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HomeMy WebLinkAbout0099 MARSTON AVENUE TOWN OF BARNSTABLE BUILDING PERMIT APPLI�CATI/O,N Map �'� Parcel Application # Health.Division Date Issuedx. Conservation Division Application Fee d Planning Dept. Permit Fee p Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address �/ cl �ivSpv� 14 ve Village Owner .&WQ 14 6f9"91.e, Addr V.40-s4: ,'ve'. )3894431k NeTelephone #41' (ell) &17-77��3630 tj Permit Request 0 + Ci D -Teo L, is 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 supporting documentation. Dwelling Type: Single Family- ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King' I ghway: Yesj❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other � �' MR Basement Finished Area (sq.ft.) Basement Unfinished Area(sq ftft) Number of Baths: Full: existing new Half: existing _ n Z 4? a Number of Bedrooms: existing _new w -- Total Room Count (not including baths): existing new First Floor Room Count?O 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) j �. Name C��r �� Telephone Numbe(L4639 d- ( /. U Address AcSkm 0''44A License# ICI e �� Home Improvement Contractor# .51 A �et�leP P er�,e6��/f c. 3� � � v�.��i, Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO a I SIGNAT DATE JVAIV �V S - `' FOR OFFICIAL USE ONLY APPLICATION# _DATE ISSUED MAP/PARCEL NO.. } C ADDRESS - VILLAGE OWNER_. A DATE OF INSPECTION: —FOUNDATION.. k> FRAME • INSULATION ' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH • -n> FINAL :FINAL BUILDING' = DATE CLOSED OUT z ASSOCIATION PLAN NO. o5� Uc �7i � Gl�t, ,t The Commonwealth of.Massachusetts Department of Industrial Accidents IOffice of Investigations 600 Washington Street Boston,MA 02111 il www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly r 1 Name(Business/Organization/Individual): t Address: + t e! City/State/Zip: Phone#: /"7 7 2>^3 6 34 Are you an employer?6eck the propriate bo Type of project(required): 1.❑ I am a employer with 4. am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. T ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL c. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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 all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 must 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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$1,500.00 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 IA for insurance coverage verification. I Zature: y certify u der t pai s d e (ties 6fperjury that the information provided above ' true a d correct Si Date: �y 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical 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 or other legal entity,employing employees. However the owner of a dwelling house having not more than.thre'e 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 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 ihat"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 of this 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-contractor(s)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 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 policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in PP (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 license 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: 1 The Commonwealth of Massachusetts - - Department of Industrial Accidents Office of Investigations 600 Washington Street- Boston,MA 02111. Tel, #617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Town of Barnstable - o„ Regulatory Services s « stixxsr�sr.E Thomas F. Geiler,Director ' 9. ,�� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: ✓"t I °� �. v JOB LOCATION: -Fo I�� _ P V 4A h BS number street g r °� vihlt e p "HOMEOWNER": /n fe 117 O "/�'.5 (0 [7 O.5�— name e phone# rk pl6ne# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, 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 Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,.bylaws,rules and regulations. - The undersigned"homeoer ces that he/she understands the Town of Barnstable Building Department minimum inspection ?oc;�:cdnure'i�-�" d requirements and that he/she will comply with said procedures and quireme Signature of Homeo er Approval of Building Official Note: .Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. . HOMEOWNER'S EXEMPTION The Code,states that:. "Any homeowner 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 the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons; In this case,our Board cannot proceed against the unlicensed personas it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor, On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:IWPFILES\FORMMom: =xemptDOC L , oFzxETa,, Town of Barnstable Regulatory Services BARPW"L, f MAM Thomas F. Geiler,Director ��►�Y Building Division Tom Perry,Building Commissioner . 