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0030 NEWSPAPER ROAD
.30 /���,,vs • h Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 2/6/19 Brian Florence CBO Town of Barnstable , Building Division ` 200 Main St. Y�13 Hyannis,MA 02601 RE: Insulation Permit 18-1933 Un Dear Mr. Florence: t4 Y4dar--S This affidavit is to certify that all work completed for 30 Newspaper Road,Cante*WRe has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements.' Sincerely, William McCluskey .� Town of Barnstable Building 'r^' ^rt���..- _" � "`w� "�,-`* a .1'Y;'��k+ tub.s r r o ,�^ �naxsrwsie PostThis Cartl So That rt is Visible From"the Street Approved Plans Must be Retained on Job anda,this Caxd Must be Kept �' '"" Posted Until Final Inspection Has Been Madero h fl% s +� ernllt s639 �� `Jl Yll ° Where a Certificate of.Occupancy is Required,such Building shall Not be Occupieduntil a.Final Inspection has been:made. . Permit No. B-18-1933 Applicant Name: . William McCluskey Approvals Date Issued: 07/09/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 01/09/2019 Foundation: Location: 30 NEWSPAPER ROAD,HYANNIS Map/Lot: 253-012 001 Zoning District: RC-1 Sheathing: Owner on Record: KAPUSTIN,ALEKSANDR&LARISATRS W: CoritractorMNa e WILLIAM J MCCLUSKEY Framing: 1 Address: 30 NEWSPAPER ROAD Contractor•ELicense CSSL-102776 2 *�` CENTERVILLE, MA 02632 f Est.,Project Cost: $5,000.00 Chimney: Description: Add R-37 cellulose,and R-38 fiberglass to the attic.,'Add R-'10 rigid , Permit Fee: $85.00 insulation to the crawls ace.Air seal the attic lane_and crawls ace Insulation: p p p * FeerPaid $85.00 with expanding foam. General weatherizatio * n Final * Date ', 7/9/2018 Project Review Req: t ' a ` Plumbing/Gas Rough Plumbing: * " Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized byt.is permit is commenced within six'months after_tlssuance. Rough Gas: All work authorized by this permit shall conform to the approved application 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'be in compliance with the local zoning 6i -laws Arid codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or',road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signures by the Building and Fire Officials are provided on this permit. Service: at Minimum of Five Call Inspections Required for All Construction Work: ' 1.Foundation or Footing a r Rough: 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final' 7.Final Inspection before Occupancy Health 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. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site — Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 00 C",J_ S��T TOWN OF BARNSTABLE BUILDING PER�41T APPLICATION I A,04�Map ��� � Parcel �I� � � !�T ,_ � ���� Application # TC� PSUTT Health Division I I Date Issued A Dp REC O Conservation Division 'OI� �� + 0 8 Application Fee Planning Dept., Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 30 NOWSCA-P� 12,0 o Village N �V Owner �� y-),yrV&-t iJ Address 140 mpo�qyV >Vy. Telephone_ C1 17 s89 - S 5 D 2 Permit Request `DQGI/- Moo Square feet: 1 st floor: exi fsting:&0°© proposed 2nd floor: existing proposed Total new d Zoning District ^ 6 Flood Plain Groundwater Overlay N'0 Project Valuation i 0 00 Construction Type_ Lot Size !�71 oo© Grandfathered: ❑Yes ,V No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes A No On Old King's Highway: ❑Yes �V No Basement Type: ❑ Full ❑ Crawl Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil . ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ 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 �fl\lo If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name J-f/tl 6ssg4 g6s (Id G. Telephone Number 7t 1 9U 3700 Address t° m Icko b91l* License # Home Improvement Contractor# Email �oU VI N /(��jsOGl �S `� Worker's Compensation # ALL CONSTRUCTIO BRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �VJ\` Y �✓I�c�'f ' SIGNATURE ATE` , FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT r ASSOCIATION PLAN NO. f __. Massachusetts -Department of Public Safety Board of.Building Regulations and Standards Construction Supervisor l.&2 Family License: CSFA-066976 } PETER J WHITE,- r. _ 17.Englewood,RoaCd. WINCHESTER'NZA•0ji)� , - � � Expiration. Commissioner . 11110/2015. I F Restricted-One-,and two-famil_ dweHings:or any fi accessory,building thereto, irrespective of,-size. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license: For UPS Licensing information visit: www.Mass.Gov/DPS kAF ` r ensee Details ra uemo hic. Information g p Full Name: PETER J-WHITE Gender: Oycer Name: LicenseAaaress inTormation Address: Address 2: City: Winchester State: MA Zipcode: 01890 o nt : United St e-s icense inTormation License No: CSFA-066976 License Type: Construction Supervisor 1 & 2 Family . Profession: Building Date of Last 11/9/2015 Licenses Renewal: Issue Date: Expiration Date: 11/10/2017 License Status: Active Today's Date: 4/7/2016 Secondary License: Doing Business s: Status Change: License Renewal rerequisi ,e inTormatio.n No Prerequisite Information �sci p u ne No Discipline Information ocumen um �;Close;lNmtlow� ' © 2011 Commonwealth of Massachusetts Site Policies Contact Us Y3 ,v, ,5 ,� :. i e+}✓ i { - ?S1y �3 f--�i°t. }Fv# i s k t Y f d 5 91te =� Office of Consumer,Affairs and Ifusiness Regulation . 10 Park Plaza - Suite 5170 Bost- h, Massach- setts 02116 Home Improvement Q�tr. for Registration Registration: 152958 �}� ���•— � , Type: Private Corporation Expiration: 10/18/2016 Tr# 259855. ZEN ASSOCIATES, INC. PETER WHITE 10 MICRO DRIVES WOBURN, MA 01801 - f Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card DPS-CA1 c'3 50M-04/04-G101216 3 Tie License or registration valid for individul use only Office of Consumer Affairs&Business Regulation g y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ,P, 52958 Type Office of Consumer Affairs and Business Regulation ` 10 Park Plaza-Suite 5170 Expiration 10/42016 Private Corporation Boston,MA 02116 ZE ASSOCIATEfS>lla0 s . 