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HomeMy WebLinkAbout0057 WOODLAND AVENUE If 9 i I ' �S \ i I l j9q.H Rn,- 6&toad i Burxd Ai-Bav,.MA:WSR r s68-86.R f740 r SPS-6 A3 7 eC �jw . Er- N E Thomas Perry;ESo 'To own of Barnst i lc,building DiVisibn 200 Main Street Hyannis MA 02601: REa::;Insulation Weathe►`ization Permits: Dear Mr.Per This afs davit is tt�cert� :that aft work completed for:'insuiat orti wotk at: 5.71loodland Ave,Flyat�nis — Gc�Mp��r'` ""� 3 f iS I► leas been'in5l3ected ding by.a c€rU ed$wil Perivrmance Institute(0P1j inspecfvr; AIl"work"peifc�rrred rtie�ts et`excoetis federal&State requirement: i C) Sincerely„ oz ii3ffrey Tone9lo Ln t , r'a . C r Ri 3r r `i 1 t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map. eParcl eA pcatio# 1 � ' Health.Division Date Issued . Conservation Division Application Fee S� Planning Dept. Permit Fee 3� Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address 52 (oOOct lCe.nCl rc_ PUcrivn'iS Village p cc rrl 5 -� i Owner 460 r1l PUf>Si 0 C7 acJd K9Address 144o 6 oclJ� Telephone Permit Request /nskel—a 5-)-0 S 5. �-v /L-(F a i;n a-t,-� chttl- ateA A-!e O a h s .a.ta_LL-� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 5�4(a 00 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. 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 Number of Bedrooms: existing —new Total Room Count (not including�ba�th3 : existing new First Floor Room Count Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other Yp � w v Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wop`"� coal stogy: ❑ems ❑ No o Detached garage: ❑ existing ❑ new size—Pool: ❑existing ❑ new size _ Barn:2 xisting r0 neva size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name J_� i'�� �✓u� �y Telephone Number (9 D Address 49 coancl a..r_1 License # LDS 3 a �- Home Improvement Contractor# d 1 u Worker's Compensation # i i d 53 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 4"} A -cr"'rS Ponc( (Ld by SIGNATURE �. ( � DATE 13 - 3 FOR OFFICIAL USE ONLY ;APPLICATION# f DATE ISSUED 'r MAP/PARCEL NO. "r { T ADDRESS VILLAGE OWNER I r DATE OF INSPECTION: r .-FOUNDATION FRAME INSULATION s FIREPLACE ELECTRICAL: ROUGH FINAL i PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING { DATE CLOSED OUT ASSOCIATION PLAN NO. '_Utz'.'=� �1� a llte L ommunweuun ud Department of Industrial Accidents Office of Investigations ' + d 600 Washington Street Boston, MA 02111 w =�•°� www.mass.gov/dia Workers' Compensation Iusnrance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Itiforination Please Print Le 'bl Name(Business/Organimdon/hadividual): Address: qCi c( �a�...3 a— City/State/Zip: U l,l (fc(c �5 u Mn Phone.#: Are town, employer? Check.the appropriate box: Type of project(required);, employer with U . 4. 0 I am a general contractor and I 6. ❑New construction . em e ployes (full and/oipnrt-time).* _ eve hired the stab-contractors 2:❑ listed on the-attached sheet 7. ❑ Remodeling I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 0 Building addition . [No workers' comp, insurance comp• insurance.$ required] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.ET I am a homeowner doing all work officers have exercised their I 11.0 Plumbing repairs or additions myself. [No workers' comp: right of exemption per MGL 12.D,Ro repairs ed t c. 152, §1(4), and we have no insurance re . employees. [No workers' f 13.0 ther �(f d4-KM+ 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. $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 is providing workers'compensation insurance for my employees. Beloiv is the policy and job site information Insurance Company Name: C cD Policy#or Self-ins.Lic.#: S 7 O S a 3 O 53, Expiration Date: 3 �J `� 4= Job Site Address; S 7 U300c(tatAc/ Ayc— City/State/Zip: ff V a/1 n l S - 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 for insurance coverage,verification. I do hereby certify under the pains-and en al of perjury that the information provided above is true and correct Si afore: • Date: Phone# Official use only. Do not write in this area, t' be completed by.cily.or town offcia! 