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 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative,to work authorized by this building permit application for. -(Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. :FORMS:O Q WNERPERMISSION certi ricate of Flame Resistance PECS O=FJ-T-` I GEG 8Y t..s �f�rttttN�ttr � s r'.Jry that tr x04ctc bem`v4 1tw-1 b0-11" fAr"AlC4,rtnF3 rtcrrr+r11�r�ad�rh�tNtr�f�tta"t•�r+�t��iarrt 1 n,OtLw V!lef ed "Che rr�+trwiftt IR`F' � fstllf!6r','lttsrti e:9 llv G3�'R:Adt iltt'�:. CTTY 701 riWXWAARd wry TV OW"&'cww tl. r"'44'4''.ai's r:. 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It is not adequate for legal Map:288 Parcel:125 boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel ED 1'=100'may not meet established map accuracy standards. The parcel lines on this map Owner:GIGGIE,DAVID A$MARIA Total Assessed Value:$486300 are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:1.12 acres Abutters E boundaries and do not represent accurate relationships to physical features on the map Location:99 MARSTON AVENUE such as building locations. Buffer /� .f DATE(MM/DD/YYYY) �M CERTIFICATE OF LIABILITY INSURANCE 6 3 2013 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MCSHEA INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE'DOES NOT AMEND, EXTEND OR 1550 Falmouth Rd Ste #2 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Centerville, MA 02632 5 0 8 4 2 0-9 011 INSURERS AFFORDING COVERAGE NAIC# INSURED Bayside Tent & Table, "Inc. INSURER A: Procrressive Casualty '40C WHITES PATH INSURERB:, TBI South Yarmouth MA 02664 INSURER C: LLOYD r S LONDON 5 0 8-8 8 8-4 9 5 6 INSURER D: Penn-America Insurance Company INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTR DD•L POLICY EFFECTIVE POLICY EXPIRATION LTR NSRD PE OF INSU CE - POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY - LIMITS - - GENERAL LIABILITY EACH OCCURRENCE $ 1 000, 000 }[ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEIT PREMISES Ea occurence $ 50.O 000 CLAIMSMADE L xJ OCCUR MED EXP(Anyone person) $ 10, 000 D PAV0006132 5/11/2013 5/11/2014- PERSONAL&ADV INJURY $ 11000, 000 GENERAL AGGREGATE $ .2,000,0 GEN'L AGGREGATE LIMIT APPLIES PER: ,` PRODUCTS-COMP/OP AGG $ 2,000,000 POLICYF_j PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT? $ ANYAUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY,, $ 100, 000 X SCHEDULED AUTOS (Per person) A HIREDAUTOS O4453770 11/30/2012, :11/30/22013 gODILYINJURY NON-OWNEDAUTOS (Peraccident) $ 3 0 0, 0 0 0 PROPERTY DAMAGE $r 1100, 000 (Peraccident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO EAACC $ , OTHER THAN ' AUTOONLY:. -AGG $ EXCESS/UMBRELLA LIABILITY EACH.00CURRENCE $ _ OCCUR CI CLAIMSMADE AGGREGATE $. $ DEDUCTIBLE $ RETENTION $ $ . WORKERS COMPENSATION AND WRSTATIUT OTH- LIABILITY TOCYLIMS ER ANY PROP.RIETOR/PARTNER/EXECUTIVE #TBI ' 05/16/2013 5/16/2014 E.L.EACH ACCIDENT . $ 1001 000° _ B OFFICERIMEMBER EXCLUDED? E.L.DISEASE-.EA EMPLOYE $ 1001 000 If yes,describe under _ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500, 000 OTHER C Property XSZ651.1 8/14/2012 8/14/2013 120,000-.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION- Town of.Barnstable DATE THEREOF,.THE ISSUING INSURER WILL ENDEAVOR•.TO MAIL10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT;,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY_OF'ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRES�AOO�' ACORD25(2001/08) ©ACORD CORPORATION 198 _. t Engineering Dept. (3rd floor) Map �. Parcel /� "' .GG� `Permit# 4� House# Date Issued Board of Health(3rd floor)-(8:15 -930/1:00-4:30) Fee ��� d l! Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning Dept:(1st floor/School Admin. Bldg.) THE tp;. DefiRPApoved by Planning Board 19 BARNSTABLE. •MAWL RFD 19.pTOWN OF BARNSTABLEBuilding Permit Application Projes � IL Village Owner Address Telephone Permit Request 30 Af First Floor . s uare feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning,District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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 No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) " ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name Telephone Number Address `%/ l�y/I,�C �''j/( License# A01 W , Home Improvement Contractor# Worker's Compensation# 14(3 0 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO_ IVCL-741t dV'' SIGNATURE DATE BUILDIN R � I WING REASON(S) G ,A A FOR OFFICIAL USE ONLY PERMIT NO. k> • DATE ISSUED y MAP/PARCEL NO. ADDRESS # VILLAGE OWNER DATE OF INSPECTION: E + FOUNDATION FRAME INSULATION FIREPLACE •ELECTRICAL: ROUGH FINAL , PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t ' r FINAL'BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. { The Town of Barnstable • nAatvereatE. • 96 Department of Health Safety and Environmental Services Eo " Building Division 367 Main Street,Hyannis MA 02601 1 Office: 508-790-6227 Ralph Crossen Fax: 508-190-6230 Building Commissioner For office use only Permit no. s Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: Z Est.Cost go O<p Address of Work: 5115 121,0%A Owner's Name Date of Permit Application: 7 1 hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: `7 A—/q "7 1 l a to Contractor Name Registration No. OR Date Owner's Name The Comman li-eafth of Afassachusern �, s ndustrial.4ccitlents Department of I lei., rat office-off/179SI19211fiffs 6#0 11'ashingtun Street Boston. Maxy. 02m workers' Compensation Insurance AMdavllt *AdIiF---1iTt—inr6F;—Iaiioi:* Please PRINTZ- @v narnci 4049-9*) citv Milne 7 1 am a homeowner performinz all work- myself. 