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HomeMy WebLinkAbout0216 STRAIGHTWAY ��� s'��iG",f�7Zv�9 Barnstable- *Permit 0p IME T°� Town ®f tbl Cf� Qy �(. s 6 months from issr nle Regulatory Services Ex` e y BARN °B,.E, + - - ik, 6% Thomas K Geiler, Director t6M HIED MPt A /1 Building Division OP S' 0 Tom Perry, CBO, Building Commissioner F�'9 19 200 Main Street, Hyannis, MA 02601 �v� www.town.barnstable.ma.us Office: 508-862-40�4` Fax: 508-790-6230 EXWESS PERMIT APPLICATION - RESIDENTIAL ONLY �} Q Not Valid without Red X-Press Imprint Map/parcel Number Property Address _ (��� A/r kT L ❑ Residential Value of"tVorl. � Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address �IWL A 57c_� j { Contractor's Name Telephone Number I Ionic Improvement Contractor License# (if applicable) Construction Supervisor's License # (if applicable) ❑Worknian's Compensation Insurance Check one: ❑ I am a sole proprietor 'KI 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 ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders. 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. QCo fco f the H a Improvement Contractors License is required. SlG'NATURE:. � ().'Wlll-ll 1:S1P0RMS\bui1ding permit Ibrms\EXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations, 600 Washington Street Boston, M4 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: K UN/ 0 r Phone.#: b fd E7" S� Are you an employer?Ch ck the appropriate box: 'type of pi-ojoct(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part.time).* . have hired the sub-contractors ..2:0 I am a sole proprietor or partder-' listed on the attached sheet. 7. .0 Remodeling ship and have no employees These sub-contractors have 8.'Q Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers-comp.-insurance comp. insurance.# required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees.[No workers' 13.0 Other . comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have erryloyees. If the sub-contractors have mployers,they must provide:their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimifi4 penalties of a finq 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 may be forwarded to the Office of Ines ' for' ranee coverage verification. I. o hereby certify u d pains-andpenalties ofperjury that the information provided above is true and correct Si Date: Phone Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health '2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions r 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 fore om en a in a om en ns -mcl�n`�1ie le re resen�a'hiTe3rSf tieceasezl layer, o�c the=._--.-.- `-'- -- g g" g g, J rP r li; 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 . the performance of public work until acre table evidence of co liance Aith the inpance enter into an contract for, p gP Y P P 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 suh-contiactor(s)name(s),-address(es)and.phone number(s) along with their certificates)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LU)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 appiicant 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 permifs or licenses. A ne*affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (Le.a dog license cr permit to btirn leaves etc.)said person is NOT required to complete this afliidavit. 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 C6mnonwealth of Massachusetts Department of Industrial Accidents Office of lavestigatians 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext-406 or 1-$77-MASSAFE Revised 11-22-06 Fax# 617-727-7749 www.mass.gov/dia The Commonwealth ofMiusachusetts Dgpartment oflndustrial Accidents z . . `Office pf rnvestigadons . 600 Washington Street Boston;MA 021I1' www.massgovldia Workers'Compensatiou 14surance.Affidavit: BnliderslContractore Electiicians(Pi ers' lican Info ation Please Print Le 1 Name(Business/orgatrizatian/7ndividual): ! G v t e G-o.�e� o �' o�- " �;_ Q �' S 'r . ur'ce, �LC • MAZ R M 1 U S •A4A City/State/Zip: PhoneR.-_ ,rb X.-?3(D — a`3 7 0 Are you an employer?Check the appropriate bar. 1.❑I am a employer with 4. [] I am a geaaral coutradm and I :Type of project(required):, ; empleiyeee(flan a u=dlorparWE2#),*. .have Nixed the attib-contrUbma 6. ❑Now construction 2. I am a stole psa�rietar or panto • ' listed on xhe•attaahed sheet: 7. Q Raaodeligg ship endhave ao employees Those sub-cwxaciors'have 8. p Demolition: *od=g for sae in any capacity, a gloyeas and have workers' (No workwo'camp.insurance gip.hiurenco' 9. 