HomeMy WebLinkAbout0073 MULBERRY STREET J,4-i,u r
of Printed On:7/9/2020
Complaint Call :Report
A 73 MULBERRY STREET, HYANNIS
° Case# C-20-68
Case#: C-20-68 Address: 73 MULBERRY STREET, Date: 2/19/2020
HYANNIS
Owner Info: Property Info:
DASILVA, GABRIELLA C REIS ET MBL:
AL
73 MULBERRY STREET 310.357
HYANNIS MA 02601
a J
Owner Notified'?.-
Complaint Details:
Type of Complaint Classification of Complaint Method of Complaint
Zoning, j Medium Priority Phone
l Complaint Summary: 7
Couple advised a woman is living in a camper that has been moved into the rear yard of the subject '
property. Staff advised that the self-contained unit has all the provisions necessary in the back yard and
the woman is not leaving to go to FLA a previously represented to staff. The couple also said that the unit
has been done over completely inside contrary to what was reported in the initial report which advised
that the unit was not habitable. On a previous occasion, Ed agreed that no one was living in it but on this
date admitted that he did not look inside the camper and accepted at face valve the information he was
told.
Action History:
Action Taken Date Description Fee Inspector
Close Case 7/9/2020 No camper on property $0.00 bowerse
Inspector Assigned to Complaint: bowerse Filed by: andersor
}
Comments:
Comment Date Commenter Comment
2/19/2020, andersor A previous complaint about the same unit but located in the driveway has
been closed as the neighbor that complained says the problem was
resolved. This maybe because the unit is no longer on the side of the
house where the neighbor's bedroom is located.
2/1912020 andersor', ' Referring to Health to check sanitary provisions for camper/RV unit in the
rear yard.
Date: 7/9/2020 Town of Barnstable
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Complaint CII Report
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13 MULBERRY STREET HYANNIS � "f6 q. 0
Case#. C-20-68:
Case#: C-20-68 Address: .73 MULBERRY STREET, Date: 2/19/2020
HYANNIS
Owner Info: Property Info:
DASILVA, GABRIELLA C REIS ET MBL:
AL
73 MULBERRY STREET - 310-357
HYANNIS MA 02601
Owner Notified?:
Complaint Details
Type of Complaint Classification of Complaint Method of Complaint
Zoning, Medium Priority Phone
Complaint Summary:
Couple advised a woman is living in a camper that has been moved into the rear yard of the subject
property. Staff advised that the self-contained unit has all the provisions necessary in the back yard and
the woman is not leaving to go to FLA a previously represented to staff. The couple also said that the unit
has been done over completely inside contrary to what was reported in the initial report which advised
that the unit was not habitable. On a previous occasion, Ed agreed that no one was living in it but on this
date admitted that he did not look inside the camper and accepted at face valve the information he was
told.
Action History:
Action Taken Date Description Fee Inspector
Inspector Assigned to Complaint: bowerse Filed by: andersor.
Comments:
Comment Date Commenter Comment
2/19/2020 andersor A previous complaint about the same unit but located in the driveway has
been closed as the neighbor that complained says the problem was
resolved. This maybe because the unit is no longer on the side of the
house where the neighbor's bedroom is located.
2/19/2020 andersor Referring to Health to check sanitary provisions for camper/RV unit in the
rear yard.
Date:
211 912 0 2 0 ' Town of Barnstable
�OFTHETp�o Town of Barnstable.
Inspectional Services
EAM9 ri S& Brian Florence,CBO
�A 039. Building Commissioner .
TE0 N1P<A 200 Main Street,,Hyannis,MA 02601
www.tow n.b a rn stab le.m a.u s
INSPECTION REPORT
Address : 73 MULBERRY STREET, HYANNIS Case# C-20-901
Inspection Type : Violation Inspector: bowerse
Description Date Unit Status Comment
Violation 01/10/2020 PASS Called person filing complaint upon returning to
I i loffice
-Arthur.Queile Stated They are no longer
sleeping in the camper and the issue is
resolved
I informed him I would be closing complaint
and informed him that he may call at any time if
any problem arises
Violation 101/10/2020 PASS Camper in back yard
iTook picture
Inspection,Type : Violation Inspector bowerse
_ . .__. ...................... ................. .......... ---
Description ?Date Unit Status Comment
Violation 01/02/2020 FAIL No one home left card in door 3T10 pm
Camper In driveway
Inspection.Type : Violation Inspector': ' bowerse
Description Date Unit Status Comment
Violation 01/03/2020 FAIL Owner Came into office spoke to Robin i
Anderson.Stated they were living in camper on
I temporary basis and plan to leave in mid Feb
;Robin informed them they were in violation of
Zoning. I have sent a letter of violation.Please
see attached
of re . Tay �,> �+ e
THE ,,off Printed On: 1/22/2020
o Cpmplainvu-411 Reoq
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°. ,"RN ;;p 73 MULBER 39. RYSTREEET, HYANNIS
;x�, CaSe�# C 2Q-901
Case#: C-20-901 Address: 73 MULBERRY STREET, Date: 1/2/2020
HYANNIS
Owner Info: Property Info:
DASILVA, GABRIELLA C REIS ET MBL:
AL
73 MULBERRY STREET 310-357
HYANNIS MA 02601 r
774-212-2927
Owner Notified?-
p
Complaint Details:
Type of Complaint Classification of Complaint Method of Complaint
Zoning, Medium Priority Phone
Complaint Summary:
People living in RV on residential property. They have to start unit to run heat and it's very loud. Unit is
situated just under bedroom window of next door neighbor.
Action History:
I
Action Taken Date Description Fee Inspector
Close Case 1/22/2020 Complaint resolved $0.00 bowerse
Neighbor states they are
no longer Sleeping in
camper
Inspector Assigned to Complaint: bowerse Filed by: andersor
Comments:
Comment Date Commenter Comment
1/2/2020 andersor Check site after 2:30 PM in order to find people returning to unit. Most
activity at night.
1/3/2020 andersor Residents of RV came in. She admitted they stay in the RV. I advised her
she can't and said a NOV would be going to property owner concerning this
ordinance violation. The unit is said to be registered and it's her expressed
intention to leave for Fla on 2/7/2020.Told her she can "organize" her
belongings inside the camper but cannot sleep overnight in it. She said
they have all of the provisions outside to allow her to live in it. Discussed
this at length and told her we would monitor the situation and if we got
another complaint we will pursue the matter to Housing Court.She agreed
to sleep in the house. I reminded her that noise was part of the complaint
and she should make every attempt to avoid disturbing her neighbors.
Date.
1/22/2020 ToW of Barnstable
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Town of Barnstable
Inspectional Services
B"R' Brian Florence,CBO
MAS&83. 0�
9�a i639• ��� _ Building Commissioner
IEO MAj A 200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
INSPECTION REPORT
Address : 73 MULBERRY STREET, HYANNIS Case # C-20-901
Inspection Type : Violation Inspector: bowerse
'Description Date Unit Status lComment
t
Violation 101/10/2020 _ PASS Called person filing complaint upon returning to
'office .
Arthur Queile Stated They are no longer
i sleeping in the camper and the issue is
resolved
informed him I would be closing complaint
E and informed him that he may call at any time if,
iany problem arises
-Violation 01/10/2020 PASS Y
Camper in back and
P
=Took P icture
Inspection Type : Violation Inspector: bowerse
......... _..
Description ' jDate Unit Status Comment
Violation 01/02/2020 iFAIL No one home left card in door 3 10 pm
Camper in driveway.
Inspection Type : Violation Inspector: bowerse
. .._... _ .. - - ._........ ..... _._.. .. _........__
;Description ?Date Unit ;Status Comment .
Violation 01/03/2020 I FAIL Owner Came into office spoke to Robin
Anderson Stated they were living in camper on
I (temporary basis and plan to leave in mid Feb
Robin informed them they were.in violation of
Zoning. I have sent a letter of violation Please
see attached
_..... ., ........ . ... _ ._i..___. . _. . ,..
oFn+er f a Printed On: 1/9/2020
Complaint ZaII..Report
73 MUt BERRYeSTREET� HYANN_ IS y ' Q
- Case# C-20=901
Case#: C-20-901 Address: 73 MULBERRY STREET, Date: 1l2/2020
HYANNIS
Owner Info: Property Info:
DASILVA, GABRIELLA C REIS ET MBL:
AL
73 MULBERRY STREET 310-357
HYANNIS MA 02601
774-212-2927
Owner Notified?..