31 - PETER WHITE 1 - 10 MICRO DRIVE g WOBURN, MA 01801 Undersecretary Not valid without signature ?7ze Comut'onivealth of- assachusetts ; De artarrerit crf Industrial Accide►its Offike Of rmwsdgutiens ` 600 Wadrington S6wet . _ Boston,MA 02111 u�v�nia mgosv/dia Mrarlmrs' Campensa# an Insurance Affidavit:BcdlderslContraartarsMecfricians(Plumbers Applicant Infwrmatian Please Print EezibIV affie a mod) Address to��O Citylstatel 'IN �RIV Ib.(�o l Phone Are you an employer?Checkthe appropriate bom T of project r Yl� F 7 { equire4= L Nrl am a employer-with _ 4 ❑I am agenmml contractor and I 6- M-New construction employees(full andlor part-time)-* Dave lured the suibr contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet 2- ❑Remodeling ship and have no employees. . These sub-contractors have g- ❑Demolition . w°ri` a far me in a capacity. employees and h nee wo&ers' ' �Cap3c t3` 9. ❑Building addition ' [No n,-orbers'comp.insurance w camp-Tn rano-0 regnued-] 5. ❑ We are a rorpoxation and its 10:❑Electoral repairs or additions ' 3.❑ I am a homeoumer doing all work officers have exercised their 1 L❑P'lumbingrepairs or additions my-self[N8 worlce,camp: right of exemption per MGL 12-❑Roafrepairs insurance required.]i c.152,§1(4�and we have no employees.(No workers' 13.❑Other. comp mmxance required-] *AmyzWicav2AsrcbeclaboxF1—stalsmMa9thesectioabeTowshmingiheanrorkexs'compeasatioupaLcyinfbnnx—d _ . I ffaamemnemviho submit dlzis afbdatff bulkrating they are doing allwal and tfimbire outddecontmammmst=omit anew affidavk i-d'�such. fCa=mctors that rhea this bad[must attached an additional sheet shovrfag the name of the sub-camtmwlDm and state whether.ornot tlmse ewes have employees.Ifthemb-comt®ctom have employees,theymosrpxwide iheu workeze tamp.policy aumber. lain an eitfplqiertliatispr4nidingitorkers"conqmzsaoninmiratzcefornzyciriplojees. Below is diepolicy Md jab site inf ornzadam Insurance company Name: kbeE Policy,p*or Self-ins.Lic.4: 0Q X=(__L_Y6 RkpiEa4iaa Date: Job Site Addres . NU`47 pf`f'� I�� b � ciiplstawzl p: Attach a copy of the workers'compensationpolicyr declaration page(showing the policy number and expiration.date). Failure to secure coverage as req*ed under Section 25A of MGL r 15 can lead to the imposition of criminal penalties of a fine up to$1,50a BOO andror one-year imprsso—mot as well as civil peualties.in the form of a STOP WORK ORDERand a fine of up to$25QOt7 a day agaimst the violator. Be adcdsed that a copy of this statement maybe forwarded to the Office of Iiavestigations o for imsuumce caves verif=iom I do Here rr a pains d pen s ta€ws prini&d abmv fs bare and correct Si Date: elf I� Phone i �7 t3fj"aciaL use surly. Da rasa writs in tk�area,tax be crrrnpFettad b}city artntrn Q,�rciat , City or Town: PermitMicease 4 Issuing Aa1ho,ritp(ca cIe one) 1.Board of Realth 1 BuilTing Department 3.cityirown Clerk 4.Electrical Inspector S.Plambmg Inspector x 6.Other Contact Person: Phone#: r. •- , Information and Instructions M2 sarj set is Creheaal Laws chapter 152 recu=all employers b provide workers'compensation for their empIoyees- pm suant to this s(datc-,an ploy=is defined as."-.every person in ffie service of another under any contract oflbire, express or implied oral or written_" An MT10yer is deemed as"an individual,partnership,associaton,corporation or other legal aatiiy,or any two or more e: and inc e ifves of a deceased employer,or the of the foregoing engaged is a joint eateapns , Turing the lega l represeata receiver or trustee of an inrTividnal,partnership,association or other Iegal entity,employing employees. However the owner of a dwelling house having not more than tree apar[m=±s and who resides therein,or the 0=4=t of the - dwelling house of another who employs persons to do maitnamm,construction or repair WD&on such dwelFmg house or on the grounds or buLVhg appar�therein shall not became of such employment be deemed to be an employer." MOL chapter 152,§25C(6)also states that"every stain or IocaI Iicensin agency shall withhold the issuance or renewal of a Hcaa a or permit to operate a business or to construct bmddh igs in the commonwealth for any applicantwho has not produced acceptable evidence of cdmpfiance with the insurance coverage required-" Additionally,MC Z chapter 152,§25C( sates'Neither,the,commonwealhnor yofitspo litical subdivisions shall _ mtz into any contract for the perfonnauce ofpublic wow until acceptable evidence of compliance vrith the iomn-ance._ requirements of this chapter have been presented to the contracting anthoxity." Applicants , Please hII out the workers'compensation affidavit completely,by chec�the boxes that apply to your situation and,if necessary,supply sub-contractors)nam(-,(s), addresses)and phone nurnber(s)along with their certificates)of mmz=ce. Limited Liability Companies(LLC)or Lmnted Liability Pmtaciships(LLP)withno employees other than the, members or partners,are not regtmed to cant'workers' compensation insman�ce If an LLC'or LLP does have employees, a policy is rega�¢r'd. Be advised that this affidavit maybe cubmi�d to the Department of Industrial Accidents for confirmation of insurance coverage- Also be sure to sign and date the affidavit The affidavit should be ret:r med to city or town that the application for tie permit or license is being requested,not the Department of En-Anstial Accidents. Should you have any questions regarding the law or if you am required to obtain a workers' comp=sa ion policy,please call tiie Department at the number listed below. Self-insured companies should eaL r their self-i soraTce license number an the appropriate line. City or Town Officials t Please be sure that the affidavit is complete and pruded legiilly- The Department has provided a space at the bottom of the affidavit for you to fll out in the event the Office,of Investigations has to co 3 3tact you regarding the applicant Please be sure to fill in the peu�itlliceme number which wM be used as a reference mmmber. In addition,an applicant that must submit multiple pexmWIicensa applications in any given year,need only submit one affidavit