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HomeMy WebLinkAbout0053 WALTON AVENUE ti i Town of Barnstable Building Department Brian Florence, CBO Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Pre-application for Business Certificate Date © ' o 2- Map���Parcel 0 Applicant Information Applicants Name KWC-C P, Applicants Address 3 W N�_TOTr) 'k\. Email Address . M �.11��c�• � e fie:roS��V\ -y��� - ^�\ Telephone Number 7 7 g 6 Zo- , Listed Unlisted ❑ Business Information New Business? ----------------------------------------- Yes No Business is a registered corporation? -------------------------- Yes No If yes Name of Corporation Does business operate under the registered corporate name? Yes No Is the business Ei;ri� r home occupation? ---_---- es No If yes then a Home Occupation Registration is required—See Building Division Staff Name of Business M i,\�LSA Al S (±!- t\ 2 SA l_O'Y-,) Business Address �'N �av �� S M�` ©2 (o O Type of Business Building Commissioner Office Use Only Conditions 6 Building Commission Date o� / z�#4 Clerk Office Use Only g119 Town of Barnstable *Permit j OFtHE tC; "I Building Department Services Exprres6moFerrom sMttvsTeBr.$. : Brian Florence,CBO 9� $ Building Commissioner AIfD MA't 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press I+nP Tint Map/parcel Number - Property Address �j L j�L .l �'U O A►N; [94esidential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C--11)c-N\!S— •,.J T Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor �✓f I am the Homeowner o � ❑ I have Worker's Compensation Insurance SEP 0 6 20V Insurance Company Name p C Workman's Comp.Policy# TOWN N yrc BAR'"STABLE Copy of Insurance Compliance Certificate must accompany each permit. Permit Reques .(check box) © Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken toh't`A ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc: ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. 1 SIGNATURE: ` r QAWPFILESTORMSUilding permit forms\EXPRESS.doc 08/16/17 Ix 4` The i SzxC'otrsrrmireaht ofMassachusetts Deprrtifferrt of rndash id Accidews Office offmcsfigatiam 600 Washington J eet _ Boston,CIA 02111 ttzrvx un=gorldia arliers, campens3u=iww2nce AfMme$wderslCcmtm ursMectncianslE'hm3bers Applizant W m=, = Please Primt Le t1y Name �-A e Z: P_.Y Q C Address: Are you an employer?Checkthe appropriate bow ' Type of project(relt ired): L❑ I rat a employer wztli ❑I am a general confrsctrw and I 6_ ❑New coas5mcfiina employees(full andfor part-#ime * Iizvelvredfhe 300-conbMd'ors 2.0 I am a sale proprietor orpartnW7 Tisfed oathe'attached sheet..' �- El Remodeling and Izat�e as employees.employees. These smb-confractors have • $_ Ilemnalifioa kvorlang forte is any capacity.. . employees "�aadbace workers* 9- ❑S,IIiIdvng acTdifion lye i4pdoew comp.iacntanee comp.inSurancf $ r - 5. ❑ We are a corporation and its . 10-El Ele`01 repaim or ad"!o 3.911 a fiozneotimm doing all wozk officers have exercised fhew M❑Plnmbsagrepaim or additions. set o wock , Wight of ez mpfiou pet MGL o rap c�oz>zF C.f52, k aadwehave no L� €repairs is�ciriaarere��d�[ §I(4 .. employees.[No wm&w&. 13_❑other comp.IIIzu=ce regz>ied.1 *Any app&cmtCst cbecksbas 01 tit also fiIloutthe Swfiaab9aw9w dog ffi&woaee 0a3peasa6aupopcyin5=X6oL #Sameownerswho satmit des Zvi!iagrx2dr, dF_Y si£•drug O Wads mA mbmbim ou d&wxt x=ist,submit a new affifte t iodic ao sxUdL rCaatacfou�astd�ecYibisbox Masisltadmd=addiema shad shacviagthenmleoftUe=1#-c msnd9xiewhethesarnotrfoseeaffdeshwe employees.If the di-Cantffi.rn kIvemnplofers,they ams'Pr otiidet1en s &e&camp.paHUaumbm I atrt all ersplaFar flmrrtfsprauiminrg workers'cozc�serzsrdian iasrirarzca 'er m}*cmglv}�es $etoov is the puffcy artd jab spa informatiom Insurance campany1fame: Tolicy 5 or Self--ire_UC_4 ExpiratiouDate: Job Oe Address cifyf5taWEV: Bch a copy of the workers'compmszdoapoRc:5-declaration page(showing the policy,number and expiration date). Fail=to secure coverage as requireduader Section 25A of MCL c.15-7 can lead to the imposition of criminal penaltes of a fine up to$1,54a OU aadfar oni-yearimpdsostned,as well as ciO penalties i a tfie font of a STOP WORK ORDERaud a$me of up to$250-1a a dap again the violator. Be adtdsed that a copy of this statement.may be f n yarded to the Office of