Complaint Details:
Type of Complaint Classification of Complaint Method of Complaint
Zoning, Medium Priority Phone
Complaint Summary:
People living in RV on residential property. They have to start unit to run heat and it's very loud. Unit is
situated'just under bedroom window of next door neighbor:
Action Histo
Action Taken Date Description Fee Inspector
Inspector Assigned to Complaint: bowerse Filed by: andersor
Comments::
Comment Date Commenter Comment
112/2020 andersor Check site after 2:30 PM in order to find,people returning to.unit. Most
activity at night.
1/3/2020 andersor; Residents of RV came in. She admitted they stay in the RV. I advised her
she can't and said a NOV would be going to property owner concerning this
ordinance violation. The unit is said to be registered and it's her expressed
intention to leave for Fla on2/7/2020.Told her she can "organize" her
belongings inside the camper but cannot sleep.overnight in it. She said
they have all of the provisions outside to allow her to live in it. Discussed
this at length and told her we would monitor the situation an if we got
another complaint we will pursue the matter to Housing Court. She agreed
to sleep in the house. I reminded her that noise was part of the-complaint . .
and she should make every attempt to avoid disturbing her neighbors.
Date: 1/9/2020. `# Town of Barnstable
Town of Barnstable
Building Department Services
Brian Florence,CBO
Building Commissioner BAR�ISTABI,E':
200 Main Street, Y �H annis MA 02601 �'
lass-zone ,
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Notice of Zoning Ordinance Violation(s) and Order to Cease, Desist and
Abate:
January 3, 2020
Re: 73 Mulberry Street, Hyannis, Ma 02601
Gabriella Dasilva 73 Mulberry Street,Hyannis Ma 02601 and all persons having notice of this
order:
As property owner or tenant of the property located at 73 Mulberry Street,Hyannis MA,
Assessors Map 310 Parcel 357,you are hereby notified that you are in violation of The Town of
Barnstable Zoning Ordinance Chapter 240—9 B-Zoning,and are ORDERED this date 1/3/2020,
to: CEASE AND DESIST all functions associated with the following violation(s)on or at the above
mentioned premises:
Summary of Violation:
On or around 1/2/2020, I received creditable evidence a violation of the Barnstable Zoning
Ordinance §240—9 B Specifically, People residing in camper in violation of this Temporary use.
Summary of Action to Abate Violation:
In order to abate this violation and to avoid further enforcement action by this office,commence
immediately upon receipt of this notice the following action:
Cease use of camper for sleeping/Living purposes.
And, if aggrieved by this notice and order, you may file an appeal with the Town Clerk of
Barnstable, specifying the ground thereof within thirty(30) days of the receipt of this order
(in accordance with Chapter 40A Section 15 of the Massachusetts General Laws). If,at the
expiration of the time allowed,action to abate this violation has not commenced,further
action as the law requires will be taken.
By Order,
Edwin Bowers
Local Inspector
I
cf tNe Y � w Printed On:1/212020
, o* Complaint Call Report
7,3�MULBiER4RY 'STRtEET HYANNIS
Case G=20-90 l
Case#: C-20-901 Address: 73 MULBERRY STREET, Date: 1/2/2020
HYANNIS
Owner Info: Property Info:
DASILVA, GABRIELLA C REIS ET MBL:
AL
73 MULBERRY STREET 310-357
HYANNIS MA 02601
Owner Notified?:
Complaint Details:
Type of Complaint Classification of Complaint Method of Complaint _
Zoning, Medium Priority Phone
Complaint Summary:
People living in RV on residential property. They have to start unit to run heat and it's very loud. Unit is
situated just under bedroom window of next door neighbor.
Action History:
Action Taken Date Description Fee Inspector
Inspector Assigned to Complaint: bowerse Filed by. andersor
Comments:
Comment Date Commenter Comment
1/2/2020 andersor Check site after 2:30 PM in order to find people returning to unit. Most
activity at night.
7 w:=*� "°" alai °ice ice,., .,,z,-;., .11 �
Date: 1/2/2020. Town of Barnstable
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Property Print Page 1 of 4
Print this page)
Owner Information
Map/Block/Lot: 310 /357/
Property Address
P
73 MULBERRY STREET
Village: Hyannis
Town Sewer At Address: Yes ��
GIS Zoning Value: RB
Owner Name as of 1/1/18:
DASILVA, GABRIELLA C REIS ET AL �
73 MULBERRY STREET
HYANNIS, MA. 02601
Co-Owner Name
Multiple Owners
Name: DASILVA, GABRIELLA C REIS ET AL
Name: DASILVA, FABIO B
Name: MACHADO, GUILHERMY LUCAS
Assessed Values
Appraised Value Assessed Value
Building Value $ 125,600 $ 125,600
Extra Features $ 28,700 $ 28,700
Outbuildings $ 2,800 $ 2,800
Land Value $ 90,300 $ 90,300
Totals $ 247,400 $ 247,400
Past Comparisons
2019 - $ 219,300
2018 - $ 201,300
2017 - $ 176,400
2016 - $ 191,600
2015 - $ 171,900
2014 - $ 172,100
2013 - $ 172,200
2012 - $ 167,500
https://www.townofbai-nstablQ.us/Departments/Assessing/Property_Values/print_20.asp?ap... 1/2/2020
Property Print Page 2 of 4
Tax Information
Hyannis FD Tax (Commercial) $ 0
Hyannis FD Tax (Residential) $ 732.30
Community Preservation Act Tax $69.54
Town Tax (Commercial) $ 0
Town Tax (Residential) - $ 2,318.14
$ 3,119.98
Sales History
Owner: Sale Date Book/Page: Sale
`Price:
DASILVA, GABRIELLA C REIS ET AL 2019-10-01 32344/ 350 $240000
MCLAUGHLIN, MARK 2007-03-22 21872/ 88 $286000
CUMMINGS, ARNOLD R & KATHARINE 2000-12-11 13420/ 198 $125000
HILDRETH, MARY J 1985-08-15 4676/279 $75000
HORGAN, GERTRUDE M & QUINN, ANNE B 1979-09-12 2981/ 129 $0
Photos
Sketches
https://www.townolbarnstable.us/Departments/Assessing/Property_Values/print_20.asp?ap... 1/2/2020
Property Print Page 3 of 4
C P w{/
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WMI
FR
F
AsBuilt Card N/A
B2N Barn-any 2nd story area FPC Open Porch Concrete Floor REF Reference Only
BAS First Floor,-Living Area FTS Third Story Living Area(Finished) SOL Solarium
BMT Basement Area (Unfinished) FUS Second Story Living Area SPE Pool Enclosure
(Finished)
BRN Barn GAR Garage TQS Three Quarters Story(Finished)
CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished)
CLP Loading Platform GRN Greenhouse UHS Half Story(Unfinished)
FAT Attic Area(Finished) GXT Garage Extension Front UST _ Utility Area(Unfinished)
FCP Carport KEN Kennel UTQ Three Quarters Story
(Unfinished)
FEP Enclosed Porch MZ1 Mezzanine, Unfinished UUA Unfinished Utility Attic
FHS Half Story (Finished) PRG Pergola UUS Full Upper 2nd Story
(Unfinished)
FOP Open or Screened in Porch PRT Portico WDK Wood Deck
PTO Patio
Construction Details
Building Details Land
Building value $ 125,600 Bedrooms 2 Bedrooms USE CODE 1010
Replacement Cost $169,690 'Bathrooms 2 Full-0 Half Lot Size(Acres) 0.25
Model Residential Total Rooms 4 Rooms Appraised Value $90,300
Style Raised Ranch Heat Fuel Gas Assessed Value $90,300
Grade Average Heat Type Hot Air
https://www,townol-barnstable.us/Departments/Assessing/Property_Values/print_20.asp?ap... 1/2/2020
Property Print Page 4 of 4
Year Built .1971 AC Type None
Effective depreciation 26 Interior Floors Carpet
Stories l Story Interior Walls Drywall
Living Area sq/ft 913 Exterior Walls Wood Shingle
Gross Area sq/ft 1,936 Roof Structure Gable/Hip
Roof Cover Asph/F GIs/Cmp
Outbuildings and Extra Features
Code Description Units/SQ ft Appraised Value Assessed Value
WDCK wood Decking w/m.il ings 140 $ 1,900 $ 1,900
FEP Enclosed porch-ceilin 32 $3,000 $3,000
roof, g
BMT Basement-Unfinished 851 $ 17,500 $ 17,500
BFA Bsmt Fin-Avg 638 $8,200 $8,200
SHED Shed 144 $900 $900
https://www.townofbai-nstable.us/Departments/Assessing/Property_Values/print_20.asp?ap... 1/2/2020
Town of BarnstableBuilding
T� p *., �..-.