indicating current policy inlfbrnation(if necessary)and under"Job Site Address"tie applicant should write"all locations in (chy 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 fume 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 venfine (fie. a dog license or pemut to bum leaves etc.)said person is NOT requited to complete this affidavit The Office of Investigations would like,to thank you is advance for your cooperation and should you have any questions, please do not heshate to give us a call The Deparimenf's address,telephone and fax number. -Thy Ca Wwjtb�of Massachuae , D(-, r =±of Iact-€ tdal Accidents Boston,MA EMI II Tf,-L#617-'27-4900 cxt 4€6 or I-M M A SSAFE Fax E17`27 7M Revised4-24-oT umaz-g-avIdia I � T Town. of Barnstable �. Regulatory Services - E A•�_•, ` ` Richard V.Scar,Director NAM �. � r Budding Division Tomrerry,BuHaIDg Commissioner 200 Mam Street,Hyaonds,MA 02501 WwW to barnsPable-ma_us Office: 508-9624038 F= 508-790-6230 Property Owner Must Complete and Sign This Section If Us Wg A Builder AWlS A ry% " �rt)h ,as Owner of the subject property heJM-byattliOEW 1 ,�20(A ftM 11TVG • to act on raybehalf is aI1 matters x0afim to work authorized bythis bml�p=it appEcation for. (Address of Job) '``Pool fences and alarms are`the responsI ity of the applicant Pools are not to be filled or ufflized before fence is installed and all final " inspections-are perfo=.ed and.accepted. S;g*p of Signature of Applicant 2 Y1W- IIV s ' Print Name PZiI3T Dame F QFoRIs. oats Town of Rarnstable Regulatory Service r � Richard V.Smr6 Director , BuffabW Division t M.EM Tam Perry-.B�mg CDMM=Z ner • Qo :e3g- �a�` 200 Main&met Hyamik MA 02601 pry wwwtowmba„-"mF US Office: 508-962-4038 - Fa= 508-790-MO ' - �a0n�ow�Lma�s��oN JOB L0CA7T0bZ ' �a s aamc ham phanc# xvcucpZionC# CURRENT MAILUM ADDRESS_ - --- ./tea - staff zip Code The r-*. =t exemption for`homeownCM"was mdmule d to mc:141 dweIImxs of six mlits or Ims and in allow homeoWners to cagage an individual for hirewho does notpossess a Hcensc,m ovided tbatffic o}vner acts as saoervisor_ DSFIl�If ORHOIIFOwbTR� P erson(s)who omens a parcel of laud on which helshe resides ar int &to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached stuct=accessory to such use and/or farm st?at=:c_ A person who constmcts n=m thaw one hnme is a two-yearperiod shall natbe consid=z i ahamc wzm 5imh=homeowner",&ball sabmitto f$e BmIUng Official on a form amrptable in the Bu Zdmg Of EmK that helsbe E ian be responsible for all sash work geed Qnderthe bur7dmr P (Section 109.L1) The tmdesigned`.homeowner"assumes responsibly for c®apHm=wil3ithe Sfair Big Code and ova applicable codes, aIId r mgmistions bylaws,rules d, nbe undcuigned`horoeownee cedifies thatbe/she tmdrrst mds f3ie Town ofBmnstable Bm dmg De2mfta ot,--nm inspv-t m. prooednzes and r0gasem=nts andthat bdShe WM COMPly whk said pm=±=and requinemem±s. Sigm3tnmofH=7/72:, Appmv l _ doing Ofdal • Note: 'Ib=-hmffy dwellings containing 35,000 cubic f=t.or lnm willbe rerparedto comply withthe Slate Bmlri% Code Seddon W.0 ConssEratfion Control aDNMDVMMIS EXnnrTmN The Code states that: `Any hmmeowner perfarmiag worm fnr which a bnii permit is required shall be exempt from the provisions of this secfl=(Section I09_I.1-Licm si g of consirarlion visors);provided f3iat if file homeowner engages a person(;)for hire to do such'Mork,that such Homeowner shall act as sap etvisar." Many homeowners who use fins exemption are uaaware.'&at they are gw=-g fe responsiby-EN of a Sx pervisor (sea Appendbc Q,P-nles&A egafmns for Licensing Constracfian SIIpetdsors,Seifinn Z 15) This Lark of a M=eSs of ra results in sedDus problems,par6cularlywhea ffie homeowner hires mffic=sed persons. In fh's case,our Board cannot proceed against the unlicensed person as it would with a liceased Supervisor_ The homeowner acting as Sapermor is uifimately respo=-ble: To easm e'rat the homeowner is fIIIIy aware of his/her imgmsffiM z'es,many eommmuffes require,a;part of the permit appIit- [ian,that tTie homeowner crx[ifp f=thelshe undersbmds tle respons�sTiii'es of aSupervisor. On The Iastpage of f Lb issue is a form currently tzed by seYeral towns. You may rare t amejad and adopt sack a fo rmlcrsfification for mein your comsanaitp. Revised 0613 I3 . Aco CERTIFICATE OF LIABILITY INSURANCE 3A22M2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACTMary Donovan NAME: Eastern Insurance Group LLC PHONE IAIC.No.Ertl, IC No:781-261-2099 77 Accord Park Drive E-MAIL ADDRESS:mdonovan@easterninsurance.com Unit 131 INSURER(S)AFFORDING COVERAGE NAIC# Norwell MA 02061 INSURERA:Selective Insurance Co of SC 19259 INSURED INSURER B NorGuard 31470 ZEN Associates Inc INSURERC: 10 Micro Drive INSURER D: INSURER E: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER:2016 Master. REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AD S R POLICY NUMBER MM/DPOLICY/YYYY MM DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE T RENTED PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE a OCCUR S 2010966 /1/2016 /1/2017 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT AP PLIES PER: -PRODUCTS-COMP/OP AGG $ 3,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT Ea accident - - 1• OOO 000 A ANY AUTO ,. BODILY INJURY(Per person) $ . ALL OWNED X SCHEDULED A, 9095381 /1/2016 /1/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Peraeoident Uninsured motorist property $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DIED RETENTION$ S2010966 /1/2016 /1/2017 $ B WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N N/A _. (Mandatory In NH) EWC604673 7/2/2016 /2/2017 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A Leased Rented Equipment S 2010966 /1/2016 /1/2017 $150,000/$500 Ded DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE -DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Information Purposes Only AUTHORIZED REPRESENTATIVE John I<oegel/RA1 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INs025 r9mnnFilM Tho Arr1Rr1 nzmo nnrl Innn nro roniefororl m2rlre of Ar non , l BERKSHIRE