0 Budding addition .] 5: 13 ate are a corporation and its 10.[]'Plectdcal repairs os additions I am a homeov aar a'11 work , often have exerofae4 their saroX[No work= 00MR, sight 6f exemption per MGL 1 i.❑ ng repairs or additions 3astaaage segairad.]t o.152,61(41 and we have no 12.[]R Roofoof regatta ®ployees,[No workers' .13.0 Other .insurance rogoirecL] *Any applicant thatcheela box#i must also Sli nut the sectic i below showing theirworkan'compennflon poHayinfimmlim, t Homeownemyho submit this afdavlt iadic*z they are doing all work and than the outside cantmactm mulct subs*anew&Mdavitindicating such: ;Contactors that aback this box must attached in additional-,het showing the name of the sub-contractors sad state whethar mot those entities have anvloyees. If the sub-contaotoms h&,re employees,that'must provide their worken'comp,poldy number. I sun an employer.that'k providing workers'compensation insuranbe for my employees:.Below k the policy and Job site information. Insurance Company Ne)Me: Policy#or Self-ius.Lie,#: , Expiration Date; ,Job Site Address: M1 t:sty state/Zip; Attach a copy of the workers'compensation policy declaration page-(showing the policy number and eViration date), Failure,to secure coverage as required under Section 25A of MGL e. 152 can lead to the inxpositim of criminal penalties of a fee tip to$1,500.00 and/or one-year impriso:omen>q as well as civil MAX"in the foam of a STOP'WORK.ORDER and a fine of up to$250.00 a day against thg violater. Be advised that a copy of fais statement maybe forwarded to t4e•0fr2ce of' Inver ' atiow of the DIA for insur=c covers a verification, ' I do hereby certify der the pains and enalties of perjury that the information prgvided above is true and correct, Si tore: ` am a s. ®el Offlptal use on y. Do not wrtfie In Jhk area,tb be comp et x c +or town offictaL City or Town: PermillLic ense# , Issuing Authority(circle one); a :1.Board of Health 2.Building Department 3,City/Town Clerk 4.Eleitrit al Inspector S.Plumbing.Inspector' .6.Other Contact Person: Phone#: Town of Barnstable �1�T°wti o� Regulatory Services r r snRrts`rwai.e„ ; Thomas F.Geller,Director `� A`�� Building Division lfD MA'I 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: 6 umber strdt villagk "HOMEOWNER' /Y -S'"Ap &ld— 7�C)5 fl e 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. s The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department mN7n tnspe roc es and requirements and that he/she will comply with said procedures and i requiremen, . rgna re o omeowner 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:\WPFILES\FORMS\homeexempt.DOC �TME Town of Barnstable Regulatory Services " B"R'' �' ` Thomas F. Geiler,Director 'OTE1 .796 .�A Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and.Sign This Section If Using A Builder I, AVISC(l6 , as Owner of the subject property herebyauthorize IVomet�euia-<z to act on my behalf, in all matters relative to work authorized by this building permit application for: (Addres(#f Job) Signature Of Owner D to Print ame If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RM S:O W N ERP ERM IS S ION Assessor's office(1st Floor): Assessor's map and lot number ✓ �P� /OL ce- i TM f Conservation Board of Health(3rd floor): Y t Deas�r�ntr Sewage Permit number � rua Engineering Department(3rd floor): - °° 9630 House number �o tlsr`• Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING IRS.PECTOR APPLICATION FOR PERMIT TO S dZJ TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 1� i�- Proposed Use IAJ4 Zoning District Fire District f. Name of Owner / Address &C /�' � /tlA-J�r ✓ � Name of Builder Address Name of Architect Address Number of Rooms Foundation Exterior Roofing t4v 4t7—c 1 firy �u Floors Interior Heating Plumbing Fireplace Approximate Cost 12�16-0 Area Diagram of Lot and Building with Dimensions Fee P OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable re arding the ab a construction. Name Construction Supervisor's License VISCASILI.LLAS7, RAFAEL A. No 3= Permit For RESHINGLE ROOF Single Family Dwelling r 7 Location 216 Straightway f` Hyannis , Owner Rafael A. Viscasillas Type of Construction Frame M Plot Lot Permit Granted June 11 , ar.19' 93 417 Date of Inspection 19� Date Completed -19 - • _ � r rM 1 r_ e /= r^' l 06/07i1993 11:07 FROM Town of Barnstable TO 91602791=127�6 P.02 TOWN OF BARNSTABLL BUILDING DEPARTMENT ` HOMEOWNER LICENSE EXEMPTION 'e'Y Please print. .BATE olv Loc.