7 1 am a sole proprietor and have no one working in any capacity -7 E4 1 am an employer providing workers' compensation for my empiovees working on this job. cn Fit[In nv name: sits nh ne n s i i r n i i c e r n. 14-V/-5,34:2 3 6""'6 I am a sole proprietor. general contractor, or homeowner(circle otte) and have hired the contractors listed below who have the Follo%ving workers' compensation polices: comonni- nitne- nhone#- in,mrinrr rn. nnlir%-N 77777�-e= conirinn%-_niin(— nddrv-;c- #! insurance Co. Attach additi naishectifnic ir.,-iiiu-r-c to secure coveraccas required under Section SA of AIGL 152 can lead to the imposition of criminal penalties 01'2 line Up 151.500.00 2ndiur une car,.;* imprisonment as well as civii penalties in the form of a STOP NVORK ORDER and a fine ofS100.00 a day against Me. I understand that cope of this staicinent mac be forwarded to the orrice of investigations of the DIA for coverage verification. I do he"bY c�r dig tints mid waltics 0fpc)Yu'7'1/101 the information prorided above is true and correct. Z--Z— Si2nature_ Date 'r Print name Phone �-Ci', .,cunit' do not write in this area to be completed by city or town ofnciai —N. cit%-or town: permit/license# riguilding Department C3Licensing Board L M check if immediate response is required 0sclectmen's 0mcc C311caith Department contact Person: phone#: r701hcr P Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for th an emplitree is dcfincd as every person in the service of another under an. employees. As quoted from the "law". contract of hire, express or implied. oral or written. An en plorcr is dcfincd as an individual. partnership, association. corporation or other legal entity, or any two or me 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 t! owner of a dwelling house haying not more than three apartments and who resides therein. or the occupant of the dweliing house of another who employs persons to do maintenance , construction or repair work on such dwcllin�_ he or out the ;,_rounds or building appurtenant.thereto shall not because of such employment be deemed to be an emplo% MGL chapter 152 section ''S also states that even state or local licensing agency si►all withhold the issuance or reneiyal of a license or permit to operate a business or to construct buildings in the commonyealth for any applicant who has not produced acceptable evidence of compliance with the in 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:his chapter m been presented to the contracting authority. -77 *-. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents foe• confirmation of insurance coverage. Also be sure to siDn and date flue affdavit_ 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 require to obtain a workers' compensation policy, please call the Department at the number listed below. Citv or'I"o�yns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at tite bottom the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pl: be sure to fill in the permi0icense number which will be used as a reference number. The affidavits may be returned the Department by mail or FAX unless other arrangements have been made. The Office of investigations would like to thank you in advance for you cooperation and should you have any questic please do not hesitate to __ive us a call. 77, The Department's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents _.. Office cf investigations 600 «'ashington Street •� . Boston,Ma. 02111 fax #: (617) 727-7749 Phone #: (617) 72 7-4900 ext. 406, 409 or 375 1• YJ}v•L 7YO,�.�..r� j ^` - r.� - Y-...��-^._a..two•R'4-71 �"��_tfla-'i/ 1. ►'IL1^L .. HOME IMPROVEMENT CONTRACTORSREGISTRATION � V Board of Building Regulations and `Standar,ds t r , i One Ashburton Place — Room '.1301 Boston ,-Massachusetts 02108. z a J ` �I 'IMPROVEMENT CONTRACTORJ.- HOME --�---- S + tly 'tyt.a . Registration 112536 Expiration ,04/06/99 .. �.-�wmwsWgy!!� Type. DBA ; T, �t k a. } HOME IMPROVEMENT CONTRACTOR h,� t Registration 112536 FRASER CONSTRUCTION ? a , ,s 4` Type DBA Ezpiraticn O4/O6/99 DEAN C . FRASER � 71 TARRAGON CIR 2 ,t 4 " COTUIT MA 02635 ' ' ' FRASER CONSTRUCTION G�caM�o C. FRASER aoM�N�I TARRAfiON CIR COTUIT NA 02635 Clio