 4/6/2007 Map Page I of I Town of Barnstable Geographic Information System Map Size Zoom Out P P V D In Parcel Viewer I F��rn Map I F Abutters I El A Abe K'A A JPG Map: 310 K h( F 0 310200 Location: N 12 Owner: UNDEf4 STREET Location In Map & Parce Location 7 -7�777 Acreage 7 Current O�% R Mailing Addi N227 Appraised iT1 0269 Extra Featur Out Building Land Buildings Total Apprai F77777 77, 310268 No Extra Featur Pilo Out Building j Land Buildings Set Scale 1" 28 Aerial Photos MAP DISCLAIMER Total Assess Copyright 2005-2008 Town of Barnstable,MA All rights reserved.Send questions or comm( BarnstableMA v1.2.3308 [Production] http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertylD=310267 1/26/2009 Parcel Detail Page 1 of 3 Z ��� S�VY� �".':. Logged In As: Parcel Detail Wednesday, Aug Parcel LookL1D Parcelinfo Parcel ID ;310-267 + Developer Lot Location!9 LINDEN STREET Pri Frontage Sec Road Sec Frontage} Village HYANNIS Fire District;HYANNIS Sewer Acct;1603 Road Index 10900 y _ Interactive y Ma � ,�f; Owner Info Owner MELLO, ROBIN M � Co-Owner Streets9 LINDEN ST 1 Street2 City :HYANN IS State 'MA zip 102601 Country,US Land Info Acres 0.07 use `Single Fam MDL-01 Zoning RB Nghbd 10105 Topography Level Road Paved Utilities All Public Location Construction Info Building I of 1 _ Roof{` Year'1947 Gable/Hip Wall Wood Shingle Built Struct - -- Effect."-, -___ ._..___. _..__�, Roof;..... . AC Area 752 Cover'Asph/F GIs/Cmp Type'None Int' ___ - Bed Style;Ranch Wall Drywall Rooms 2 Bedrooms Int _..___..___._ __ Bath Floor Rooms Model iResidentlal J 1 9 1 Full I �-- - - - r . .._ Total Grade!Average Minus Type,._Hot Water Rooms 5 Rooms http://issql/intranet/propdata/ParcelDetail.aspx?ID=25810 8/9/2006 Parcel Detail Page 2 of 3 iV ANY _... Heat - _ Found- stories 1 Story Fuel Gas anon Conc. Block Permit History Issue Date Purpose Permit# Amount Insp Date Comments 10/18/1999 New Siding 41739 $6,000 Visit History Date Who Purpose 6/29/2006 12:00:00 AM Jason Streebel In Office Review 12/19/2003 12:00:00 AM Paul Talbot Meas/Est 5/23/2003 12:00:00 AM Paul Talbot Meas/Listed 3/23/2001 12:00:00 AM Paul Talbot Meas/Listed 9/15/1987 12:00:00 AM ML Sales History Line Sale Date Owner Book/Page Sale P 1 7/23/2003 MELLO, ROBIN M 17317/239 2 11/15/1995 APONTE, LISA A 9913/299 3 3/15/1985 GUALTIERI, LAWRENCE J & 4465/206 4 VANBEEK, FRANCES 1626/229 Assessment History _ Save# Year Building Value XF Value OB Value Land Value Total Parc( 1 2006 $68,900 $2,400 $300 $220,900 2 2005 $64,800 $2,300 $300 $110,400 3 2004 $52,400 $2,300 $300 $45,000 4 2003 $45,200 $2,300 $300 $32,800 5 2002 $45,200 $2,300 $300 $32,800 6 2001 $45,200 $2,300 $200 $32,800 7 2000 $40,500 $2,300 $100 $11,900 8 1999 $40,500 $2,300 $100 $11,900 9 1998 $40,500 $2,300 $100 $11,900 10 1997 $33,000 $0 $0 $10,200 http://issql/intranet/propdata/PareelDetail.aspx?ID=25810 8/9/2006 r� Parcel Detail Page 3 of 3 11 1996 $33,000 $0 $0 $10,200 12 1995 $33,000 $0 $0 $10,200 13 1994 $34,500 $0 $0 $12,200 14 1993 $34,500 $0 $0 $12,200 15 1992 $39,200 $0 $0 $13,600 16 1991 $47,300 $0 $0 $22,100 17 1990 $47,300 $0 $0 $22,100 18 1989 $47,300 $0 $0 $22,100 19 1988 $35,100 $0 $0 $11,200 20 1987 $35,100 $0 $0 $11,200 21 1986 $35,100 $0 $0 $11,200 Photos http://issql/intranet/propdata/ParcelDetail.aspx?ID=25810 8/9/2006 7 08/09/2006 TOWN OF BARNSTABLE PAGE 1 11:25:53 APPLICATIONS pipropmt Applied Completed Status Project Use Zone ---------- ---------- ---------- ------------------------------ ---------- ----- 10/18/1999 11/22/1999 COMPLETE WINDOW/SIDING RESIDENTIAL SINGLE FAM RB 11/24/1999 11/24/1999 COMPLETE ELECTRIC RES. ADD/ALTER SINGLE FAM RB 09/15/2004 12/22/2004 COMPLETE GAS RESIDENTIAL SINGLE FAM RB 09/15/2004 05/23/2005 COMPLETE PLUMBING RESIDENTIAL SINGLE FAM RB ** END OF REPORT ** ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �d Parcel c2 6 `7 Permit# Health Division Date Issued �Q 8 Conservation Division Fee2�"-�r� Tax Collector Treasurer ale2�.� /o Planning Dept. Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 7 4/AIA J-,V Village 411 /� Owner //5'A /`•tDVAV74 Address 1,//11 cAJ` Telephone T dc�f ej Permit Request 06 zc14L 6- /&A/z S' RCPL-�K � Square feet: 1 st floor:a isting proposed- 2nd floor: existing proposed Total new Estimated Project Cos d3 Zoning District Flood Plain Groundwater Overlay 1 9 Y Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. J_ 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:0 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 BUILDER INFORMATION Name .dal/' �, I.46Kir4w Telephone Number Address , 23 11,5741,;l J'`1( License# ®.,<tl P-� Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE /0 'lq- 99 , - FOR OFFICIAL USE ONLY PERMIT NO. � r Y DATE ISSUED 7 MAP/PARCEL NO. '. ;� r '�{� ham. ,..