HomeMy WebLinkAbout0063 MIDWAY DRIVE - - - -- - - -
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y X-! REDS PERMIT
JUL 3 0 2007 Town Of Barnstable *Permit# v" oq�
TOWN OF BARNSTABLE Expires
6 nontlts front i�date
Regulatory Services • Fee }�
Thomas F.Geiler,Director p ?
Building Division t
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
.Not Valid without Red X-Press Imprint
Map/parcel Number � 0 7
Property Address /a 71 rK r d LL)&" l �/�_, y�l°IJ�v ij m A 6 Z 6 v 1
[residential Value of Work J 06 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address / /4 Cu A�u C-{
Contractor's Name LA Telephone Number 7 7,,�`
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
[ram.the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side i
Replacement Windows/doors/sliders. U-Value /vw 3 r(maximum.44)
"Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
copy of the Home Improvement Contractors License is required.
SIGNATURE
Q:Forms:expmtrg
Revise061306
f
t
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
a
' d 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers'' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Le0bly
Name(Business/Organization/Individual):.
Address: � 'D
City/State/Zip: wt5 t'V\ (A- i0 Ztoo i Phone.#: So
Are you an employer? Check the appropriate bog: -Type of project(required):.
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction .
employees (full and/or part-time).* have hired the stab-contractors
2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• #. 9. ❑Building addition
[No workers' comp.insurance comp. insurance,
re aired.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their 11.❑Plumbing repairs or additions,
'3. am a homeowner doing all work , P
myself: [No workers' camp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no s
employees. [No workers' 13, rQ Other cv, ",off euJ r
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.
tContractors 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 maybe forwarded to.the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify' der the pains•and penalties ofperjury that the information provided above is true and correct:
Simafore: '`— Date: 0 73 0-- 0 '7
Phone#: 7 2 9
Official use only. Do not write in this area,tb be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.BuiIding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
.5
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, 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 be an employer."
MCTL 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 complfauce with the insmznce
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
sub-contractors names address es and hone numbers along with their certificate(s)of
necessary,supply ( ) ( ),address(es) p ( ) g
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-insurange 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 (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 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 Industdal Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06,
www.rnass.gov/dia