9POSt This Card So That t is Uis�ble;From the Street Approved Plans Must be Retained on Job and this Card Must be Kept #
v M^ Posted,Until Final Inspection Has Been'Made h , •
... . e
"feor�c° ;Where'"a Certificate,:of Occupancy is Required,such Building shall Not 6e'Occupwduuntil a-Final Inspection has been made
Permit NO. B-19-4050 Applicant Name: Steve spengler Approvals
Current Use: Structure
Date Issued: 12/18/2019 e
Permit Type: Building-Solar Panel-Residential Expiration Date: 06/18/2020 Foundation:
Location: 73 MULBERRY STREET, HYANNIS Map/Lot: 310-357 Zoning District: RB Sheathing:
Owner on Record: MCLAUGHLIN, MARK Contractor Name:;.- VIVINT SOLAR DEVELOPER LLC. Framing: 1
Address: 73 MULBERRY STREET Contractor License: 170848 2
HYANNIS, MA 02601 Est Project Cost: $ 1,126.00 Chimney:
Description: Installation of roof mounted photovoltaic solar systems 2.56kw 8 Permit Fee: $85.00
Insulation:
Panels Fee Paid'. $85.00
Project Review Req: Date `s 12/18/2019 Final:
Plumbing/Gas
�• Rough Plumbing:
MIMI
This permit shall be deemed abandoned and invalid unless the work authorized.by thisFpermit iscommenced'withm six months after issuan2. Final Plumbing:
All work authorized by this permit shall conform to the approved applicatioe and the,approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall bein compliance with the local zoning by laws.and codes. Rough Gas:
This permit shall be displayed in a location clearly visible from access street or road sand shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. j Final Gas:
.;
The Certificate of Occupancy will not be issued until all applicable signatures by:the Building and Fire de Officials�arre prowd,on thispermit. Electrical
Minimum of Five Call Inspections Required for All Construction Work:
1.Foundation or Footing
Service:
2.Sheathing Inspection 2
3.All Fireplaces must be inspected at the throat level before firest flue Iming is installed Rough:
ro.
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
Final:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation
Low Voltage Rough:
7.Final Inspection before Occupancy
' Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Health
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
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I
Anderson, Robin
From: O'Connell, Timothy
Sent: Wednesday, April 24, 2013 3:29 PM
To: Anderson, Robin
Cc: Parziale, Jim
To whom it may concern:
On 4-24-13 1 conducted a Rental Inspection at 73 Mulberry Street Hyannis, MA. During inspection I observed three
rooms being used as bedrooms and property is on town sewer. Measurements were approximately 100, 110, and 80
square feet. Each bedroom only had one bed within it. This will entitle them to a rental permit for 3 bedrooms with 5 adult
occupants. The lower level was set up as a living room/game room. Observed that a 5.0ft cased opening was created to
turn two rooms into one and the kitchen area had been removed. ( i.e no stove or other devices that are typically within a
kitchen). Furthermore, I did not observe any signs of overcrowding.
Timothy B O'Connell, R.S
Health Inspector
Town of Barnstable
200 Main Street
Hyannis, MA 02601
(508)862-4646
Email: timothy.oconnell@town.barnstable.ma.us
i
Anderson, Robin
From: Anderson, Robin
Sent: Wednesday, April 10, 2013 8:54 AM
To: Parziale, Jim
Subject: RE:
Jim, I have a couple of questions - Have you been there to inspect property as a rental or
are they not registered at all? Do you know if the entire house is rented or is it rented
as two units? What is the septic capacity? Do they have too many bedrooms? Please
advise. Robin
Robin C. Anderson
Zoning Enforcement Officer
Town of Barnstable
200 Main Street
Hyannis, MA 02601
508-862-4027
-----Original Message-----
From: Parziale, Jim
Sent: Tuesday, April 09, 2013 3:21 PM
To: Anderson, Robin
Subject:
Hey robin,
Mark McLaughlin, owner of 73 Mulberry st hyannis was 'ordered by you to open up the
doorways in the lower level to cased openings and to remove a lower level kitchen back in
2011. This permit is still open and now owner has rented the house out and there are
overcrowding complaints. Not sure what you can do about the building issues. Sending one
your way, Jim
1
Anderson, Robin
From: Parziale, Jim
Sent: Tuesday, April 09, 2013 3:21 PM
To: Anderson, Robin g
Hey robin,
Mark McLaughlin, owner of 73 Mulberry st hyannis was ordered by you to open up the
doorways in the lower level .to cased openings and to remove a lower level kitchen back in
2011. This permit is still open and now Iowner has rented the house out and there are
overcrowding complaints. Not sure what you can do about the building issues. Sending one
your way, Jim
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 3no Parcel Application #
Health Division q-1 l Date Issued
Conservation Division Application Fee
Planning,Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address -73
Village 81.;e ,1,5
Owner 12 iKrfI ��/��� �l �-� Address
Telephone 3
Permit Request
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation
3Z72? Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) S= o
Age of Existing Structure d lS Historic House: ❑Yes o On Old Kmg`s RHighway Ll Y ❑ No
Basement Type: q Full ❑ Crawl Walkout ❑ Other70
j
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
4 vy 6
Number of Baths: Full: existing new Half: existing n�bv'
Number of Bedrooms: 3 existing —new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: P4as ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes )940 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 ' N.0 If yes, site plan review#
Current Use_ - ______ Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
�r l 1 ., �v
Name � Telephone Number 3� `I
Address / J b �� License
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATUR&0::%� DATE
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A FOR OFFICIAL USE ONLY
,r APPLICATION#
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DATE ISSUED f r
MAP/PARCEL NO. -
ADDRESS VILLAGE_
OWNER -
DATE OF INSPECTION:
F
FOUNDATION
t ✓ t�''
FRAME
l
a INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL--
q I
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
t
r4. DATE CLOSED OUT,,-
ASSOCIATION PLAN NO. `
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N The.Commonwealth of Massachusetts,
l f Department of Industrial Accidents
Office of Investigations ..
/+ 600 Washington Street ;
Boston,MA 02111
e a www.masi.gov/din
Workers' Compensation tnsarance Affidavit:Bnilders/Contractors/Eledtiicians/PInmbers
Applicant Information
'Please Print Legibly
Name (Business/Organization/Individual): 7,,,4 A,Lr�w�� •�.`�
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Address: d6x �;-
City/State/Zip: d }� cil Phone#:- ��d "S, Q, �` 7
Are you an employer?Check the appropriate box.' Type of projecf(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6_ New construction
employees(full and/or part-time).* i have hired=the sub-contractors
2.❑ I am a sole proprietor or partner listed on the attached sheet.t 7• ❑ kemodeling r
ship and have no employees These sub-contractors have + 8.'`( Demolition .
working forme in any capacity.'. _ 4 workers' comp.insurance.n 9 ❑ Buildingaddition'
lin
IMP-
[No workers' comp, insurance ' S:, ❑ We are a,corporation and its
required.] `officers have exercised their I0.❑ Electrical repairs or additions
li
am a homeowner doing all work 'Tightof exemption per MGL > 11.❑ Plumbing repairs oradditions
myself. [No workers' comp. FF.; c.152, §1(4), and we have no 12.0 Roof repairs
insurance required] t A employees. [No workers'" .'
• comp.insurance.required.]. - �° ��''�rrS. .
.Y 13 Other"
*Arty applicant that.cheeks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowner;who submit this affidavit indicating they aredoing 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 thc�nameaof the sub-contractors and their workeri"coin policy nformation.
P P cY i
I am an employer that is providing workers'compensation insurance for my employees; Below is the policy and job site
information. ,
1411
Insurance Company Name:
Policy#or Self-_ins.Lic.#: Expiration Date:"
a. h
Job Site Address:
_ City/State/Zip. 4
Attach a copy of the workers' compensation policy declaration gage(showing the policy number and expiration date).
Failure to secure coverage as required underSection.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.civilpenalties in the'fonn 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 ma be forwardedYto the Office of
Investigations of the DIA for,insurance coverage verification.'
I do hereby cerkfy under the pains and' enalties of perjury that the information provided above is` a andcorrect
Si .atttr Date.
�' �� �a
Phone#: ? 7
Offtcia1 use only. Do not write in this area;to be completed by city or town'official
�e
City or Town:' Permit/Licetise#
Issuing Authority(circle one): u
I. Board of Health 2;`Building I3epartment.3..City/T own,:Clerk'4.1 Electrical Inspector 5.P.lumbing Inspector
.�
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 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."