HATHAWAY worker's Compensation and Employer's Liability Policy GUARDCOMPANIES NorGUARD Insurance Company - A Stock Company Policy Number ZEWC604673 Renewal of ZEWC50393C NCCI No. [25844] Policy Information Page [1]Named Insured and Mailing Address Agency Zen Associates Inc EASTERN INSURANCE GROUP 10 Micro Dr 233 West Central Street Woburn, MA 01801 - Natick, MA 01760 Agency Code: MAEAIN10 Federal Employer's ID 04-2728163 Insured is Corporation Risk ID Number 9115.11983 Locations on Policy (1-2) 2321 Distribution Circle , Silver Spring, MD 20901-1261 (07/02/2015 07/02/2016) (1-3) 6402 Waterway Drive, Falls Church,'-VA 22040 - (07/02/2015 - 07/02/2016): [2] Policy Period From July 2, 2015 to July 2, 2016, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers'.Compensation Insurance -:Part One.of this policy applies to the Workers' Compensation. Law of the following states: District of Columbia;Massachusetts,Maryland,New.Hampshire,New York,Virginia B. Employer's.Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $100,000 Bodily Injury by Disease = each employee $100,000 Bodily Injury by Disease- policy limit $500,000 C. Other States Insurance - Part Three of this policy applies.to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications,:Rates, and Rating Plans. All required information is subject to verification and change by audit. .(Continued on another page) Total Estimated Policy Premium Total Surcharges/Assessments $ i Total Estimated Cost - INTERNAL USE xx Information Page - MGA :ZEWC604673 WC 000001A Date : 07/01/2015 MANOTE Issuing Office:P.O. Box A-H, 16 S. River Street, Wh .-A 18703-0020 9 www.guard.com Town:of Ba'fistab o*Permit le Permit �.� Expires 6 months from issue date Regulatory Services Fee iARN6GIS i MASS 639 ,A,b� Thomas F.Geiler,Director BujIahng'DivW6n Tom Perry,CBO,�Building Commissioner 200 Main Stree 'H y ,MA 02601 wwwaown.barnstable.ma.us �. ". . Office: 508-862-4038 Fax: 508-790=6230 EXPRESS PERMIT APPLICATION ='.RESIDENTIAL ONLY Not Valid without Red X-Preis Imprint- Map/parcel Number o��j�j l Property Address 61 �(/ _ E�JS �lAc� �i9 �l/S= Residential Value of Work 306 e Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address Contractor's Name, - Telephone Number Cz% , � �a�C d Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) CS 'v f,f '^ EAMIT ❑Workman s Compensation Insurance Check one: 2 2�12 ❑ Lam a sole proprietor SEP ❑ I am the Homeowner = I have Worker's Compensation Insurance TABU Insurance Company NameE z . TOWN OF BARNS Workman's Comp.Policy# Copy.of Insurance Compliance Certificate must accompany each permit Permit Request(check box)• ❑ Re-roof(hurricane nailed)(stripping old shingles).All construction debris will betake- n to Re-roof(hurricane nailed)'(not stripping;Gomg'over existiug'layers of roof) R El Re-side' s f g s#of doors± ` Replacement Vmdows/doors/shders.U-Value ofwmdows { - .s❑ Smoke/Carbon Monoxide detectors 4 floor,plans marked with red`Sand .inspections required n'; Separate Electrical&Fire Pernnits required *Where required: Issuance oftivs permi.dccs not.exem cam hance P = ether town department regulations;i.e.Historic,Conservation,etc. +**plfl e Pro Owner must 'gn Property Owner_Letter oaf Pe mission t A copy o t}ie$Dine Im ovement Contra ors.License&`C coon Supe i Licen use E uire SIGI'�ATURE: �' 5? ):\Wpm RRllR C\ P f The Commonwealth:of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,,AM 02111 •�•`' www.mass.gov/dia ; Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /�yyJJ � Please Print Legibly Name(Business/Organization/Individual): .Cb 6t�/10oZ //i/VA, ' C ZA ' Address: k City/State/Zip: t/,1 Q�2NSY: A4 oda Phone dDy- Are you an employer?Check the appropriate box: Type of project(required):. 1. I am a e to er.with 4. I am a general contractor and I mP Y 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. Q Remodeling ship and have no employees These sub contractors have g. Demolition working for me in any capacity. employees and have workers' 9 Building addition o workers ' comp.insurance comp.insurance.$ required.] S. E] We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per.MGL 12.❑Roof repairs insurance required.]t . c. 152, §1(4),and we have no employees. [No workers' 13.Al Other4)lvbcw /J A6t_C- UW, - comp.insurance required.] . "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inf ormation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such: $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 0'009s-0 104 Expiration Date; Job Site Address: 30A1,wrAAAEY&" b City/State/Zip: Ay/1Jya Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required.under Section 25A of MGL c. 152 can lead to the.imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA foi insurance coverage verification. I do her certi under at s and penalties of perjury that the information provided above is true and correct Si a Date: 10�s '40, Phone#: 5722f Ad&— p?4 f Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or'written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,.association or other legal entity,employing employees. However the owner of a dwelling house having not more than 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-anti!acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call.the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant'should write"all-locations in__(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 Industrial Accidonts - Office of Investigations 600 Washington Street Boston„ MA 02111 Tel.