�,TION 1 S7j-r T4J �� ,` :� , Number St t Addre Sect�on 'Of Town: "HOMEOWNER" 1S IC Co- % 97k dov2 1 ` Name Home Phone Work. Phoae ' .'PRESENT MAILING ADDRESS S APPv� .� - 9S- City/Town State Zip Code The current exemption for "homeowners" was extended to include owner- occupied dwelljUs of six units. or Jess and to allow such homeowners to engage an individual for hire who does not possess a license, ,provided that .1ho .owner acts„ as supervisor. R: DEFINITION OF HOMEOWNER : :.,Verson(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 to .six family„ . .."dwelling, attached or detached structures accessory to such use end%or .farA St�ttCtures. A person who constructs more than one home xn . a two-year: . ::-Period` shall not be considered a homeowner. Such "homeowner" shall" aubzait ::,to the Building Official on a form acceptable to the Building Official, that heLshe shall be ,rgjponsible_for all such work pofoxmed under „the lding Perm (Section 109. 1. 1) ,;The undersigned "homeowner" assumes responsibility for compliance-with the 'State Building Code and other applicable codes, by-laws, rules and ;regulations. , The undersigned "homeowner" certifies that he/she .understands the Town of Barnstable Building,De a minimu inspection procedures and requirements HOMEOWNER'S SIGNATURE . APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be requiredto comply with State Building Code Section 127.0, Construction :Control. 17 . r , g .v[C Town of-Barnstable *Permit M dam Regulator Services 6r' t ,"i Me M&a Thomas F.Geller,Director 2013 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 TOWN!OF BARNSTABLE '- www.town.bamstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY G /1 O O Not VW without Red X-Press Imprint, Map/parcel Number O Property Address a 1 (a S?'RA ► it N r W A y , N YA NN S., M A OoZ!o 01 ®Residential Value of Work D a Minimum fee of$35.00 for work under,S6000.00 Owner's Name 8t Address KAFAGL VALE'KIE . V I ECAS I LLAf 5 WILD IZOSE' 'LMO S,#orZ WOn0, MN SS'33 � Contractor's Name R RUZ ee 06kftw �pt V Telephone Number'50$ 73(o '0370 Home Improvement Contractor License#(if applicable) S 01 (o Construction Supervisor's License#(if applicable) ❑Workmen's Compensation Insurance Check one: I on the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit R uest(check box) Lj Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to 0 Re-roof(hurricane nailed)(not stripping. Going over. existing layers of roof) _ F , KRe-side #of doors ® Replacement Windows/doors/sliders.U-Value,3,0 4 .3 4 (maximum.35)#of windows 3 Smoke/Carbon Monoxide detectors 4 Boor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. t: •Where required: lssuarrce of this permit does not exempt compliance with odor town department regulations,i.e.Historic,Conservation,etc. ., ***Note: Property Owner'must sign Property Owner Letter of Permission; otthe me Improvement Contractors License'&Construction Supervisors License is requi ` SIGNATURE• C:\UsersWwdlikWppDataU=W\Microsoft\Windown\Tcmporary Internet Files\Cmrtent.Outlook\QRE6ZUBMEXPRESS.doc Revised 053012 S f Town of Barnstable 11 Regulatory Services Thomas F.Geller,Director ,,,,;• Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstablema.us Office: 508-862-4038 Fax: 508-796-6230 HOMEOWNER LICENSE EXEMPTION DATE: /a 0 13 Plew Pdst , JOB LOCATION: a/b ST RA 16 H T uj A Y 14 YA NN S number street village "HOMEOWNER~: RAF41=L- V IS(A-S 1Cl/a-3 9Sa-y 7L/ iarne lame plane M work phone# CURRENT MAILING ADDRESS: 2 (,a OS' Wd d R n s e L N SAor-*Lv0 J MM cityRown 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 forth 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. Th igned"ho wrier"certifies'that he/she understands the Town of Barnstable Building Department minimum inspection ores d ments and that he/she will.comply with said procedures and requirements. Signae o omeowner. 