MGL chapter 152, §25C(6)also states that"every state or local licensing akency*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-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 than 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
PIease be sure thatt'he 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.app!ications_in any given year,need only submit one affidavit indicating current
policy inforrnatio.,(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy"f 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:
u, The Commonwealth of Massachusetts
Department of Industrial Accidents `
Office of Investigations
600 Washington Street
B aston,MA 02111
Tel. # 617-727-4900 ext 406 ar 1-9.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Town of Barnst_aWa
Regulatory Services
a uexsTABLF,
,�.s
Thomas F. Geiler, Director
L.
Building Division
-
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.t6wn.barnstable.ma.us
Office: 508-862-4038 Fax: 509-790-6230
HOMEOWNER LICENSE EXEMPTION
a - Please Print '
DATE:
JOB LOCATION:
number street village
"HOMEOWNER": �� (i1/I rV�� . ' L5 c-o 3 —7
name � � - home phonc# work phone#
CURRENT MAILING ADDRESS:
.; CD t.
cityhowo ' 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 as sumeryiSl)
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 strictures. A
person who constructs more than one home in a two-year period shiiJhnot be considered a�homeowrier.'Such-.
"homeowner"shall submit to the Building Official on a form acceptable-to the Building Official, that he/she shall fie
responsible for all such work performed under the building all such work performed under the building permit. (Section']09 1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations_
The undersigned"homeowner",certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will.comply wiEksaid procedures and
requirements.
store of Hb
Approval of Building Official �r
l
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 EXEMMON
The Code states that "Any hhmeowmcr performing work for which a building permit is inquired shall be czanpifrom the p tvisions
�\
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." 4/
Many homeowners who use this cxemption'arc unaware that they am assuming the responsibilities of a supervisor(see Appcodix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2-15) This lack ofawarencss often results in serious-problems,particularly
when the homeowner hives unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of hisAcr responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilitiep 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 forr✓certification for use in your community.
Q:forms:homccxcrnpt
-4
�F TFtE Toy,
Wit,Sri u�r
M` Town of Barnstable
Regulatory Serdees
Thomas F. Geiler,Director
Building Division
Thomas Perry, CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us I
Office: 508-862-403 8 ` Fax: 508-790-623 0.
Property Owner Must
` Complete and Sign'Tbis4Sect-ion
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:
/t rV duo
(Address o Job) ;
Si of Owner Date
It
Print Name
If Property Owner is applyingfor permit, please complete the Homeowners License Exemption Form on the
reverse side.
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Town of Barnstable
..��I"E'°w Regulatory Services
Thomas F. Geiler,Director
B" ASS.MASS. ' Building Division
16.19.y M �q
0
4''°lFo MA'S a` Tom Perry Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
COMPLAINVINQUIRY REPORT
Date: (o / Rec'd by: '04
Complaint Name: Map/Parcel
Location 01
Address:
Originator Name:
Street:
-
Village: State:' Zip:.
Telephone:
Complaint Description: W�S
01
. o
w
FOR OFFICE USE ONLY
Inspector's Action/Comments Date: �c �' (( Inspector:
i P --
Qi�s i
Additional Info.Attached 3 r _
f
a Town of Barnstable *Permit# 2-COO 6��c
�{. Expires 6 mo jr sue date
Regulatory Services Fee
# r
�,� .: Thomas F.Geiler,Director
1M3 Jq. ,�� Building Division
rEDMAyA
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.
�/X9,4 Valid without Bed X--Press Imprint
Map/parcel Number /
Property Address I / 'v16�
.Residential Value of Work c - Minimum fee of$25.00 for work under$6000.00
/Owner's Name&Address
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor ®PRESS PERMITAI am the Homeowner
❑ I have Worker's Compensation Insurance MAY 12 2008
Insurance Company Name LE
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box) G
-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof),
Re-side C74
❑ Replacement Windows/doors/sliders.U-Value (maximum
*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.
A copy of the Home Improvement Contractors License is required.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revise020108
The Commonwealth of Massachusetts
Department of Industrial 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
�f
Name(Business/Organization/Individud): % f
Address:
City/State/Zip: /7/y, Phone.#: �6-
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 0 I 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 7. ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. e�loyees and have workers' 9. El Building addition
[No workers' comp.-insurance comp.insurance
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 11.0 Plumbing repairs or additions
self o workers' comp. right of exemption per MGL 12 oof repairs
s equire&]t c. 152, §1(4),and we have no
insurance r 13.❑ Other
employees. [No workers'
comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing then workers'compensation policy information.
t Homeowners who subunit this affidavit indicating they art doing all work and then hire outside contractors must submit a new affidavit indicating such.
Y--Mtractors that check this box trust 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 pmvidt 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 tip 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 under the pains-and penalties of perjury that the information provided above is true and correct
Si ature: Date:
Phone#
Official use only. Do not write in this area,to be completed by city or town offtciaL .
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#•
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."
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 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-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 Towp 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 permitllicense 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 on;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 btim 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.
Ile Cammonwcalth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washingfnn Street
Boston, MA 02111
Tel. #617-727-4900 ext 4-06 or 1-977-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
Town of Barnstable
VE t ti
Regulatory Services
Thomas F.Geiler,Director
BARNSTABLE,
MASs
p$ 019. ��� Building Division
Plfo �A Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601 .
Krmv.town.b arnstabl e.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
--r
JOB LOCATION:
number streeetty� village
"HOMEOWNER": ..—.f�./ i!%[�.. ... ✓y�(V V t/�r?�Ca � �
name home phone# work phone#
CURRENT MAILING ADDRESS: 73Z4)
8",
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"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signatur owner
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 persons)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 person as 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 forrn/certification for use in your community.
r
�FTHE►� Town of Barnstable,
Regulatory Services
9NAS& '�; Thomas F. Geiler,Director
f16.19i - . Building Division
Tom Perry, .Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-623 0
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.
oF� Town of Barnstable, *Permit#� 6Oa7
.l, Expires 6 months from issue date
Regulatory Services Fee :Cx.�
RAMsz,,sr t
Thomas F.Geiler,Director P�
Building Division
pJFD MP'I�
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 P.
Map/parcel Number 1 ! l
Property.Address J U f' r s`� NG-KV1
Residential Value of Work ,. Y Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
23 /0 L) h-e r I-/ S�-
Contractor's Name J�APU I IPJA II-AA r �,r Telephone Number S� ` 6 9'2
Home Improvement Contractor License#(if applicable) &A !
3 .
❑Workman's Compensation Insurance X-PRESS PERMIT
Check one:
❑ I am a sole proprietor MAY 3 0 2008
I am the Homeowner
[ I have Worker's Compensation InsuranceQ TOWN OF BARNSTABLE
Insurance Company Name /V C 14 H / cy#f� 1�
Workman's Comp.Policy# ( a S S`
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will betaken to
❑Re-roof(not stripping. Going over- existing layers of roof)
❑ Re-side
O"eplacement Windows/doors/sliders.U-Value k 2 r (maximum.,A
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contracfors License is required.
SIGNATURE: c^ tC
QAWPFILES\FORMS\building permit forms\EXPRESS.doc
Revise020108
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia"
I UV.
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers
Applicant Information Please Print Le 'bl
Name(Business/Organization/IndMdual): m E J�)I�Jo r Al, A'm e SfR L)1 C(s
Address: p y S P.4 C 41141
City/State/Zip:11-7 `I c1 G k 36 331 Phone.#: �7 — 5-1 ��
Are you an employer? Check the appropriate box: Type of project(required):
1.&1 am a employer with l b 4. ❑ I am a general contractor and I 6. ❑New construction
employees($ill and/or part-time).* have hired the stib-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
employee's and have workers'
working for me in any capacity. $ 9. ❑Building addition
[No workers' comp.-insurance comp.insurance. 10. Electrical airs or additions
required.] 5, ❑ We are a corporation and its ❑Electr repairs
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myselL [No workers' comp. right of exemption per MGL 12.❑Roof repairs
t c. 152, §1(4),and we have no �
insurance required.] employees. [No workers' 13. ther
comp.insurance required.]
*Any applicant that checks box M must also fill out the section below showing their workers'con4xnsation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new of davit indicating such.
lContractws that check this box must attached m additional sheet showing the name of the sub-contractnrs and state whether or not those entities have
employees. if the sub-contmctors have employees,they must prwidt 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. _e ,,U' r I
Insurance Company Name: V Pi
1q of � 7 55 Expiration Date: '3 l d I
Policy#or Self-ins.Lie.#: �
Job Site Address: 5 <v' UI b-0 rf- �"� 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 crimirial penalties of a
fine tip to$1,500.00 and/or one-year unprisonment, 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
Investi lions of the WA for insurance coyr-mize verification.