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#: r ACoR® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/21/2013 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 endorsements). PRODUCER CONTACT Susan Starr NAME: Small Business Insurance Agency, Inc. PHONE . (508)795-0635 (A/F—FA� No):(508)798-500e 542 Main Street E-MAIL DD INSURERS AFFORDING COVERAGE NA1C# Worcester MA 01608 INSURERA:Libert (WC) Mutual Ins. Co 010 INSURED INSURER B: Resolution Energy INSURERC: 49 Herring Pond Road INSURER D: INSURER E: Buzzards Bay MA 02532 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1332103955 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 DLSUBR TYPE OF INSURANCE POLICY NUMBER MMUD EFF MMIDPOLID� LTR LIMITS GENERAL LIABILITY EACH OCCURRENCE $ CGE TO RENTED OMMERCIAL GENERAL LIABILITY PREMISES SES(Ea occurrence) $ CLAIMS-MADE 0OCCUR MED FRCP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ JFCT 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 LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ RED I I RETENTION$ $ A WORKERS COMPENSATION X WC STATU- R OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N I A (Mandatory in NH) 531S370523053 /12/2013 /12/2014 E.L.DISEASE-EAEMPLOYE $ 500,000 If yes,des C cribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Housing Assistance Corporation ACCORDANCE WITH THE POLICY PROVISIONS. 460 West Main St Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE E Scarborough/ELISCA c_ ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD i '- �Iii��nchu�crtr - Dclt;trhrtcnt nl Pnlrlii `;ilct a E3n;ir-rl nl' 13uilrlin� Rt':'ulutirn: ;ntrl �iaiiil:irrl� Construction Supervisor License License: CS 53202 JEFFREY R TONELLO PO BOX 1516 SAGAMORE BEACH. MA 02552 r I'1, r' ;..�� Expiration: 7/14/2013 ( nnnri<.intt•P Try: 21481 .)7tlrr<ry�f�i r� f�/ Office of Consumer Affairs&Busi ess Regulation License or registration valid for inds'vidut use only h ffOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: f �egistration: 162458 Type: Office of Consumer Affairs and Busi9 ess Regulation expiration: 1/2612615 Individual 10)Park Plaza-Suite 5170 JEFFREY R.TONELLO Boston,MA 02116 JEFFREY TONELLO C r 60 STATE RD. � SAGAMORE BEACH,M / 02562 7 E---T� :�i s t _ Undersecretary �---- N T - a9idl thout signature; TENANT/PROPERTY OWNERIAGENCY WEATHERlZATION AGREEMENT 1. T}1ei Park s to tA9emnt are the following: (hereafter known as Tenant), - (print your tenant's name) - (hereafter known as Property Owner) (print your.name) and Housing Assistance Corporation (hereafter°known as Agency)_ reafter stated,the Parties agree as follows: In consideration of the mutual promises he 2. The date of Agency's signature will be the effective date of this Agreement. 3. Property Owner and Tenant consent and agree that the Agency may do the following with respect to the prope I ated at(stree ,town) , ry� unit# and currently leased or rented to the Tenant: a) Enter the premises for the purpose of performing a Weatherization inspection. b) Enter the premises to perform Weatherization work.which the Agency determines in its discretion is necessary and appropriate as a result of the Agency's inspection of the property and in accordance with the appropriate,priority list for the type of dwelling. The Agency and the Agency's'contractors may also enter the appropriate comm areas of the building for the purpose of accomplishing the Weatherization work. The Agency and representatives of the Commonwealth of Massachusetts, Department of Housing &Community Development(DHCD)may further enter the property to inspect any and all work hereunder. The Agency will provide reasonable notice of the timing of the Weatherization work and inspections. The Weatherization work will be performed in accordance with the Property Owner's consent as further specified below "** INITIAL ONLY ONE OF THE FOLLOWING "* the Agency and its con 1 consent to performance by 9 Y tractors of anyro appropriate b the Agency as a Weatherization work determined necessary and app p Y g y IF of its inspection of the property_ I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of work. I will provide a separate consent to performance by the Agency and its contractors of Weatherization work following my receipt of the Agency's ment.of_the estimated work and associated value. inspection report and a state This additional consent will be sent under separate cover as Attachment A. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work. 4. The Property Owner understands and agrees that any and all work, including related repairs for which the Property may also be eligible,will be performed at the Agency's discretion. The Agency estimated completion of the Weatherization work by the end of 2012. 