##617--727-4900 ext 406 or I=877-NIASSAFE i Revised 11-22-06 Fax 4 617-727-7749 www.mass.gov/dia Client#:22235 2LEDGEWOODMA ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYl� 09/(MMIDD 2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling 8r O'Neil PHONE 508 775-1620 FAX A/C No Ext: MC,No): 5087781218 Insurance Agency E-MAIL ADDRESS: 973 lyannough Rd., PO Box 1990 INSURERS)AFFORDING COVERAGE NAICf1 Hyannis,MA 02601 INSURER A:National Grange Mutual Insuranc INSURED INSURER B:Associated Employers Insurance Ledgewood Manor Corp. INSURER C P.0.Box 617 INSURER D: West Barnstable,MA 02668 INSURER E: i INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD A GENERAL LIABILITY MPF7998P 0811512012 08/15/2013 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occuence $500 000 CLAIMS-MADE Ex�OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 JECT POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIF $ AB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WC5008501012012 8/18/2012 08/18/201 X WC STATUIMI- OTH- AND EMPLOYERS'LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 000 OFFICERIMEMBER EXCLUDED? F N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500:000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) David Thomas is excluded from the workers compensation policy. RE: 1248 Cragiville Beach Road,Centerville,MA Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S100416/M100415 LS1 °FTHE t Town of Barnstable ti Regulatory Services y MASS.IE�, Thomas F.Geiler,Director i ,19 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 wwwtown.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 l as Owner of the prop subject l p p e rtY . . hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit: 0 M6"151 413ex A(14;('1V1S (Address of Job).. **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of OWL Signature of Applicant" Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS 6/2012 �tKE Tay. Town, of Barnstable Regulatory Services snaxsrMLF. : Thomas F.Geiler,Director tAss. 9�A 1639• ,�� Building Division . rED MA't A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 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 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 minimurn 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 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 form/certification for use in your community. Q:forms:homeexempt i 9 Massachusetts-Department of Public Safety- - Board of Building Regulations and Standards Construction Supemisur - License: CS-001715 `��44 f t:S !J� RICHARD C TW6W4S� 1248 CRAIGVII.LE BEA rRD CE1MRVILLE MA d02632b Commissioner Expiration 12111/2013 � CJ/ee �pa�c�cea�cufeul��a�vc�ci[JJ«c�uJe��. . ^.N _ � _M1L •�----.� � _�-. _:_—...,_��..�n.�_: � Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: ,1D2026 Type: I Office of Consumer Affairs and Business Regulation Expiration 6130/2014 Private Corporatir t 10 Park Plaza-Suite 5170. r Boston MA 02116 LEDGEWOOD MANOR CORP } DAVID THOMAS 238 OLD COUNTY RDA ti. n E.SANDWICH,MA 02537--" Oudersecretary ; Not valid without signature {1 Town of Barnstable Approved - Regulatory Services Fee Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 _ Z 7 o 3 Home Occupation Registration Date: S Name: c wcc�S v Phone#: 1 3 /ve,�,v Village d�,i1.it�t5 Address 0 s s' r�r �- Name of Business: Type of Business: (M yS c C, Map/Lot: Z S 3 Q Z 00/ oning Districts RF and RC-1 require Special Permit from Zoning Board of Appeals. Zoning Distlic-Z INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the 'r activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to,the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following con tions: t/rhe activity is carried on by permanent resident of a single family residential dwelling unit,located thin that dwelling unit. uch use occupies no more than 400 square feet of space. There are no external alterations to the dwelling which are not customary in residential building's,and there s no outside evidence of such use. o traffic will be generated in excess of normal residential volumes. The use does not involve the production of offensive noise,vibration,smoke,dust or other particular /matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. .�f There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities., y need for parking generated by such use shall be met on the same lot containing the Customary.Home, Occupation,and not within the required front yard. ere is no exterior storage.or display of materials or equipment. There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to e eed 4 tires,parked on the same lot containing the Customary Home Occupation. o sign shall be displayed indicating the Customary Home Occupation. s If the Custo me'Occupation is-listed or advertised as a business,the`street address shall not be: �- uded.�1 � v o person shall,be employed m the Customa ome Occupation who'is not a permanent resident of the ' dwelling unit i ed have read and agree with the above restrictions for my home occupation I am registering.° e undersigned, g I the � . n P , `'�. Applicant. Date: z Ua3 r�. ¢ Homeoc.doc : A'i /1414. v1� TO ALL N W BUSINESS OWNERS DATE: -5- -L2 03 - Fill in please: APPLICANT'S r 'r YOUR NAME: BUSINESS YOUR HOME ADDRESS:_ 3o .Ne.wsPc4�r- 2� TELEPHONE - -Telephone Number Home s o%- 7,ro 35 �� NAME OF NEW BUSINESS elc ,I ke—co-r S TYPE OF BUSINESS �tus.'C cc) IS THIS A HOME OCCUPATION';� _YES NOv Have you been given approval from the building division? YES NO = ADDRESS OF BUSINESS ZO t (zd. MAPIPARCEL NUMBER , �- J.� Lo�!l When starting a new business there are sev rat things you must de in order to be in compliance with the r:.r;es and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained 'he required signatures, listed below, you may apply for a business certificate at the Town Clerk's Office (Ist floor - To�•,m Hall) or if you get the business certificate first you MUST go to the following office to make sure yo- have 7_:: the required permits and licc�s�s., GO TO 200 Main St. — (corner.of Yarmouth Rd. & Main Street) and you will find the following offices: 1. BUILDING COMMISSIONER'S FICE This individual has bee rmed f ny permit requirements that pertain to this type of business. A. rize Signature** COMMENTS: 2: BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** . COMMENTS: 3. CO'NSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informer: of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Business certificates (cost $20.