I do her cer*under the pains-and penalties of perjury that the information provided above�yis true and correct
Signature C/�-�iL `� fie, j� Date 0� DD
dr
Phone#
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.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
( nntnrtPerson.: - • 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."
association,corporation or other legal entity, or any two or more
er is defined as an individual,partnership, asso t n, rp g
An employer � P
P y P
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."
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 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-contractors)namc(s),address(cs) 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'
e listed below. Self-insured
. compensation policy,please call the Department at the number hs companies should enter their
self-insurance license number on the appropriate line.
P -
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 onp 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.Whcre a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(Le. a dog license or permit to born 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 C6MMOnweaM. of Massachusetts
Depa rtmt,-nt of Industrial Accidents
Office of Investigations
600 WashingtGn St=t
Boston, MA 02111
TO. # 617-727-4900 ext 4.06 ar 1-M-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gav/dia
oFIKElo Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-962-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
`
I, Arl�- ....V LOWL 4- I ' , as Owner of the subject property
hereby authorize / A 11 to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address ofjob)
AD 'q �, �� 2
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the Homeowners License
Exemption.Form on the reverse side.
Town of Barnstable
mop IHE tp��
Regulatory Services
" Thomas F.Geiler,Director
BARNSTAU9,
9 MASS.
059. Building Division
PIEDv a Tom Perry,Building Commissioner .
200 Main Street, Hyannis,MA 02601
w mv.town.b2rnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
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 Iicense,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"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
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 log.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
vrhen the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as 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.
MAY-15-2008 13:17 HOME DEPOT HYANNIS P.006
o] 04•M7
....".t;.�.—
IMPROVEMENT-CONTRACT,
Sold,Fo wished and Installed by:
Branch Name 611115 Datec I M— �. TI#D AtJ-Iome Services,Inc. Q
d/b/a The'HoateDejiot-Aa$ome Services x
345A Greemvood•Strect,'•WorcestCr,MA 01607
G .Toll:Frce. 800.657-5182 FAx:=508-75,6-2859
Branchdilnmtier..:: ::;'',Sa : .-.....,,-':.:•Job#:'='''�r6.Q.� � ( ).
' .. Ftdaul IIID'ti?5-2698460'MC I.ic#.C'0T.439�RI Cone Licl116427
fLic#565522; MA2iomelmprovemen[ConnactorRe8.#126893
Installation Address:".... j.. S�'` . ..,
- Ci State;. zip
Last:4 Diglts of Driver's . .,
Piuchaser(s)b' ..'Lic.ox&1 Mo/Yr: Work Phone' Rome Phone:
5U59 (9b) (o -a3 "1�z(003
Homc Address . .
(If different from Installeb -Address) City. State: '. Zip,
email Address'(to'recclve.updatcs and promotions'•fiom;The'Home Depot):
project Informiation: 7/We/You.("Purchaser"),the owners.of the-.property located at the,above installation address,offer to
contract with Tfa At-Home'Services,Inc.("Borne'D .,e)to famish;deliver and arrange for:the installation of all materials
as described on thcsttaehed Spec Sheet# l OR - incorporated'herein by zeference aud-mide•&-part hereof.
HomeDcpofreservesthe.right"to cancelthi3.contract if,'upon-rainspcedtinoftbcjob;'IlomeDepot.determincs'.thatit
cannot-perform'irs'obligations'duc to a strnetural-problem•withthe home;pricing errors or•'bccauaie work'requircd to
complete..the job was not-in'eluded;in;.the.Spce-Sheet or.Contrack,' '
. .;' "DEPQSIT RAXMENT'OPTIONS'.
... . 'a. ';(Subject to fund va•i'fimtioa and/orcretlit•ipprovuL)' .
9 .
"CONTRACT AMOUNT $!; � is•'Check!,Coshicrn.Ghcck or US PoalnlServiceMoney Order
(Made-payable w Tbc Homc Depot).
Z
#LESS DEPOSIT' '$ 2. C'redit Card*'nud/or-0ihcrPayment0In-2;-ClrdcOdeBetos:
Visa '..Mate<('ard Di!covcr American"a
BALANCE:DCTE:...:
ON COMPLETION $ :.71r 1Horne-DcpocHoee
Home D
yem5atLo The Ho— epot.CreditCard
j'Mioimnm 25%ofCoutraet"Amount due upon.
Account, C4Wpg AeCeunt• (HM&MCC ONLY)
_ cxectition ofthis contract. _ "AvAltal,la Credit:S (HQ.'&HDCC ONLY
Indicate Payment Method For Accttl: 3$ at1Qb 5112>;xp,:oatc t
BALANCE DUE,'ON COMPLET1ON: e ....
• .. as4tappeur�oncard:._'�(�,�i( "�tr�. �1.1
.. � �� ,� Name ,.
*-By'r6y/our si0at'w•ebelowi IfWe agree to allow Home Depot to
charge the above referenced credit card for the deposit'indicated.
`Whca you provide a.&eck as:payment;you authorize us,cithcr.•. ;. .: K_ K-G
to use infom,sriod from youz check to n.&u one-umo electronic Curdholdc.exsigt Date
Lund tninsfer from your account or to procenn the payment ux.a .
'check tnmau2tion:VAh we-usc infommtion from your.ehe&to - :IIX.or:HDCC.AnthorJzation Codes
make acclocromePundtnmafer funds may be..withdiavm;from..'
account as soma m.the paymedt4sieeciged,.mul you will.not DC Sit Final.Pa. ent
yam; . ,.`
# # ot48d
reanveyourchccY.bacic� - .. .d��y{Y
P.wrb.iser'agrees.that,immediately upon COMpjetd6n ofthe:work,Ptuchascrwill-executea Completion-Certificate and pay any
balance.due I'urcbaser also agrees to be jointly and'severally obligated- liable hcreunder.'
=ntit[e_Aureem t-."Tb�ag�eement;and .attachments including any
betweenflic fmaneing agxecment,contain the compkte,agrcement
-parties`an
can nof�ie amended ar mo�ifie8'im3essffi�vn a.sepatutc�greeaie�srgsi'e�'jiql;ath�iatues •
�_NOTICF TO PURCHASER .
Do not nthis'contrartbefore.yowrcad4t>.You'"areentiticdto'a:completely.filled-in.copy ofthe:contxact,atthe•time . .
you:sign:;I{ecp:it<to protcct'your;,rights.JDo:not sign.`&:Completion Certificate be£orc::this project is.complete.: Law .
prohibits.home'repair contractors:from.requesting or.,acccptinS.a Completion•certificate:sigaed by the owner prior to
the actual completion of tberivork to be performed under the.contract .
Yoa maycaucel tbis'iransaction any time prior.to midnigbt ofthe'third business dayafterthe date ofthis Contract See
Notice of:Cancellation. -explanation of this right. ..Therc will be'a'.Bervlce charge equal,to•1'0%of the contract
amount Itjob is.canccllt ''bY Pitrebaser AFTER the third-business day,but'BEF'ORE materials are ordered.There will.
ben service charge egnal.to"25"/0 of the contract amou t-if job.•is cancelled by Puicbmer AFTER materials are ordered.
BY W/OUR SIGNATURE BELOW,IAVE UNDERSTAND.THAT'T+M AGREEMENT MAYBE SUBJECT TO REVIEW
OF MY/OUR,CREDIT 'HISTORY AND'I/WF-'AUTHORIZE HOME DEPOT TO 'VERIFY AND'REVIEW MY/OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT:.REPORTING AGENCY AND.RELEASE T1IEM FROM'ALL
LIABILITY INCURRED.FROM INADVERTENT OMISSIONS OR ERRORS.
BY.MY/OUR SIGNATURE BELOW,TAVE AGpE.E'T'O BE BOUND By.THE.TERMS OF,THIS CONTRACT. I/WE
ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE
OF CANCELLATION:
S1JBIvTITTEI).SY: Date-._5 td-0
s
Date:
ACCEPTED BY:
-
Dater
NOTICE:ADDITIONAL TERMS AND CONDITIONS.ARE STATED'ON.THE REVERSE SIDE
AND ARE PART OF THIS.CONTRACT
9-21-07 rev 4-2-07:C-SC White—.DranchFle` Yellow—Customer-Pink=Sales'Consultant
TOTAI. P.ftt1R
1 1nw IlYINDOW SPECIFICATION SHEET Spec. Sheet#: . 6 5 Sheet: 1 of �
Customer: �+yr fob p: ^�� •CortsultanL
Date:' t�
Existing Window New Window
O I Measurements Grids Product Options Labor �s°L«aeans
Options Frorn—Wd%Left fO RWM
a .ROYgh OP°M1�� - II W rare• or ban - ...BayA Bowe.Carmb,
iPnl,us*L,RorS
Lacalion
a GIs,Hardwr,Screens, MJsc items
9 µ
� 3 _ = Mull Code
c fYraPs Style Series E A u R 9 F«eoasuae^s•=.meo.ay .