5. If the Property Owner is required to make repairs to the property prior to the commencement of Weatherization work by the Agency, the Property Owner will be notified e. Except where by the Agency and will be required to make the repairse Agency,soon time islof the essence in e Pro a Owner receives a written extension from th �Y p the performance of repairs by the.Property Owner. T�1 � n;.r;= 'matter iti' >=ilit'1�1 i_wQ �i t_l 'jy_t�;i;—�GI�`•. �iTl•+T'�l:��s'�`',cii.`.'�t�;:tt::s'_� _.t''._�L.� 1` doc I r, 11. For breach of this Agreement by the Property Owner, the Property Owner shall reimburse the Agency in an amount equal to the cost, as certified by the Agency, of the Weatherization materials installed and labor performed on the premises, as well as attorney's fee and court costs. The Property Owner may also be liable for damages to the Tenant in accordance with applicable law; in such instance, the Property Owner shall reimburse the Tenant for attorney's fees and court costs. Without limiting the foregoing,the Agency may at its option terminate this Agreement, by providing written notice to the Property Owner and Tenant, in the event of breach by the Property Owner or Tenant. 12, Performance of the Weatherization work hereunder by the Agency is contingent upon the availability of funds to the Agency from the commonwealth of Massachusetts and the federal government, as well as the eligibility of the Tenant under WAP program requirements. The Agency may terminate this Agreement, by providing written notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility of the Tenant warrants termination. 13. The Parties acknowledge that this Agreement is under seal_ It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shalt have a right of enforcement. Property OwneY/rl RE 4 Signature:N - Date � 0 / Phone: � 77L 7Z2;_;' Address: 7"J� � � a/`, z' f3ARNSTABLE HOUSING AtJhIAM 146SOUfHSTHEET r Alm (}� WYANNIS,MA Wi DiTenant Signature DateC.. C)1' Agency Approved Weatherization Company All Cape Energy Cape Cod Insulation Cape Save Frontier Energy Solutions Lohr& Sons Resolution Energy Agency Signature Date c`JEa'.{iv;i 4_ ' `.j.l..j_ _-_:" jir 1-2.1_v5� of Town of Barnstable *Permit# e 559 A Expires 6 months from issue rr"te Regulatory Services Fee.- Thomas F.Geiler�Director s674• �0 Building Division Tom Perry, Building Commissioner X-PRESS PERW41T 200 Main Street,.Hyannis,MA 02601 Office: 508-862-4038 J U L 1 9 2005 ' Fax: 508-790-6230 VL EXPRESS PERIM APPLICATION - RESIDENTIA QMjDF BARNSTABLE Not Valid without Red X-Press Imprint aplparcel Number. .operty Address C5- ? eih \ 1 " i J Residential Value of Work 3� 61 Minimum fee of•$25.00 for work under$6000.00 �k - - . - wner's Name&Address N A� 'e 1 L* to !ontractor_s_Name . M ^ `�e C `t1 Telephone Number `o�o�b `�a b 1 (0 [ome Improvement Contractor License#(if applicable) ,,onstruction Supervisor's License#(if applicable) ]Workmen's Compensation Insurance Check one. ❑ I am a.sole proprietor ` ❑__J,am the Homeowner El I have Worker's Compensation Insurance nsurance Company Name Nokman's Comp.Policy# F� ( to o°Z `;b t AQbq :opy of Insurance Compliance Cerdficate must be on Me. ?ermit Request(check box) Bl�roof(stripping old shingles) All construction debris will be taken to 5 A k6 io cir ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44)- *Where required: Issuance of this permit do not exempt compliance with other town department regulations,i.e,Historic,Conservation,etc. ***Note: Prop e wner t ga operty Owner Letter of Permission. 0 ov t ctors License is required. Signature QFortas:cxpmtrg _ Revise063004 ��� � re`r �a-x ' � a `�.f'�'tt �t� �� c '°'T+^2'• � +�•� _ ��v1 ���� d� y ry' "''� "� $ 35 Peep Toad F << Centerville MA 02632 a f (508) 420-6216 cell phone 774-238-2938 YlS h K f r; PROPOSAL S TED TO:. WORK PERFORMED AT: , Barnstable Housing Authoriy , ATT. David Hart 57 Woodland Ave. t +T 146 South St Hyannis 1GIA 02601 Hyannis AM 02601 y `1 Cell phone 508-280-5702` 4 d aYr n� az We herby propose to furnish the materials and perform the labor necessary for the completion of the following; New Roo . /remove I laver of existing shim '- Install 8"drip edge Install ice &water shield at edge Install I51b. felt paper Install Certainteed