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. - It does not give you permission to operate - you must get that throu�;'i completion of the processes from the various departments involved. "SIGNIFIES APPROVAL FOR A BUSINESS CERTIFICATE ONLY. , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 15 Parcel 017_- 00 -Permit# 78 90 7 Health Division N 11AL,4 L-1 -3°!v Date Issued Conservation Division 1l lam- . Application Fee �60 Tax Collector Permit Fee Treasurer EXISM SBM SYSTEM Planning Dept. UMMWTIO.#0F9WR00MS Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 30 /VUO6100,Eer [%!K_ E Village Owner IRot�erf ctd. k)CL Address 36 Ntws, aper Telephone �t�Sr 77� uft7a® Permit Request •- len��hq aw rco&% ivy ay di�fkq I X21 a-arnae cif con s-11 u S . I� sY2l � a Square feet: 1 st floor: existing proposed ' ® 2nd floor: existing proposed ® Total new-0 Zoning District Flood Plain Groundwater Overlay Project Valuation # 51,-00 Construction Type I ep"oc e Lot Size cr'cre- Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family a Two Family ❑ Multi-Family(#units) Age of Existing Structure ra.Historic House: ❑Yes 2Mo On Old King's Highway: ❑Yes QJ-Wo Basement Type: ❑Full Crawl X Walkout ❑Other Basement Finished Area(sq.ft.) 700 Basement Unfinished Area(sq.ft) � Number of Baths: Full: existing -3 new / Half: existing ® ' new A ' Number of Bedrooms: existing new 0 e Total Room Count(not including baths): existing /® new O First Floor Room Count = � cap Heat Type and Fuel: ®Gas ❑Oil X Electric ❑Other o Central Air: ❑Yes Qi No Fireplaces: Existing 1 New Existing woo /coal stove: Yes ❑No w . Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn ❑existin*g ❑d9w size Attached garage:04 existing ❑new size Z� Shed: ❑existing ❑new size Oth r: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes S No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name � (Vando" /Telephone Number Address 30 -eev l J License# �l�_ wellp 1�)26 3 2— Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3c> d r FOR OFFICIAL USE ONLY f , PERMIT NO. DATE ISSUED MAP%PARCEL NO. , ADDRESS VILLAGE OWNER .T ` DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE r ELECTRICAL: ROUGH .FINAL PLUMBING: ROUGHFINAL +' GAS: ROU I.- FINAL . FINAL BUILDING co Ir ` DATE CLOSED OUT ASSOCIATION PLAN NOw t _ The Commonwealth of Massachusetts Department of Industrial Accidents 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit-General Businesses i / i address: ��{� y �^ Vity��GU l t�°J�[n state: la"� zip' 02,1 G- phone# work site location(full address): ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Restaurant/Bar/Eating Establishment working in any capacity. ❑Office❑ Sales(including Real Estate,Autos etc.) ❑I am an em loyer with n//ff�emp oyees(full& art time) Ither i�% %///j////////jjjjjjjjjj/�//%j�jj/j//////j/j%j/j%jjj%j [S I am an employer providing workers'compensation for my employees working on this job. company name: address: ..:. city phone#:`. insurance.cot oli'c # ///// / / / / / / ------- I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: company name: address C1tV:. 77777777 insurance co. olic` # i /// /. .. / .. / address city::. phone#: insurance so. "olicv#: ' Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DU for coverage verification. ` I do hereby i nde a pai and penalties of perjury that the information provided above is true nd co recta Signature `Date Print name O Dt r-� `4)et Phone# -?—Z r J y--26 p.official use only do not write in this area to be completed by city or town official cityermittlicense# or town: p []Building Department ❑ Board check if immediate response is required ❑Selectmen's Office E ❑Health Department contact person: phone#; ❑Other (mdsed Sept 2003) - Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 section 25 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,neither the corrnrionwealth 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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pernni0icense number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any 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 BMW of Inllesdgwons 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 is oF 'Es. Town, of Barnstable Regulatory Services Thomas F.Geiler,Director ss q, 0.19• Building Division AIFD MPt k Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862•4038 Permit no. Date AFMAVIT HOME ZIPROvEMMNT CONTRACTOR LAW SUppLEMENT TO PERMIT APPLICATION MGL c.142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, -improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. I L Type of Work c� � ti f Estimated C ¢{ osf' ��;Lo yP — t( , Address of Work: .3D !V Sv` " Owner's Name: �'� JGc)Corrt.CV`�I - Date of Application: 26 I hereby certffY that: Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 []Building not owner-occupied [Owner pulling own permit Notice i$hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMTROVEMENT WORKDO NOT HAVE ACCESS TO TEE ARBITRATION PRO GRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Contractor Name Registration No. Date Date Owner's Name nC c:MV.Ate! . Tabte.IiZ,1b(noatiAued? gated trttb 1<o�1I F'ue1� prrsarlptrYe Fsekxgcs far daa sad Tyra-i+tm�S'tldeatiil Hnildialp hffNiMViK Slab 'gcaiing/Caaling UM cas c`cn • AXfM Buera mt FJF� �M ' Ceiling wt111 Hoar upsn Arm'('h) 11 valuas R.value R-Vaduz-{ R-vslcse! R � A yal", �. pac�sgC 31tl1 to 85tl0 Pirating Degm 17;�' 6 blannal 38 13 19 10 6 Nanaal o.40 I9 i9 10 6 15 AFUF. 30 0.52+ 13 ig 10 WA Namsal 12y. 0.50 33 N1A a .� 15+/. 03fi.. 19 19 15a M 15+/: 0.44 38 l0 U 3 a 13 25 NIA 6A 15 AFUE Y 15%+ 0.44 19 19 10 Normal 15+/4 042 30 15 N/A TI/A 18y. 032, 31 13 N/A Nomtal 38 X 0.42 19 2s NIA 6 90 AF LIE Y 1 % 0.42 3i 13 19 10 18 6 90•AF� 18'/. x 30 19 19 I0 0.s0. 