Room.' Floor aM°Code fY+ Code Code n $ N v 8 a o or�c•-opereKrp.
... _ ww'n ligtgM ul V a -+ 7
I _
l AWE
5C'
z
x
E-
0 1.: T
[zl rap cMor t, - - - - SPECIAL CONSIDERATION$: .
i1
Interior Casing Type : `�
s Bay Qr Bow wiri((bw;
1 �t o Cu54v��e�
Seatboard IAalerlal:(viriyl qnl -Brroh,orOak)
r. ° eW C3 ge-M ti � n� t10{� Yl `Say ProJocU-An4re{30 or45 J
Bay Fiarkt r Typo(DH,a"orCsrnnQ
op otwindoyySo sotfil Qnotlesl
l If Tled to soffit,color of sa(fie maledal 1 haze reviewed and a ree with all the db s
f ,.. ConstnucLRoo�S1e+PrHo�' - -
B J pecifications above and the
" SpeClal Terns end CondifWj;orilhe bads of file Yellow{Customer)Dopy.
CO ; >. .Garden Wi'dow':
o r Seatboard Il aferial :{vinyl only-White PJonite,
In 1 Thickness,(inches}
_ � CustorrM.Y Slg�fure .
i ![ddhronal Shell es or No)
� I 1,There i5 no guarrinfgo 11la1 rew sM7�es wit march exlsCrg tofu. / '
e
$R—Af- N1a2fi8 rifite-ReHa-rel Yalorr-CtsHarier Pick•Sales Canwnan
1 11-iDr68
Board of Building-Regulations an&Standards
jVj HOME IMPROVEMENT CONTRACTOR
t Re6istratio 126893
{`{ EXp�rat�on 8/3/2008 i
trl
qpplement Card
i� TYPe , n:• •
THE Home Depot At Home SIN—
VARK NIADA
p`✓
3200 COBB GALLEF.I p pY/#20
`atWNTA,GA 30339: Adminis*rator — --
'3
To`vn of Barnstable *Permit# c.?1609
-PR.ESS :��� � ® Expires 6 montlis from issue date
eye ]Regulatory Services. 'Fee ' c�S 6�
JAN 16 2008 Thomas F.Geiler,Director
TOWN OF BARNSTABL Building Division
E
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
Property Address 13 A, I k ���� /Lt�r 01,601
EMesidential Value of Work O Minimum fee of$25.0.0 for work under$6000.00
Owner's Name&Address c 4% h 1, 73 G 14,j4
Contractor's Name A6t`p f/e y g e Q jpcT At d o n,e Telephone Number S'(D 9-q 6 a-6 C1 V;V
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance:
Check one:
❑ I am a sole proprietor
❑ I.am the Homeowner
[v]'I have Worker's Compensation Insurance'
Insurance Company Name l Ug w. Ya in Q s kIre i, g. G a
Workman's Comp.Policy-# I7a I l C)
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 -
Q1 Replacement Windows/doors/sliders. U-Value i 3 (maximum.44 7
*Where required: Issuance of this permit does not exempt compliance with other town department regulations;i.e.Historic,Conservation,etc.
Property Owner-must sign Property Owner Letter o.f Permission-',
A copy of the Home Improvement Contractors License is required. -
SIGNATURE:
Q:Forms:expmtrg
Revise061306 '
all} �� 'i' t�i�t t s
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O f: r,l>�} , I} � ` `t� t I_M I - ttr =� < ri r}rr} ' a k f ,mot a� i=,>ba 1r , 1~� ,� lC F r
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i� t �t , s �.L1JLrrttlFCllt Of 1rlduStlllll ACC[dCntS, �titli � �c, lk } Stec' { ;: iq
;fit
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E
E Iloston,`AMA 02111 . '` �s
t` +, wrvry mass.gov/dia ,
'+ p ance Affidavit Builders/Contractors/EI'ectriclaas/Plumbers
Workers Com ensatron Insur V°z , I
Applicant Information Please'Print Le ibl
, iJ wi � r ,
Name (Business/Organization/Individual) �/ (� e
.��� ° 17 t
� l r
Address: ,�;s a4 CP S �e✓ k
City/State/Zip. ,fitH 4 A;'r 03 Phone# }
a , _ � *`, l ,... t f �rx }l li + �iLL Are you an.employer? Check the appropriate box;t �F ` Type of project(required):
1.[� 1 am a employer with 4. I am a general contractor and I r' 6 a[]New construction I°
employees(full and�or part-time) * = have hired the sub-contractors a; E
listed on the attached sheet =7. ❑Remodeling yr
2.❑ I am a sole proprietor or partner-. - �
These sub contractors have g, 0 Demolition ;. 5
ship and have no employees
,employees and have workers
working for mein,any capacity. comp.
t #9.,[]Building addition
No workers' com insurance co insurance. ., #,.
10.0 Electrical repatrs'or additions
[ p 5 A` We are a corporation-'and its 3
required.]
3.❑ I am a homeowner doing all work officers have exercised rtheir„ 11.0 Plumbing repays or additions
right of exemption per MG '
myself. [No workers' comp 12.0 Roof repass R'
insurance re uired. t . c.=152,§1(4), and w. have no
u
9
employees. [No workers' z ` '; 13 Other t-t et acv
r' y '•,`�'
comp. insurance'requred 17 " {"
*Any applicant that checks box#I 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 musrattached an additional sheet showing the name of thesub-contractors and state'whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance jor'my employees Below is the policy and job site i
information.. µ J t�
NL
w rrUp st.,e .�vt s Insurance Company Name
Ld, `� i. a Exprahon Date i � i
Policy#or Self-ins. Luc. #.
Job Site Address: '7 City/State/Zip:" �osi l r
Attach a copy of the workers'compensation policyedeclaration 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 unpositionaof criiriiriaTpenalties of a r
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOPWORK 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 io the Office of
Investi ations of the DIA for insurance coverage verification:
I do hereby certify under the pains and Pena ies of perjury that the information provided above is true and correct..'
• `; . ,_ � Date:
Signature _
-� .. ¢ - - -
Phone#: a
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/Tow n Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Phone#:
Contact Person:
EIisYr€- rr�}} f(F,ks '" •.i
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+ r'etts.(:,:elleral°Illa;%%s`cha terl>2.;requtres all employers to p�o�uie ��ork'crs 'compe nsatio I}hlr,f r, ii�:r4r
11 .riq..,'3 ., t. '
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statute.,an employee,is delfned,as ) p - er am �ontrac t if hire fit, ftt ' ��`�ii
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res� of rmpl4ed.'oral or w-ritten
h
An`employer a defined as 'an uldi�>dual pa nership, association, corporation of 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 �-
r 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
t t
{ dwelling house of another who employs persons to do maintenance, construction or repair work on'such dwelling house
t i or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152, §25C(6)also states that`every state or local licensing agency shall withhold the issuance or i=
renewal of a license or permit to operate abusiness or to construct buildings in the commonwealth for any t'J� #
. a hcarifwho has not produced acceptable evidence of compliance with the insurance coverage required:'
v
PP ay �, y PsubdivisionsItt t
Additionally,MGL chapter 152, §25C(7)states:Neither the commonwealth nor an of its political :shall
P
er ter into'an}�contract for the performance of public work until acceptable evidence.of compliance with the insurance` ; � !
:.a
requirements of this chapter have been presented to the contracting authonty.
�t
0.
Y
{ t Applicants;! `r
t. i. Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if a F r
t rr
with their certificate s)of
necessary,supply sub-contractor(s),name(s),address(es)and phone number(s)along
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
€ Y t:
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.
a
t 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 iK
' that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current 1.
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 i` M
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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.
i
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 Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFI✓
Fax # 617-727-77.49
Revised 11-22-06 N\-w",.mass.gov/dia
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_{ A F / C19 TtFICATE NUMBER " T '
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PRODUCER
THIS CERTIFICATE IS ISSUfiO AS A MATTER OR INFORMATION ONLY AND CONFERS 0
MARSH USA,I INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
homedepot.certrequestQmarsh.cam POLICY,THIS CERTIFICATE ODES,NOT AMEN,EXTEND OR ALTER THE COVERAGE FAX(212)948-0902 > AFFORDED BY THE POLICIES DESCRIBED HEREIN,
34L PIEDMONT ROAD,SUITE 1200 COMPANIES AFFORDING COVERAGE
ATANTA,GA 30305 "
COMPANY
00492-THD-IPUSA 07-08" IPUSA A STEADFAST INSURANCE COMPANY
INSURED
COMPANY
HOME DEPOT USA,INC. A. ZURICH AMERICAN INSURANCE COMPANY
2455 PACES FERRY ROAD NW --——
BUILDING C-8 COMPANY
ATLANTA,GA 30339
C AMERICAN HOME ASSURANCE COMPANY
COMPANY
D NEW HAMPSHIRE INS COMPANY
' ta!t=•,��,+ ,..yt.•' ,•^ "�17'rtis...w�., n" :"..?xa'" "S�a+?,g1" x '�' d'"$SFu:�.+��- x•».-`•�aew�.,..-..�:
. ,..3�..�...._��r ���;�� ����t�f t ��_-�tet ,..,�•�r���f��..���9�.�na�s��`� e:d�cgttit e?�'" r��.Ra�-:�.���late... e1. �' '� �:- �{ ,z �;_�� .