Woodscape 30 Algae Resistant shingles Color of choice] 4 Cut ridge &install cobra vent � Storm nail all shingles All debris cleaned daily 'q Price includes material. labor&dump,fees � d All material is guaranteed to be as specified,and above work to Qerformed in ;� F accordance with specifications submitted for above, and completed in a substantial ` workmanlike manner for the sum of Three-Thousand Eight-Hundred&Forty } Dollars( $3,840.00)with payments as follows;full amount due upon completion 3 ` *Any alteration(s)from bove ' olvin extra costs will be added under written k agreement,and beco e a c r over and above signed estimate/agreement RESPEC D Signature ' 0 -12-05 �� •~ 3 ACCEPTANCE OF PROPOSAL The above prices specification&conditions are satisfactory,we herby-accept 1 you are authorize o do ; and payments will be as specified above. i f Signature(s) 3 _ Date: *This proposal may be withdrawn by said company if not accepted within 30 days { � FF� A�f OUSINQ AU i. dORU ftl�X i i l r vy tg�ry��r� 02601 . t " n R �i 41 Board of Buy di ag Regulatio r HOME IM ns and Standards ; f'd2OVEMENT CON Re TRACTOR gistr�'fif?fl� 6480 rttx _ rt 8/2006 MARK HE RBsr ' OF- , � idual A - d MARK H. „. ,ERB$r 335 PEEP: rOgp z RD� � ` CENTERVILLE, "'�'�5.� _ • MA 02632 + Admi . .. uistr - ator. Engineering Dept. (3rd floor) Map 2(09 Parcel 059 Permit# . �� p House# 5`2 � Date Issued 's' O Board of Health' .(3rd floor)(8:15 -9:30/1:00-4:30) Fee. ,ZS" Conservation Office(4th floor)(8:30- 9:30/1:00 2:00) Planning Dept.(1st floor/School Admin. Bldg.) De ' 'tive P n Approved by Planning Board 19 �. r : BARNUABU, ` TOWN OYBARNSTABLE 57 Building'Permit Application ; Project Street Address �W 0 A JP— , Village RYA, IJ IJ T t E Owner k&'r:Nrl tVblt. Hov r)w' Authmh)l— Address ili6 SP&JH SSneG1 k -mNaS Telephone ;Permit Request JL %E (Lyv 1$,&' AWL6 xinr -.c ,�, 10 as4 f First Floor square feet Second Floor square feet ,-Construction Type W00,0, Estimated Project Cost $ 4aC, cry 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: �NFFull ❑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 3 New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas Oil ❑Electric ❑Other Central Air ❑Yes _.'Ef No Fireplaces: Existing New Existing wood/coal stove ❑Yes ']RfNo Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) ,s Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes J No If yes, site plan review# Current Use Proposed Use A.6r% Diem ml Builder Information Name ZtU JJ kAnnisulJ Lp-!Irlmin Telephone Number "? 1 7�-�- Address I], 1.►,I A N CA R'R; License# 0 1 1 0 3 S' �nivrT a- O-Z-G'3 1 Home Improvement Contractor# Worker's Compensation# Ltd 1 O S G a 3 5 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO b4 (),w,r. -Lmc SIGNATURE w„s..,o DATE 1 i 3 q BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) +� r FOR OFFICIAL USE ONLY PERMIT NO DATE ISSUED MAP/PARCEL NO. i _ ' •; k ADDRESS VILLAGE " OWNER - t DATE OF INSPECTION: FOUNDATION^ FRAME INSULATION f, FIREPLACE ELECTRICAL: ROUGH FINAL — PLUMBING: ROUGH FINAL GAS: ROUGH I FINAL _ + FINAL BUILDING - DATE CLOSED OUT s t ASSOCIATION PLAN NO. , i a L •O L O7 W W V T H �J •• Ol W p •ti C d. Z m C S 2 s> Y Z CC d a L f— I� G! •L Z � N S E vl ¢ _ w :J tt � t Fl t.•y sue._ - oa m C c d O � .ti C y O N N V L d � O m N O O A m q S Y U N U UI C � •` 10 N�1 oc u �. The Town . of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Building Commissic: Fax: 508-790-6230 For office use only ` Permit no. Date AFFIDAVIT r HOME MOROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL�c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or constracdon of an addition to any pre-ezisting 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. Type of Work: P 1$� F®� Est Cost Address of Work: 1 ®o c¢ r Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reasou(s): Work excluded by law _ Job under S1,000. Building not owner-occupied 2c Owner pulling own permit Notice is hereby given that:OWNERS . PULLING 'AID OWN PERMIT OR I�IVIPRODEALJNG WITHV'EMENT WORK DO NOT CONTRACTORS FOR APPLICABLE HOME ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. 9 31 � s Contractor Name Registration No. Date �� T/ic• Cunrrrrunlveft/t/t of:1lassachusells Department of ludttstrial Accidents Mice 011ayes1192111ans 600 I!a.0higiun Strcu ��•��� -',•' Bustoa.A1asa: 02111 Workers' Compensation Insurance AlMdavit �1lililirintintorntatirin• Please PRINT narnr• �t1C'1tIOn' ril-v nhnnr• -0 1 am a homeowner performing all work myself. 