1,A • 1� ADDRESS OF PROPERTY: ALLS: • •� 2. SQUARE FOOTAGE OF ALL EXTERIOR W _ 3. SQUARE FOOTAGE OP ALL GLAZING: 4, 1/6GLAZING AREA(#3 DIVMED BY 02): 5 SDLECT PACKAGE(Q--AA'' See Chart aboYo):STRODS OF � O'I RMORE INVOLVED ORTHIS INFORMA List G ORGY REQUffZEMENTS Na'�� ARE AVAILABLI ASS US ` ,BUILDING INSPECTOR APPROVAL. N0; YES. q-facrns-flS0303a r RESIDENTIAL BUILDING PERMT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations �� Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable) AI,TERATIONS/RENOVATIONS OF EXISTING SPACE � - '72- /zzs% Rio 50 3? square feet x$64/sq.foot= plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30,00= (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee projcost 1 , J FILE W MIP 28225 CENSUS TRACT# 128 CLIENT: DUNNING& KIRRANE, L.L.P. DEED BOOK 11390 PAGE 155 OWNER:- RL J. & MARGO PISACANOLAN B?50K 231 - PAGE 17 LOT APPLICANT: ROBERT A. &PRISCILLA S. SWANSON ASSESSORS PLAN 253 PLOT 001 M O R T G A G E I N S P E C T I O N P L A N O F L A N .LOCATED AT 30 NEWSPAPER ROAD BARNSTABLE, MASSACHUSETTS SCALE: V=40' SHALLOW P©ND October 24, 2002 94' ± ► 49± I \ 1 Q i Z Il SToR'( FO 1/L 3 PO RCN O 112.73 o L0T X, ` 84 84' NEWS PAPER 45 C ROAD 1 I CERTIFY TO: DUNNING & KIRRANE, L.L.P., MORTGAGE CORP OF THE EAST III, AND ITS TITLE INSURANCE COMPANY,THAT THERE ARE NO VISIBLE ENCROACHMENTS OR EASEMENTS EXCEPT A SHOWN AND THAT THIS PLAN WAS PREPARED UNDER MY IMMEDIATE SUPERVISION. THE LOCATION OF THE DWELLING AS SHOWN HEREON IS IN COMPLIANCE WITH THE LOCAL APPLICABLE ZONING BY-LAWS WITH RESPECT TO HORIZONTAL a DIMENSIONAL REQUIREMENTS. THE DWELLING SHOWN HERE DOES NOT FALL WITHIN ;.q� N '/'I U, / A SPECIAL FLOOD HAZARD ZONE AS DELINEATED ON A 'r1,:.G!_ �F.::; �• MAP OF COMMUNITY#250001-0005C DATED 8/19/85 BY THE v' F.I.A. Kenneth R. Ferreira Engineering, Inc. P.O. Box 1903 S New Bedford, MA 02741- ��, 1903 508-992-0020 Fax: 992-3374 ENERAL NOTES:(1)The declarations made above are on the basis of my knowledge,information,and belief as the result of a morigage'plot plan tape survey rispection Houle to the normal standard of care of registered land surveyors practicing in Massachusetts. (2)Declarations are made to the above named client only as of this date. 3)1'his plan was not made for recording purposes,for use in preparing deed descriptions or for constructions. (4)Verifications of property line dimensions,building offsets, noes,or lot configuration may be accomplished only by an accurate instrument survey. oFtt�,� Town of Barnstable Regulatory Services r a w BARNgrimp. : Thomas F.Geiler,Director 039. p.0� Building Division lED W1A't Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 ------------ HOMEOWNER LICENSE EXEMPTION bo Please Print DATE: - 3d / JOB LOCATION: W /G CeLt number street village "HOMEOWNER': ✓x �2 e ctjl�/_v1 name / home phone# work phone# CURRENT MAILING ADDRESS: �/6�' !�[ 2�p�,( QcrQ2� RQ A`�1Lr(e 9,14- / . city/town state 6 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 it nt . 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 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed 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. Q:forms:homeexempt ypi TM E Tp�t TOWN OF BARNSTABLE 00 no Z sesasresc 6 q. MASSACHUSETTS V �CMAY�� mob` Solid Fuel Stove Permit vy DATE OF APPLICATION ....................kD,.. .,/5...-...9....1'........ EI T. ISSUING PERMIT ............................................................ AME (owne ) ..... .... c� S �......(...5..1c4.'t' .... NAME (Installer) ........................................:.....................................,...........,........... ADDRESS ...... ............................... ........................... ADDRESS ........ .............,........,...........,................,............................................................. STOVE TYPE ...............4W. ..............'b....................................................... CHIMNEY: NEW ........................ EXISTING ........................ �G G/l?/ G /, e� _.. Manufacturer .................................................................................................................... CHIMNEY: Masonry ...,.................................................................,,.....:................ MMp Mass. A roval l .........�..�..l f...................................... . CHIMNEY: Metal s This is to certify that the above installer has permission to install a solid fuel burning appliance at the listed address in accordance with an application on file with the .........................:......................................................................... Fire Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. IssuedBy: ...... ...................................:....................r.....,e...............................Title .. ..�-....�-�..Z.............`..�'�� ....... Date Permit to install expires 60 days after'issue date } ,� �� Pd Stove ..L................... ...................................!.........................................................................................,...........,......................................................................................... StoveClearance ....................................U..�'"................................................................................................,....,.......................,............................................................................................... Floor ;r Y'c ptf v�- i .......................................... ..................................................................................................................................................................................................................................................... Smoke Pie ........................................:�'f!r! Zt �L SmokePipe Clearance .................... .............................................................................................,...,....,,.....,....,.,........................,...,.............................,..,,............................,..,...... Chimney ............................................./G �/f!fJ� .��.......................................................................................................................,..............,..................,................................................... SmokeDetector ................................ ......................,..................,......................................... ,......................................................... ........ .......,........................................................................ The undersigned hereby certifies that the installation of solid fuel burning stove and equipment, made under au- thority of permit dated ..... .. /.. Co................. has been made in accordance with provisions of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto .................:..................................................... Installer j' i1 INSTALLATION APPROVED .....,�1....�date 14 .............. By- .............�%% ••••••�/ `'�— Title: /41�5 S,y� date / WHITE: FIRE DEPARTMENT — CANARY: BUILDING INSPECTOR — PINK: APPLICANT f 2-31o6 Town of Barnstable *Permit# 72. X-PRESS PERMIT Expires 6 the rom issue date Regulatory Services Fee - C)6 MAR Y O ZOO6 . Thomas F.Geiler,Director TOWN OF BARNSTA13LE Building Division ____.-_, 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 3 l C 1'1 1 A tkResidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 3,p Aj-ex, y Contractor's Name Telephone Number J 0OD 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 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 (y Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side - - ❑ Replacement Windows. U-Value (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. Home Im ement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations ' d 600 Washington Street Boston,MI 02111 o^M SV•Jt www masSgov/dia Workers' Compensation,Insurance Affidavit: Builders/Contractors/Electricians/Plurnbers Applicant Information Please Print Le l<bl Name (Business/orpnization/Individual): a Address: City/State/Zip:.._ Arw A, MA- Phone#: - ire you an employer? Check the-appropriate box:. ❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors 6• ❑ New construction ❑ I am a sole proprietor or partner- listed on the attached sheet 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein an ca aci . workers' comp. insurance o workers' co %g a i on [N mp.insurance 5• We are a corporation and its ,required..] officers have exercised their 10.❑ Electrical repairs or-additions I.am a homeowner doing all work. right of exemption per MGL : M❑ Plumbing repairs or additions "myself. [No workers' comp: c. 152,§1(4),and we have no 12.® Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑ Other oy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' omeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. >ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information man employer that is providing workers'compensation insurance for my employees- Below is the policy and job site ormation. urance Company Name: !icy#or Self-ins.Lic.#: Expiration Date: Site Address: City/State/Zip: :ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a up to$.1,500•.00 and/or one-year imprisonment, as well as civil penalties in.tlie form of a STOP WORK ORDER and a fine .cp to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of estigations of the DIA for insurance coverage verification. hereby certify un " the pains and penalties of perjury that the information provided above is true and correct. nature:k Date: )fJ`icial use only. Do not write in this area,to be completed by city,or town officiaL , �ity or Town: Permit/License# ssuing Authority(circle one): .Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector •. Other 'ontact Person: Phone#: I 1 Information and Instructions F .,. [assachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. nrsuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, cpress or implied,oral or written." ,n employer is defined as:'an individual,partnership,association, corporation or othez legal eantity,or any two or more f the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the ,ceiver or trustee of an individual,partnership, association or other legal entity, employing employees. Howev..er:the wner of a dwelling house having not more than three apartments and who resides therein, or.the occupant of the aintenance, construction or repair work-on such dwelling house welling house of another who employs persons to do m r on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." dGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or •enewal 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." kdditionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall ;rater into any contract for the performance of public work until acceptable evidence of compliance with the insurance -equirements of this chapter have been presented to the contracting authority." 4pplicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if. necessary., supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(I-LP)with no employees other than the members or partners' are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below.. Self-insured companies should enter their self-insurance license number on the appropriate-line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit'license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (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:fixture 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: The Commonwealth of Massachusetts . Department of Industrial.Accidents Office of Investigations r 600 Washingfon$ reet� . Boston,MA 0211 L Tel. #617-727-4900 ext 406 or,1-877-MASSAFE Fax#617-7274749 revised 5-26-05 www.mass.gov/dia V , 'CCII/ n i I i t - ! ., t f �c[�� 1�jli �73Vj� 1. � •1 , I I is t 1 LLIV[j4� 711 T ' T' .T i t - I ; Yl 1 g1 ; I i ! , I i i I 7 f 1 i C` ../ I I I T : •i. i ImpoRTANT ANY CONSTRQCTIO�N THAT INCREASES LIVING SPACE! { a T r 1 i s T BEYOND 1200 SO! FT. PER LEVEL MAY REQUIRE THEE j { INSTALLATION OF ADDITIONAL SMOKE DETECTORS. 1 T I T 1 N OT j ? INSTALLATION• A' 0 8M IS REQUIRED 'FOR:THE! ' 3 p E PERMIT SMOKE DETECTORS THE ELECTRICAL' PERMIT DOES NOT SATISFY THIS REQUIREMENT. } U r _ r � , . " - i - c ,✓ - .i s. 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