TH IS.IS:TO CERTIFY THAT'POLItrIES:OF,INSURANCE.DESCRIBED HEREIN'HAVE BEEN ISSUED TO THE;:INSURED.NAMED HEREIN FOR{THE POLICY PERIOA WOICATE0
NOPNITHSTANOINGANY REQUIREMENT'TERM OR CONORION OF ANY CONTRACTOR OTHER DOCUMENT WRH RESPECT 10 WHICH THE CERTIFICATE MAY 0E ISSUED OR MAY ,
PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES OESCRI6E0 HEREIN LS SUBJECT TO AIL.THE TERMS,CON01T10NS AND EXCLUSIONS.OF SUCH POLICIES.AGGREGATE
CIMfTS SHOWN MAY HAVE BEEN RE0UCE0 8Y PAID CLAIMS. '" r` ''
LTR TYPE OF INSURANCE i'': ' POLICY NUMBER', POLICY EFFECTIVE POLICY EXPIRATION
• DATE(MMlCDIYY) OATS(MMIDDIYY) ' '
LIMITS
q • GENERAL LIABILITY . IPR3757608-02 7 031011/07 03/0148 GENERAL AGGREGATE $ 4,000,000
X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS'_ PRODUCTS•COMP/OP AGO $ 4,000,000
CLAIMS MAOE a OCCUR 'OF SIR:$1,000,000 PER OCC PERSONAL 8 ADV INJURY $ 4,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ ' 4,000,000
FIRE OAMAGE(Any one Rre) $ 1.000,000
MED EXP IAg One person)
$ EXCLUDED
B auioMoelLEuaelun BAP.2938863-04. 03/01/07 03101/08 "
X ANYAUTO SING MI $ 1.000,000
COMBINED " LE U 1"
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS
_ ... (Per person)
HIRED AUTOS..: BODILY INJURY
NON•OWNEDAUTOS , (Peracadint) $
X ELF-INSURED AUTO
HYSICAL DAMAGE - PROPERTY DAMAGE $
GARAGE LIABILITY
AUTO ONLY-EA ACCIDENT' $
ANYAUTO -� - fi z
OTHER THAN AUTO ONLY s N 414_ x?a
EACH ACCIDENT $ .
,EXCESS UABIUTY AGGREGATE $
A APR 3757 608 02 03/01/07 03/01/08 EACH OCCURRENCE $• 5;000,000
X. UMBRELLA FORM AGGREGATE $ 5,000,000
OTHER THAN UMBRELLA FORM ' $
C WORKERS COMPENSATION ANO 2921209(CA) O3/01/OT O3I01/08 X W A OTH
EMPLOYERS LIABILITY TORYLIMITS ER * -? L,
E : 2921210(FL) 03/01/07 .. 03/01/08 EL EACH ACCIDENT y$ 11000,000
F. THE PROPRIETOR/ X INCL 2921211(AZ',ID,MD,VA) 03/01/07 03/01/08 EL DISEASE-POLICY LIMIT $ 1,000,000'
D PARTNERSIEXECUTIVE .
OFFICERS ARE: " EXCL 2921208(ADS) 03/01/07 03/01/08 . ELDISEASE-EACH.EMPLOYEE $ 1,000,000
E` OTHER. 2921213(QSI) 03/01/07 03/01/08
E WORKERS'COMPENSATION "•.2921212(KY,MO,NY,WI)': 03/01/07 03/01/08
u TEXAS EMPLOYERS TNS-C44642086(TX): 03/01/07 03/01/0.8 EACH OCCURENCE 25,000,000
EXCESS LIABILITY SIR 2,000,000
3ESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS
- _ - SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL•�(�DAYS WRITTEN NOTICE TO THE
FOR EVIDENCE ONLY::
j t- CERTIFX:ATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
s - LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE.ITS AGENTS OR REPRESENTATIVES,OR THE
c ISSUER OF THIS CERTIFICATE
MARSH USA INC
MaryRadaSZewski t.Lt.J l :d f ;��tIL /��-
lot I#(il
I}• i i i€t�Jr+i��i � did+Fy# I#�, ` #h�f`' #(1' � + '�
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3 '
DATE(lllMIDONYI. p
COMPANIES AFFORDING`GOVERAQE
28�0
PRODUCER
MARSH USA INO COMPANY
hamedepot.certrequestQmarsh com E ILLINOIS NATIONAL INSURANCE COMPANY
FAX(212)948-0902
3475 PIEDMONT ROAD SUITE 1200
ATLANTA,GA 30300 coMPANY
p NATIONAL UNION FIRE INS CO
-THO-IPUSA-07-08. IPUSA
100492 .
INSURED
COMPANY
HOME SPOT USA;INC. G ILLINOIS UNION INSURANCE CO
2455 PACES FERRY ROAD NW
6UILDINGC-8
ATLANTA,,GA 30339 caMPANyH .
low I MA
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CERTIr,ICATE=HQLDER c � +r a' + �r � �»� ' : �i �7 _ v � w
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FOREVIDENCE ONLY
#+
+# MARSHtJSAINC BY
} µ,r I.1;. d Nl(#+ { I Mary;Radaszewskl r
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063-A-038
40-4 5 DH
CM
(.qoo Renovations
Double Hunq - Vinyl
ArgOn/bt d E SC
r r No Grids
NFR . 2001
ENERGY PERFORMANCE RATINGS
U-Factor(U.SJI-P) Solar Heat Gain Coefficient
0 . 34 0 . 29
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
0 . 49
mm*ctuwsgpumast Athese raings conform to applicableNFRC procedures for detertnlntng whole
duct performence.NFlIC tatingsam delermined for afbmd set of emironmentst coneons and a.
pro
pros loproduct Sim.Consult manufacturer's literature for other product perfanname irdonnation.
spe
WWW.nfrcorg
Wob—
EIdEf�11'SSW
Unit qualifies for Energy Star
Region(s): Northern, North
Central, South Central,
southern
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rll INZti: REINO0lGI,ASS SSf H—R30
LJ a 30 Test size: 44 x 60
order #c3030873030001 40318 HS
.7le -eani»zo�uuea" o1ji aaak ae&
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 4
Board of Building Regulations and Standards
Registration; 126893 One Ashburton Place Rm 1301
Expiration _8/3/2008 Boston,Ma.02108
` g TYPe BuPPiement Card
f
THE Home Depot Ak Home Servic
DANIEL PELOQUIN=
3200 COBS GALLERIA EKI{V.Y#20 �,,,`
Atlantic,GA 30339 Administrator Not valid without signature
HOME LNPROVF-%IE"%-r COfiPi'1RAC b _
Branch Yams: h Date: S"t'�� so1d;burnished aad Instelledby
• �` THDAt•Home SeMoe%hr_
-- -�• . . - _ drbla TheROmtlDepotAbHotneSeaseces - _ - .. _
-- - .-----araaeb_lliinver:--'-�t-------7onif:'35a$�3��-=—�i3Acneeawoedste�womoesca,Mad16o7 ----
Toll then(M0)657-5182;Fax;SW7i62844
FaderdID47S2698160)alk6CMM pjCmtiaepEt6W
CII6oOMMU2 bdAEra� yxRgy8128693
IastallrtloeAddren: 3 17ti tt+�`3t" L�M,QnhtS t1f1A 4'�(a� _
city State Zip
P+nsbaaer(r}; IastlDiBllrofDrlreaae _
C iEAe®&B MOfYrr Work Phone: Home Phone.-
Borne Address:
{li'diflfere tfiamt,& Monsa - ) City State Zip
L-auU Address @D receive opf[ea ad pMmofioas fiUM the How tnts�
erect Infbrmat[an: UVVeetCoa("Ptu+cha'Mj,the aCOatEadisners of the �IoeSted at the abo�x iostallalion nffex to-wish TED At-Home ServIM6 Lna.eHome Depon to fiemrsh,deluge and w nge far the inUB&tion of ail materials
as desmbeden the attached Spec Sheet d 7Stsets ,iacor�tad herein by xefereaoe sad made a
.�q g7c • partheaer►f:
Home Depot reserves the right to eatteei this contract fi,uposl M-1610ecdoo of the JON Home DqW determines that It
cannot perforat Its obligations due fe a itraehsral problem wit flit homey pricing erven or bmuse work required to
complete the job tuns not included to the Spec Sheet or Coatmet.