•S 7 `+' . ADDRESS --VILLAGE i. �:� _ OWNER DATE OF INSPECTION. ' FOUNDATION FRAME f INSULATION ' FIREPL'ACE - ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ` ' ~ r . t DATE CLOSED OUT ASSOCIATION PLAN NO. , The Town of Barnstable 1109 Department of Health Safety and Environmental Services Eo n+o� Building Division 367 Main Street,Hyannis MA 02601 , Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building'Commissione. Permit no. Date /`d /c/ AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. r Type of Work: RE-S/l��u�i9�� �LV,C 46 &110 s Estimated Cost 000 � Address of Work: //vacly At sIVA Owner's Name: ADor✓Te— Date of Application: %01/`/ `? 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 MOROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Name q:fbr ms:Affidav The Commonwealth of Massachusetts �iWW-F=— --== D ep anment of Industrial Accidents `==�=_ .�-_�� Offrct nllatresti8atioos � - z: 600 Washington Street ltzze Boston,Mass. 02111 Workers' Con ie nsation Insurance Afridavit name: location- city z2AI vs— phone# ❑ I am a homeowner performing all work myself. �I am a sole proprietor and have no one tivariting in any capacity • ❑ I am an employer providing workers' compensation for my employees working,on this job. comnnnv name: address: city: phone#: insurance co. policy# r /// /////////////////////,la'l�!�ll// i� /LU///� ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have , the follo%%ing workers' compensation polices: comnanv name: ad d reps: :•: :..:. city phone#: :::...... porky#• commany name: :: ..........:..... address: cth- phone#� :. . .: :::;;...;:•;:;:;; „,.... . Insurance co. oiicv# , Faaure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a Me up to 51.500.00 andtor one vears'imprisotunent as well as civil penalties in the form of a STOP WORK ORDER and a ane of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. I do hereby certify'under the pains and penalties of perjury that;the information provided above is true and correct Si�ature_c \ U= ___Pate AQ Print name —L�—A A/ ,a. V��CK55n AJ Phoae# se2g C)—15WC)l official u3e only do not write in this area to be completed by city or town of ebt city or town: permitNcerue# ❑Building Department C]Licensing Board ❑ check if immediate response is required ❑Selectmen's Omce ❑Health Department contact person: phone#: ❑Other�� cmv=a 945 PJA7 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for thy.: employees. As quoted from the "law", an employee is defined as every person in the service of another under any co=- 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 rec.n-1 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 dwelling house of another who employs persons to do maintenance, construction or repair work an such dwelling house or on the grounds c: building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local Iicensing agency shall withhold the issuance or renewa- 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,neither the . commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work acceptable evidence of compliance with the insurance requirements of this chapter have bees presented to the contracting authority. , Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Deparnent 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. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out ire the event the Office of investigations has to contact you regarding the applicant Please be sure to fill in the permidUcease number which will be used as a reference number. The affidavits may be retzaned fo the Department by mail or FAX unless other arramgemeats have been made. The Office of.Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. Tie Deparanent's`address,telephone and fax number. The Commonwealth OFMassachusetts Department of Industrial Accidents OttlCe of Wesduatlons 600 Washington street Boston; Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 ext. 406, 409 or 375 ,;Cf!4 �a�•:� �er.ay.--.ae"� •.�.�r8" ..:ra���s'�`'-�� - �w�..'��i�:�'$2i�':s�'m.._ -:s.C"vIT+H�`d""e4F -z�""^.•.,a-r a.."�_x4Zr ax+._ ,7� -C � ' Boa-rd -of Buildiwr.g..,.Regulations and Standard?, `0:ne ;Ashbu.r.,t.on-•Plane_- - "Room _13,01 h ..Sost.:4 ,-Mass achusetts "0210£ � Hom( Improvement Contracytor Registration Registratlon= `106523 n Expi ratio x,7/23/00� k < �j �OofnOx4fxIA9[s�I/l..o� �de� HOME IMPROVEMENT CONTRACTOR {n Registration: 106523 ��R. r , O• S1Etl•JCT.ION �,�,�. ��� ���,'} ;;;�'���,, �'' '�.� . �;'�:�}�"�: �� , �:� � �Ezpiration =`.���7/23/00 � ..`.. 5.i c s:. l i .. .f. - 4h--,<� yi i`..f.��t�::,� ���['3��x;�is 1'p�;,t'�)i ,'4 V•'S�' +2 2#' . , n ., 1� _Ian ':7ackson = , Ng, }� _� *3 , rTrpe 08 . } ±, § � r �. A a�',a '} � A .. 273 .MAIN •STREET HARWLCH } :, k MA 02645 `�� JACSON CONSTRUCTION Ian Jackson 273 MAIN STREET Via' ' ADMINISTRATOR HARVICH MA 42645 ,mow._.•.._ _ . . DEPARTMENT OF PUBLIC SAFETY ' CONSTRUCTION SUPERVISOR LICENSE Number _ Expires: } ' Restricted To 88 i IAN 8 JACKSON 273 MAIN ST N HARWICH. NA 62645