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 ihomeowner 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 are t amend and adopt such a form/cerdtication for use In your community. C:\Uwrs\dlecollik\AppDWaU.mW\Micnmft\Wirxkms\Tempontry Internet Files\Content.Oudook\QRE6ZUBNIEXPRESS.doc Revised 053012 r x'" Tie.C�Mlnon t t Qf txssachusetft a ttireew of Inrlirslrial Accidence,�ewar D rce of Inmastrgadons 600 Washrrrgton Sheet } liostr,►,�t,'1�A'.U2.,t1I , � - x , Workers' Compensation Lnsuramce-Atidavit''Badeis/CeAtaa t nMectriciansffluiiibens Auulieant Information Pike Print 1Le�b]ti* _. NaffiB($nSinP niza+on/lrid[trttinaa): U( 0-1 6/Y1 p Sa?t V 1 t PS ' Address. I S 3 LV E 2 6.lec ei-i 02 i v Ci /State/Z p: ^A2 5 Ibr-3 A u-t 5 .. A b z c�,Phone# TO8—7 3.6— 0 3.7 d Are you an employer?Check the appropriate boz.. T of project r. 4- I am a contractor and I }'Ps . P l { squired}: 1.❑ I am a employer with ❑. 6. New oonstrnction . employees(full andfor part-time).* -.'have hired the`sub-contractors 2. I am a sole proprietor or partaer- listed on the attached sheet. . 7. ❑Remodeling and have no employees Tl�sub-contractors have 9. ❑Demolition. F working formee in any capacity.' ' dim and haVe,wodrers',. , [No wort s'comp.insurance comp:m 9. Huiidin addition sursuml required.] , 5 •We area corporation and its 10❑Electrical repairs or additions ' 3.❑ I am a homeowner doin e 11sa . Plumbing a+eprs or additi `. myself[No workers'comp. right of exemption per 1.A+IGL insurance required.]Y c..i'52,§1(4�and we have no 12.0 Reof r epairs „ eugiltiy s. 6Le [No Workers' i$_®t)ther ���ren� comp.insurance required.] 'Any whcant that checks has#1 mast also 8ll curt the section belasn showing the&wo*ets'compenmtion policy=fotamtloa t i Hameamms ivho submit this affidavit in&cating they ate.doiag aU via&and alien]tire outside caatractcrs m m submit a um affidavit nodicatigg such. k=Ictors that chKk this box mast attached an additions.shed showing the name of the sub-conttactais and state urbetlter or nut those eotetees bst� employees. If the sub•counwats have mpi oyms,they roast pmvide their workm'cmnp.policy ntmaber. ; I am ari�/a3�mpioper thrut is pining»rorers'a ottsrrlion usararice for hr.Y employees. $storm is hireb. policy arm f ob.svte tnforrnrttu►u. 3 } Insurance Company Name: Policy#or:Self ins:Lic. x Job Site Address: City/Statelzip: ' Attach a copy of the workers'eompensato©policy dlacation page(showing the policy number and expiration date). Failure to secure cav siege as regriited undue 5edioa 25A of MGL C. 152 can lead to the imposition of criminal penalties of a Fine up to$1,50D.OD and/or one-year impost ument;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 for insurance coverage verificatic.n. I do Hereby recur der thepairrs and penalties ofgerfury that thar, nfotmatian provided above rs bate.and correct Sienature. Date: /3 Phone# :Sa - 7 3 6 03 Apffleiel use only. Do Trot avrttar ill t3ais area,to be ctrmpleteai by city or to m'of c L , City or Torun: Pe rmit7Lreense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrotun Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 9: ' The Commonwealth of Massachusetts viDepartment 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 Name(Business/Organization/Individual): �a(e Address: /( rzu�4 City/State/Zip: M &P 1 S m t U 1 Phone Are you an employer?Check the appropriate box: Type of project(required): 1 1.❑ I am a employer with 4. P�I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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. employees and have workers' [No workers' comp. insurance comp. insurance. t 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g P 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.gL0the &9Ud S S-[diov comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: fl" S—rE41 7-0, ` City/State/Zip: ,0//S ! A61 Attach a copy of the workers' compe ation policy declaration page(showing the policy n mber 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 11 forwarded to the Office of Investigations ofjtheJ21A for insurance coverage verification. I do hereb certify under t e ains d penalties of perjury that the information provided above is true and correct. Si afore: Date: 1/7//-3 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than 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-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 homeowner 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 600 Washington Street - Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax.#617-727-7749 www.mass.gov/dia