DEPOSIT PAYMULNT OPTIOIss-
COA'TR�ICtAhiUtJ.*P'[' 5�53�e�o (BabJeetto4mds+edfleddamae6crersAdtat�prar�al)
1. f}�eek;{hshfenCbiaekocUslsasmttiavieeldamey0�
fpara�beolDatlame Depa}
. TLE6SDEPOSIT
2 Qed+t{dad++indtpra6arp3'MRM QP&M-Orde One B&w
BALANCE DUE vas .atomac n hmmtn®t ar
Off CO'1"TION" $ .t�i2
/�� ����eotiam TLoHeaeogwlao�itCea�6 -
tMiafmom2s%4CloatnctAmcuctdaeapoa SY Afteoas pt3 ftgAeoraet QM&MCC&&YI
' execution of dill contract A►attabtr Craft.4w g�
4 (ffi.&HDC�C W4LYl
Indkate Pgrment I+ahod For Aecte;
BALANCE DUEON COMPLET(O : ` l ,
C+C1CtS�+- Ea* N+m ulsaMemsaccedi%tigR'i t►ncl.�t l.t
•'Bq MYAW Bites below,L Vt agree to allow Hoare DeW to
oiarge the above tefetuaoed sand 6or die depoit indicated,
+yam}m pc-W a aback as paYmeot,Yon mdiedw a 46W
to osr tntbcma+�'ioq Cram � ��s`��
Yaacbeckromrkasameimelta400ic otdar'as� Dee
1haQ 4aasilr tmm yoar a CWA or ti prams the paYment m a
check eamaac6aa pr3ea VMuse intorM5am fmmYMA0&b
ante ea eleetroeto timd cmaecr U&ffaY be w bison bm RLL or BDQC Ant6orlaadoo Codes
3 aoaoeat as soon t4�eDaymear is saceived aa6}nu sift not
aweiveYorrrbadcbeek Ffia(P we6t
# Oct4! # '1
balanced+agrees thas immediately� mpietiom of the 'Ork,PW%huw vrt71 execute a Completion C W60ate And `
balance due.1 also sgFees Mae jreoimly and severafhy obligated and lieblc�• Pay e7Y
° :This aveemeat and its attwhmenisr including any f*mm tg avewma.contain the oompiete agreeaneat between tie parties and can not the amended of modified unless in Ardfeng m a sepwU agecem nt signed by bolt parties.
NOTICE TO PURCHASER
Do Oct sign finis contract before you read it. You are entitled to a co letely tilled In eopY of the contrast at the t€�me
Pr s�o. Keep it to protect roar dgktr, Da cot sign a Completion Crxtificate before fhb project fs campfeta Law
Pg t e 110M o�om re contractors lfram regnesdog or nerepting a Completion Cer Mate signed by the owner prior to
pied0d Of the work to be Wormed under the oontrock
Yore may ancei this transacttan any time prior to midnight of the third basinest deny after tt+e date of this contract. See
ti
JAN-05-2008 18:09 HOME DEPOT HYANNIS P.007
withTHL t/Waly ,tho cam•oP'the meaty located at t tl�c above losta11ut3ofi address~offs
as desoiibed Oa the a{ g CH- "j to flunfn;$;GeLver and msmt�c+for fho i t aP uli mazer
. hCrotn by teForoM and mado g part here
Bam Dew re the rtgbt bsed ea ab CIMIM R ff.Open n Of the iob.Sane Aepot detandow%a
Ba
(re1'fatm US ObilRattous doe to a 8hWt0ral probieat whb Me home,pAddu errors or ha raft wort roquited
dhe job-M fiat toduded do the Spec Short or Contract
OEPOW FA7fMMT OPTIONS
• I ('�leoPtormiQPaisaoennaAElaawdit.ppa,gt.)
CONTRACTAMOUNT S VL
L aotk'.CaYliah Cheek a us Pastor 8w i.U..y
thdr
I _ fiL>�S D> Tr $�� ,p G1 �er�abO mx6c ttoma lk�, ,
`_• Cmditcursfiord/orQ&wV =w4pww-grk(me&bw
+01YC0IYII'I.t4MN, $
1 —'�-�••��• ,//'�edtomvneprK�a,rag�veetmtt,ono 71�ettamenggec�eme�Ono
tMc MM WA Gf C Ar4d Amogpt due wM i�Hoa Accaaet Q 1�CLq Aeaa>ytt tL&7IDOC t)NL1�
e�5eostdoa et thjs eoatraQt AvaBspbr S s
�.`_ �A IkotlC astY.v)
ludictrbe P�4Ymcat Meth Far AcuA I t3xy sore;
BALANCE I{ M ON CoMpLrrWNo
F40Mas ftappomanwfm CLQ
"BY Wbdr aigosttrro below.Me agree w allow 111omerDgw t
chops the above he&mc d ' card for the deposit inftated.
iffraj *�vAes Y�Da6vide i rA06Get pit,yea e m e1� f
t Lad aroa n dofim 00 a yew do*
X*W fir m�a ObWY®a �e gjdm /
t Dab
Awk usmeodeo,Wban we ose ma D w dko a o
f ttbke m tbcyaok fora trym er tuada � °Bonk m
i! 7M m appi as tle m0Y to•witl�drnWa form HIIi al BOILS q Cadls
zdodva>°m twotc lmYh aTeertred.andye„war1w # Demit 1nns1P
f �'� .i>ffihrcdiately be Idion of the wortr Yutdi W will wwoute a Co{ gmtreo due.Pa s agm=1a be join and soveraldy obi tgned and liable horamder. as Cerdfieate sad pay an)
fill x6ie Woonmm'and its aua ,dwh:dM a W fim log age meat,eoWdn tho compicm apeemwl
+f bat wem ft perti n mhd can na be mhmnded or modified unku in writing in a sepmmc agent yiped by botb pwti..
NOTICE TO PVACHAdWdt
Do a"Fr9F'thk Ooatraa boffins you read it you firs endued toe comC rediedan of
pyou Win. sCae�p it to prow your A by not, a Corygpletlon � the coao,tei at the am
the sepmi�e �ntraetotu fnom uesting or sees g a Cowplotlo0 CatllRpta Jut tOmptat4 3tmw
. i an�Of the wOelt to ho�ed under rho contract trt by the Owner preor to
Yoa ohmy easeot dtlg trha>aaRtZan�, prdOT to t of!be t>frd bhsinss ft saw tha date of this Colscraet see
IVotteo Of Comtsddatian inr trli o:plpaaton cf thta right, There wID be x eavlee cha equal I
umoust if job 1g caaceilet)hY FPri�hhaer AFTER tAc ffi!rd bnaiotaa dqy.bat B O04/9 of am em"act
RX walerkb an ordered.There wM
v fie fi eer�tce ebahyte equal to 25'/o efthe eoattmat tttthoaat U job b eageeHod by Pordhsaw AFTER mazer kb are ordav ,
BY MYlOUR b'I(3NATURE B13LOW,UWE UNDERSTATdp THAT Td tt+A6RFdihtl 'MAY BE SURMCT TO REVIEW
OF l�lY/OUNt CREQti'HiSZt)RY ANI) I/WE AU1TfOR� HOt DI3PpI'TO VEAWY AND REVIEW MY/OUR
CREDIT RECORD WITH AN JNA1Dt$VDBN(`CREDIT RnSO--R IYO AGIONt':Y AAII>RELEAsg TfUM FROM ALL
• [dAS1Ld7'X YIYL' p FROM INADVFatTENT OMISSIONS OR ERRORS,
OF NA0NCW t WON
RAW TIEWW,Y"ACME TO BE BOWI)BY M.TERMS OF T"M COIV RACP" ME.
AQ[CVbWLEDt3E F.CE<pT OF A COPY OF THIS To AND TWO COMPi.1r M Cop=OF TIC NO'C1GE
' OF CAMCELLATTON.
ACCEPM
' suHa�1-�By
> : Dom: -
_ Date:. —
NonCE:ADDI•OWALTM6AM CONDMONS APE STAT F.D ON T►t REVg�iE SIDE
ARE PART OF TIM CONTRACT
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