1 am a sole proprietor and have no one workings in any capaciry I am an emplover providing workers' compensation for my emplovees working on this job. cnrn •n• v n rne- f3AI.Ni`l bk HOUSttat4 /�iyT vn.tT 'Itl(lrrcc• )LI tsOy6r1 �1nP61' // city. ��ltg NAl1J" �� Ithnnc#• (�0�� �"�1 �a-7•Z-- _ incur-tnce ^n !V.HH fLD 11 , tar-toup )Avr1 nolicv# (ilk l o-3 ® A3 9 I am a sole proprietor, general contractor, or home oi� er(et(eirci otrej and have hired the contractors listed below who ha%: the following workers compensation polices: comn•tnv n-rrne •ttlrlrrc�• city•• nhnnr&• incur^nrr rn nnliev# .�� -� _�. _ �...Y... _- -�rev:��ta iT"f!�.w1�..� -�T. _ ��►�...--� cmmninv nntnc•• rite•• nhnnr#• incur-nnce rn noire•d _ Attach additional sheet if necessary` '"�• .=-.n- v-- F:trlurc to secure cttverat:c as required under Section 25A of AIGL 152 can lead to the imposition of cnminai penalties o!'a line up to 51.500.00 andiur unc c cars' imprunnment as .ell as chit penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement ma% be furnvarded to the Olrce of Investigations of the DIA for cavcrage verification. /do hereht•crrrift•uatler the pains and penalties of perjun•that the information prorided above is true and correct. Si_..^.aturc "a AM", 1'�i^n1�-t..� Date Print namc. �tLll9n1 AYb111N-0 Phone# 77 ) 77k2-Z-- w oRcial use unh_• do not write in this arcs to be completed by tiny or town official cin•or town: permitilicense if rJUuilding Department ❑Licensing Board tt 0 check if immediate response is required ❑ selectmen's oracc t l•. ❑ticaith Department phone#; rlUthcr contact person; i. t r. Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovees to provide workers' Coll,Peltsttthill for :. employees. As quoted from the "ia��". all empluree is defined as every person in the service of another under sny contract of hire, express or implied. oral or written. " An enrplot-er is dcf-mcd as an individual. partnership. association. corporation or other legal entity, or an}• two or ,r., the foreaoing cnanged in a,joint enterprise, and including the legal representatives of a deceased emplover. or the recci\•er or tnistee of an individual . partnership. association,or other legal entity, employing employees. Howe:•cr owner of a dwelling house haying 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: :: or on the `_rounds or building appurtenant thereto shall not because of such employment be deemed to be an empio,- MGL chapter 152 section 25 also states that e'%•en•state or local licensing agency shall withhold the issuance or 110%111 uf:: license or permit to operate a business or to construct buildings in the commonwealth for any icant who has not produced acceptable evidence of compliance with the insurance coverage required. Adc::ionaliy. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performz,!ce of public work until acceptable evidence of compliance with the insurance requirements of this cltaptc- been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation anc supplying company names. address and phone numbers as all affidavits may be submitted to the Department of industrialkccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The ''.ia%,it should be returned to the city or town that the application for the permit or license is being requested. rn ;he Department of-Industrial Xccidents. Should you have any questions regarding the "law" or if you are recui-_- 0 obtain a workers* compensation policy. please call the Department at the number listed below. City or -I-owns Plea-e be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the a,"davit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P'.. be _ _ to fill in the permit/license number which will be used as a reference number. The affidavits may be returnee -pie 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 am questie please do not hesitate to _give us a call. I 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 fax n: (617) 727-7749 nhone -�i: (617) 727-4900 exr. 406. 409 or j75 y ' o. m . + .� q .may 1 ♦O L W m N fH Cr L 1 y N •d � m i N N nY O Z Z H C O Z Cr 4.1 L 'S CC I� iJ 2 V Or m rr m _ f a:# 1 1 d � p N c y O N J L d y O+y V ,O c C �• y or ca � N m O O A y y S y ca N p +- p T W 6 y O ..- y N I V GC