Investigations of the DFA far ihsarw3ce-coverage y-eQfr a. , Urfa kersby cRrti;fig uardRr d tr pgrtaif s of perjarf thattfie viformatwupr-m rT,ed abot,e fs hiss arzd wrred SitszaiaM_ `�� Date: �� D Phone ik U,�rsfcd use arFz£y. Ua drat nrrrta in tidy axarz,trr be arrupTeted 5 cry artan�u njiciat City or Town: PeraatMicense 9 Lwxhg Auflrer€ty(drde one): L Board of$ealth 2.Building Departure t 3.QtylTown Clerk 4.Electrical Inspector SS.Phz- bmg h pecf Pr b.Oth-er Contact Person: Phone 9: — -- -- - 6 Imformation and lnstruc iffl's ' Mas__3�G==-9 Laws chapter 152 rrq=m all employers to Pie Warkras' ensE =for'tlieir='Ployees. ParSaaltiv this ,an eazplopre is defined as.6.everpperson.in.$re service of ana&m under any contact of hfir, express or implied,oral or written." er is dCfined as"aa mdiva1,p��,asso�on,corporatton or o•[ber Iegal eE ity,or arty two or more . � and,inch JImg the legal represetaiives of a deceased employer,or the is¢Joint , o€the{pregoiiig engaged loyees. However the othCrI �Y�MP or_iafi[sa or �•tY, recer4m or trastes of an mdividizal,pip,ass or the o of the- owner of a dweIImghhonsefiav ngmtmorotlmtlr a ar[meots aad�ho residesiberrm, dwuIIbrg house of ano e9r who=ploys persons to do ,construc on.or repair wok on such 322 CIO g house or on.the grounds ar bmldmg aPP=h .�theaeto shaTlnotbecanse of sash employmeait be d�edta be an enployer.'° MGL chapter 152,§25C(6)also stales that-every st d:e or Iocal IiceusiMg agency shall wi$ihold$ie issuance or renewal of a Hcease or permit to operate a b=simess or to cunsfrIIc#bmldings za the cornmonwtal$i for any applirantw•h.o bzs notprodtced acceptable evidence of edmpTranM Wn the ftmurance coveragereqused." Ad,didxmaIIy,MG I.chapter M.§25CM states-Neifher the Comm nor nay of its political snbdxvi lions shall enfPr into any coaiiact f 3 rtT c p=f rmMW Ofpubho word acre ptable evidence of compliancewn the msaran=-. req==Mfs of-d=d3aptzshave been p==drdtn the mnfnfrac- .auffioitly_" AppHcaat� '. 'co eBsation affidavit completely,by cher�g the boxes ibat apply to your sitoat<on and,if Please f a off'the Worms' mp s aI withibeir s)of necessatY,soPply sob (s) �s�' (�)and Pie� ) other than.the „mnznc:e_ Lmmi�dLAMY Companies(LLC)or Lfii UabiIity Partoe Fs(�)Ta * �Plopees members orparfn�are not regakedto oaaywo6=e compensafioninsm�ce- If anLLCorLLY does have PSnpT_oyees,apolicyisregnice(L BeadYisedtbatthisa$daYit maybe mbmitte�dto the;Depa-fineatOflndusbral Accide Eds for confirmation of msman ce coverage Also be sate to sign and date are of davit. The affidavit should beretamed to-dLe city ortownthatthe application fn=thapermit or license is beingrrgvestad,not the Depmd memf of ons the law or ffyou are rimed to obtain aworlcm, mid r-ri�iF-nip_ Sf onIdyouhave any questions reg�g anies should entr.�rtheir eompensaf.onpoTicy,Pl�ecallthe,DepartneotatfbenumberlistedbeIo4v. pelf-�uedca� . self-irz�*'�ce liceuse nnurber on the appropriate line. City,or Town Offfcials - r Please be sure that th'e affidavit is MmpIct�-and prod Iep7iIy The Department has provided a space at the bott mi of the affida-Vitfor youto fM oat inthe event the Office oflnvesfigafluns has to cooba yoaregardmgiize applicant used as arofi✓rence=mber Tn addition,an applicant Please be sure to fr7.linthe pe�Ilicensc rrrrnber whichwiQbe us at that'must submit mzr�Ie penmtuceose applicafions m any given year,need only submit one¢$davit indica�g c policy mf0=3±ion.(if nwessary)and•®der"Tob�A des"the applica�should w,rifc-aU locafi6ns is (61Y Or town.)^A copy of the a$daYittbat has bey officially shaped or maimed by the eiiy or town may be provide$to tb e applicant as proofthat a valid affidavit is.on file for fatal peunits or Iicenses Anew affidavitmus-t be filled out each • year.Where a home ovtner or ci$.zen is obfa�img a Iiceuse or pe�.it not rrJat�d:to�Y business or commercial ve��re - . adoglicenseorpexmittob nleavEs -)�P�onis NOT xeq�cdtoCQ�Ie#etillsaffidaYif: The Office of aver gad=wouldlfir- th to ank you in advance for your coopmz ran and should you have ml3r qtcst'=3, please do nothcsifatc to gc Ms a caM Me,I)LeparFmexes address,telephone and fax number y a vet of Massach Departamt of xndmodal.AmUenta ' Of ava-Of 67�4-V�. _T(-,L161-f- -49W i4xt 446 or I-977 MA MAC Fax#a7 727 7M Town of Barnstable Building Department Services .� Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 snsNISTAIM KAM �, www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: S `�-� = number street v-illlaap "HOMEOWNER": � ��� ��:� �-+;tv 'Li �A I 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 buil ft& emut..(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 r7wrements 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 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFIL.ES\FORMS\building permit forms\EXPRESS.doc 08/16/17 Town of Barnstable Building Department Services asess.SS,A ' Brian Florence, CBO 165 Building Commissioner . 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maxs Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. - If Using A Builder I, as Owner of the subject property hereby authorize to act on my beh24 in all matters relative to work authorized by this building permit application for: (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 Owner Signature of Applicant Print Name Print Name Date ERMSSIONPOOLS Q:FORMS:OWNERP Rev:08/16/17 YOU WISH TO OPEN A BUSINESS? ra For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) usiness Certificates are available at the Town Clerk's Office, 1 FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: 09 �, . Fill in please: APPLICANT'S YOUR NAME/S: C� M\LS�vJ 1 ��S BUSINESS YOUR HOME ADDRESS: S 3 +�JE N. �,s r�trE��'e�t -..'Nis° r� ?� n TELEPHONE # Home Telephone Number NAME OF CORPORATION: --Nt ( DI t\j C.7 NAME OF NEW BUSINESS N lu�.�v +v.r� 'Tfzd-D1`+-1 1'1 TYPE OF BUSINESS_j_E►v PeOVQCT IS THIS A HOME OCCUPATION? Y NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER tb 1� ``-Y [Assessing] When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St_- (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. MUST COMPLY WITH HOME OCCUPATION 1. BUILDING COMIVI%Aupged, ER'S OF CE RULES AND REGULATIONS. FAILURE TO S This individualn infior, a an pe mit requirements�that pertain to this type of business COMPLY MAY RESULT IN FINES.. Sigraatta OMMENTS. C- � ' 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Town of Barnstable Regulatory Services o Thomas F. Geiler,Director Building Division s.+xrrs-rear.E, iMAS& Tom Perry,Building Commissioner �DTEo A3i�A��1 no Main Street, Hyannis,MA 02601 Office: 509-862-4038 Fax: 5 -790-6230 Approved. "" Fee: Permit#: HOME OCCUPATION REGISTRATION D ate: CJ \1 O O Name:. ����—�s�l� C ���1 Phone M -' Address: Name of Business: NIE'AD (�CAL- °^�� 1 IJ� �-fi Ct��� T �. -�� I TypeofBusiness: D6 Q- - S'C}1� *\1Z f�WS'0p/Lot: INTl1W: 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 activity o 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 conditions: 1 • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. . • Such use occupies no more than 400 square feet of space: There are no external alterations to the dwelling which are not customary in residential buildings, and there is no outside evidence of such use. • No traffic will be generated in excess of,normal residential volumes, • The use does riot involve the production of offensive noise, vibration,smoke,dust or other particular matter,' odors, electrical disturbance,heat,glare,humidity or other objectionable effects, , • There is no-storage-or.-use of toxic or-hazardous materials,or flammable or explosive materials,in excess of normal household quantities. Any need for parking generated by such use shall be me o' n the 'same lot containing the Customary Home Occupation,,and not within the required front yard. Y • . There 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-upAguek notto.exceed-one tort.capacity,and one trailer not to exceed 20 feet in length and not to -- exu&d 4 tires,.parked on the same lot containing the Customary Home Occupation. • No sign shallbe displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business, the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit` I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. AT,r,h�o„r.' . Tlatr.r 6 Engineering Dept. (3rd floor) Map Parcel Permit# House# Date Issue r.., - t:: 19 ' �I�f '�cE'�"— J L. TOWN OF BARNSTABLE • _ �Building Peit App lication L* *Address kw\ Ve Village l 1 da S8 A, Owner o, Address S �� I n,� J Q Telephone Permit Request a,r— i e First Floor square feet Second Floor square feet Construction Type yo q Estimated Project Cost $ �. Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use IBuilder Information a q�/ Xme �C C C� Telephone Number 0 33 / 7 p C Address [ License# o`o o(�o of c ,M MA Home Improvement Contractor# �p� o��� Worker's Compensation# L Q 0,3 a NEW CONSTRUCT N OR ADDIT NS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STR URES ON E LOT. ALL CONST CTION DE S SULTING FROM THIS PROJECT WILL BE TAKEN TO Gad' SIGNATUR BUILDING PE M DENIE FOLLOWING REASON(S) l e wpim x w my w V, o_wr,a�`:a*�m fi 1 9 ha"�' WO Uzi; ,d... Yf. I . . r' +` The Cotntttontt'calth of Afassachuseas •�si� -�''-_-'=�; �- Department of Industrial Accidernts . t Y � � t ._ 1 OfficeofinyesOnfogs 600 If urltingtun Street Burton. A1usc 02111 Workers' Compensation Insurance Affidavit �pplicanf.formation• -. Please PRINTIe;��,,� name: - locition- city nhonc# I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ` , -•,..- ^^-•-•-•-'a-' � .tLtT.-qAr�...r..,.,[,�.i..;;s•-�r.a:Y.., ' - :::.: �;;�;ri, r--..^rn*^.."'�w."�"�.. ""�",'"'."`�^"._,.e•- 1 am an emplover providing workers' compensation for my employees working on this job. company nam • Iddres : G �SG AS e+ it Q a e- OA insurance co. UV ax-4 LJ policy# tl 3 J 1 am a sole proprietor, eneral contrac , r homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: cotonnny name, address• city nhonc#• insurance co policy# , I..r'R... :f'1�iti '.-�'• ,,�;-� _ �•J.�r .f.l�_TyT►i j�:iKt�.i.Yi2�6 company name: address: city- phone#• insurance co policy# Attach additional sheet if necessarx,, s•::. W^�=T. �. � r:1f �rFr tr.�1 .<•.,r�..y.-.+.•aa.. •...«,• .. q.r�� w c' , MM�� _ _ ...��, r -�rY._-�4:;i.-.�.� .,yam•, _ .:�a.LYe�.C..�tl..Mr:r,;:.�+a: Failure to secure c rage as re fired under Section 25A of NICL 152 can lead to the imposition of criminal penalties of a fine up to SI.500.00 andiur unc years'impr-•onment as well ivil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this'it. Cement may be f w d to the Office of Investigations of the D1A fur coverage verification. I do hereht• •rtif•till t e pail 'and names of perjun•that the information provided above is true and correct. Si_natur Date Apt Print name C 0, Phone# . iff- 3 32 r- oci;t�:-c ialuse Iv do not write in this area to be completed by city or town oRcial or town; permidliccnsc# r'1Buiiding Department Licensing Board17 _ check if immediate response is required Selectmen's Office C311calth Department . contact person: phone#• r•'1Othcr : freviaed 3;o5 rtAi 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 emph ree is defined as every person in the service of another under anv contract of hire, express or implied, oral or written. An empinrer is defined as an individual, partnership, association. corporation or other legal entity. or any two or more the foregoing enLagcd in a joint enterprise, and including the legal representatives of a deceased employer, or the rcceiver 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 haus or on the urounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that even, state or local licensing agenc}•shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commow-vealth for any applicant ,who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requireinents of this chapter ha- been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents 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. .. . .. ice+:� ' •' .yV,:�. .++� 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. Pleas be sure to fill in the permit/license 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. ......�..�Aw�+tw—�•n!f�w�.w.7•�a!+v{c'T.'�--�r.r.l�Alsr.•►aa . Tile Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 i 4 The Town of Barnstable MAM �' Department of Health Safety and Environmental Services "9. Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-790-6227 Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions, ng with other require nts. c2� Est.Cost � S�Type of Work: Address of Work: Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME RIlVIPRAO�,ME�DW�ER MGL DO O 142A� ACCESS TO THE ARBIT RATION SIGNED UNDER PENAPERJURY I hereby apply for a perm nt of e . Date Contractor Name Registration No. OR Date Owner's Name