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HomeMy WebLinkAbout0043 BRIARCLIFF LANE A Mz v elf Z7 P.1 4'4 I��;:­ i;Ei iiiIA-�qP 6,�i "'l" 44, p, WAI), If, . "l, , 'e, ;,� 1�it 11 1-'I,I I , "(,� ;g IT I lj!_� lzi "'A "y "I'll,J,I J. TI- p"'j�i' 1-t J� j,� '4" ri .1 1 i't I T'll 14, If. 1"',"A jy It, : , _, , ��i,�; . 14 .;I_, ,,l�i I'. o'.I I 1,,I'�,, ",ii,"t 3,;i"4i tl T. �4 k", C�l Pf �j%, It,,s.(1 ,. 4 1 1.11,1 y F";, C, A 1,11 1,, .1 -0"i"' V 0 A, 41' V i i il I 111 ,, '_ " V it ,it t. tll "W it f f, ...... 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I� j j;, Alli Z-'Aol"t k"W z l0llil� 5;11ir,;i fi� 'A, l I "AMP. .......... fI "ft", b! 00, A;j A V M t "'P 1 f �i;Z li'Wi %w IN(,,l��, JA , , )"t'jil"I,� , i � 'g-1� _",L il j��!,,,�,, VIP, lfe lffli,�,4 I Y I ,,4"",, , ,;i,Aj;� lr ,A '0 f!f, 1 1,4 1 I V,f" i '141 tf�., j,", T, q A i— t,,: j-_'e'. , �Ife;5, 0,,i V, xi ....... 'j, fel 'Tj�i,r" ,�i,,;�,`l ��ft,!4,7�A�"', �' 011 4" M ..... "Mo, J'fi 6 i..; A i 9�j I, .........I "RN 14 "i, 'Ci ti, Vi, c' f,;,4 6l 4i 1,�;�:, 'ff"'h 4p, t 6", 5, ;f f, YA- AIR;, At Wif, vi" t t�:� A �I iIAVi o 15 f" t',p ........... 21 t 5;'W 'A"WeL)", i", I, r.4-1 itt .,ieftw Town of Barnstable stab e oFTHe,q�, Regulatory Services do Richard V.Scali,Director Building Division BARNSTABLE ► BMMSTABLE, i oaadsrae¢•ax*mv!uc•coivrt•muiti!s Paul Roma, ws;3r9 2014n4B4¢M4-cE Building Commissioner' 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us April 11, 2017 Bonnie Campbell - 43 Briarcliff Ln. Centerville, MA 02632 RE: Shed over property line . Dear Miss Campbell, = It has come to the attention of the building department that your shed is partially on the neighboring property. As we.discussed in March, a reasonable time frame to have the shed moved would have resulted in the shed being moved by the first week in April. Please contact this office.with an update of your progress. I can be reached at'508- 862-4035. Thank you. Sincerely,- Patrick-Franey n ux how Q w 1 o 9oZS: 1 980 O v aDJ-. m Z 4 cSO. Qom. O v M ,,o A 18,200 6 U pp� �T . P .P (o0 4j 9,0 3 o� }1 G o C 42,000 vr ......------- .APPROVAL NOT REQUIRED UNDER. C \� ' REGISTRY THE SUBDIVISION CONTROL LAW ^°s6' MAR]2 I963 TOWN OF BARNSTABLE y ! 9 H/O n� CZ_M � PLANNING BOARD !tF;C0RD D DATE I to or, o� Suaoiv/srON OA L AND /N KILSov . _ • SEA.P.SE : CENTER VI 1,C E• BARNSTABLE -MASS. . BdSLONGYNQ TO . DONALD A �` KAYE F MA s oN `��,�o►M�� SCALar//ru•40Fr.• MARcm 7, /963 NZLBON b*ARSC RICHAAD JAW•(ANO $t/RVCYOgg RL A W - See p No.1?7r6� r /en a/ /3s nafaile CFNYFRVlLLG� MA5:3. .,Re9islry, 8k./40 P9 29 _ `� 5 a9eR- 3652 . ,_ gap 2 ©Y Parcel / 6 Permit# q 7 8:30-9:30/1:00-2:00) Daie Issued w -9� ® Board of Health(3rd�flo_or)(8:15 -9:30/1:00-4:45) 7`1 .S;4 �( Engineering Dept. (3rd floor) House IKE . © �°�:.. • BARNSTABLE. • '�. TOWN OF BARNSTABLE 'Ci i Building Permit Application Pr reet Address ) F Village•— Owner �GQ . C e ` Address nju—�ui,�si (Telephone — 790 000 1 9 w-04k' x 700 ,;,�Krmit Request 4 F j First Floor square feet Second Floor square feet stimated Project Cost $ 0-XrV da Zoning District Flood Plain Water Protection Lot Size Grandfathered ? a Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family a/ Two Family Multi-Family.' . Age of Existing Structure TS yPes Basement Type: Finished F Historic House A/0 Unfinished Old King's Highway APO Number of Baths No. of Bedrooms Total Room Count(not including baths) t 10 J First Floor Heat Type and Fuel Central Air 'Fireplaces Garage: Detached / Other Detached Structures: Pool Attached Barn None Sheds Other / Builder Inform 'on Name Z—Lf &1)ecyyy L % 422�/njey�ll Telephone Number (1/22 6 2429 Address Ca2jq2-n/ 4y License# 05-6/36 &S r7/n yn 4. 0 z/3/ Home Improvement Contractor# //Q 9 C.O Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(A$ BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN.TO �� SIGNATURE DATE BUILDING PER T DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP ARCEL NO. _ } /P ADDRESS VILLAGE OWNER DATE OF INSPECTION: j FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ' ROUGH FINAL ► y PLUMBING:, ROUGH; FINAL t , GAS: ROUGH 1 FINAL FINAL BUILDING DATE CLOSED OUT } r ASSOCIATION PLAN NO. Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee 'P fjES°S pE Thomas F.Geiler,Director Building Division ©EC — 3 200 Tom Perry,CBO, Building Commissioner C �Q��®F 8� g 200 Main Street,Hyannis,MA_02601 /VSTAftc www.town.bamstable.ma.us Office: 508-862-4038 Fax: 50.8-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Z� Property Address ( C�—l P � e C"U l C C) L C YL C Residential Value of Work 5C'VC'-'19 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address (�C V� rvO 10 C� Contractor's Name CA P C l o C C'�� 1(t �� l S 9 Telephone Number y `C z_8 `L0 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) l k i ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Y'CNOyC U QLA I &J"AjcC 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 betaken to - CA&S C C(/t ❑ 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. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): yIC C C S L'G� Address: L 9,01- �Z 2 8 C O'l City/State/Zip: Phone.#: S `� Z S O a 651 Are you an employer?Check the appropriate box: 'Type of project(required):. 1.® lam a employer with (a 4. I am a general contractor and I * have hired the sub-contractors []New construction . employees(full and/or part-time). 2.El 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 workingfor me in an capacity. employees and have workers' Y p tY• $• 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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.❑ 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. $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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is-the policy and job site information. Insurance Company Name: n J 0 SA [N S U JAIU CC- Policy#or Self-ins.Lic.#: e 49-__T G Z Expiration Date: Job Site Address: 3 �( �CL< ��� CA NC City/State/Zip CfC—'L't C`'l� 1. 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 maybe forwarded to the Office of Investigations of the DU for insurance coverage verification. I do hereby certify under the pains-and penalties of perjury that the information provided above is true and correct ' Si afore: Date: 2 2 . 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): A.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 TPcPLvpr nr trustee of an individual,uartnership,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." Mc,L 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 ti ,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 io 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: h,,Commonwealth of Massaeh=tts Depart=at of I.dustdai A.widonts Office Qf In-Vestigat €ears 600 Washingteti Street Boston,ILIA 02111 Tel. 617-727-4900.ext 406 or 1-M-MASSAFE Fax#617-727-7749 Revised 11-22-06 wwwmass.pv/dia ACORD CERTIFICATE OF LIABILITY INSURANCE oaiiiz o' PRODUCER _(800)752-0251 FAX (781)261-2099 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE E HOLDER.,THIS CERTIFICATE DOES NOT AMEND,EXTEND QQR 77 Accord Park. Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELVW. Unit Bl 4, Norwel 1, MA 02061 INSURERS AFFORDING COVERAGE NAIC# INSURED Capewide Enterprises LLC INSURER A: Hanover Insurance Co. 22292 PO Box 763 INSURER B: ACE USA Centerville, MA 02632 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rA AID TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONTE DATE IMMIDDIYYI LIMITS GENERAL LIABILITY LBN5336555 04,130/2009 0413012010 EACH OCCURRENCE $ 1,000,0061 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,004 CLAIMS MADE I OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&AqV INJURY $ 11 DOO,OO GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00( P PRO LOC POLICY JECT AUTOMOBILE LIABILITY TBD AUTO 0412012009 0412012010 COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO nt 1,000,006 ALL OWNED AUTOS BODILY INJURY (Per person) $ q X .SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY (Per accident) $ X NON-OWNEDAUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY UHN5336545 0412012009 0412012010 EACH OCCURRENCE $ 2,000,OO OCCUR CLAIMS MADE AGGREGATE $ q 2,000,000 $ 2,000,00 DEDUCTIBLE $ X RETENTION $ 10,00 $ WORKERS.COMPENSATION AND C45761472 0411412009 0411412010 WC STATUS OTH- EMPLOYERS'LIABILITY r E.L.EACH ACCIDENT $ 5001 0O B, ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,OO If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,OO SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Evidence of Insurance. .CERTIFICATE HOLDER. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 4 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ' AUTHORIZED REPRESENTATIVE* Ronald C7eaves/KC1. ACORD 25(2001/08) ©ACORD CORPORATION 1988 f _ �la:aachtisctt� - l.)clt;u`lntc.nt nl 1'ulriii ti:tl�'t� „a ,. l�u;irtl nl 13uiltlin, 4tct�ulutinn� ;Intl atnntl;rrcl� ' Construction Supervisor License License: CS 89273 . Restricted to: 00 rt RICHAR'D M CAPE'N 122 WHiTMAR RD " COTU IT, MA 02635 ' �y---- Expiration: 11/27/2011 ( ninii•.i ncr Tr-: 9638 Restricted to: 00 00- Unrestricted 1G- 1 2 Family Homes i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS �. fie oowew.,wntioea&X o f -114=ac4u� 5-\ Mfrdrof B filding`Wgulati'ons and'Standirds V�'—j HOME10ROVEMENT'CONTRACTOR Registration; .1433'58 Ezipi'ratton::;T/8/2010 Tr# 272627 Type: 'Ltd?Liability Corpor CAP'EWIDE.ENTERPRI'SES L:+L.C. RI'CHARD CAPEN 450.7R RTE,28 COTUIT,MA'/;0263"5 Admtnrstrafor 1 ua -- — License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regu4tations and Standards One Ashburton Place Rim 1301 Boston,Nia.02'108 VO.t..}alid without ignature �oF,Me>�y Town of Barnstable. Regulatory Services � LE'$ Thomas F.Geiler,Director 3,639.� ��'OrFJD MpI Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.Ma..us Office: 508-862-4038 Fax: 508-7.90-6230 Property Owner Dust Complete acid Sign'This Section If Using A Builder I,Z /^ as Owner of the subject property hereby authorize =6�PCCk)lV3 C_AJ(C—N P I. Z-- -o aatt on my behalf, m all rnatters relative to work authorized by this building permit application for:. . Address ofjob) Signature.of.Owner Date Print Naine Q s ORM S:0-W NERP ERM IS S ION _ The Town of Barnstable Nam$ Department of Health Safety and Environmental Services P Building Division Ma 367 Main Street,Hyannis MA 02601 Ralph Crosser Office: 508 790-6n7 Building Cemmissio: F= 508 775-3344 For office use only I Permit no._,_ Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A rewires that the"r=nstruction,alterations,renovation,repair,modernization,conversion, ed improvement,remcnal, demolition. or construction of an addition to any prt;-e�dsting owner occupied ibuilding containing at least one but not more than four dwelling units or to strew which am adjacent to such residence or building be done by registered contractors,with certain C=pdons,along with other requirements. Type of Work: �7—_T Old Est Cost, � 0—C) Address of Work: 3 ��I/�ZCGif'f Owner.Name: �YI�C E O G//I'�,-i AIC Date of Permit Application: I herein,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'TI�iR OIIv1PPROVIIvfENTWORKERMIT OR G DO NOT ACCESS 'f000NTRA�'I FOR APPLICABLE HONE HE 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. Date ontractor a Registration No. OR 9J) G/�yv �v 6r2t n A Owners name COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY OF `, _`.'ONE ASHBORTON PLACE � MASSACHUSETTS - BOSTON,MA 02108 : EXPIRATION DATE L I C EN S E CONSTR. SUPERVISOR 2/ / 9 7 RESTRICTIONS EFFECTIVE DATE LIC N0. } NONE 03/31/1994 056136 LAWRENCE T MCDONOUGH 48 CERDAIA! AVE * BOSTON MA 02131 � PHOTO(BLASTING 013 ONLY) F `( 0. CIO NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY HEIGHT: ' STAMPED-OR-SIGNATURE OF THE COMMISSIONER i' f F THIS DOCUME':T MUST BE � CARRIED ON TI;_PERSON OF SIGNATURE OF LICENSE) THE HOLDER WHEN Chi- 0 1-HERS-RIGHT THUMB PRINT GAGEDINTHIS:'.:CUPATIOI: - - i mu , . NONE�iKPROVENENT:COMIRACIOR- Registratton'`110960 r a } 4w� tti 1YPe ; INDIVIDUAL g s �Ir��SExpir-ation' y$#il/18/98 ., �„ LAARENCE 1 MCDONOUGH 4 - ADMINISTRATORENCE T NCOONOU6H tip: N , 48 CERDAN AVE-"'P t I 1. The• C(;nz montrealth of Massachusetts „;,: _ *---.J"y Department of Industrial Accidents ' 011/ceol/mrest/9a1/oos . iiw L 1.iti '' � ^' 601) ri'ashinrton Street Boston.Mass. (12111 �- Workers' Compensation Insurance Affidavit Please PRINT le 1 AnnLcpnt information .i1LY ae�— me �ryd11�s/rlE/►�C� T� ��O7?(lYtd/! ' GC�2n,�i✓ � nhonc#�/ I am a homeowner performing all work myself. am a sole proprietor and have no.one working in any capacity i..:.�:air':"e"? '%"`-""'-;'T:..:: 3�.= ., •.1 .� _ -- --- I am an employer providing workers' compensation for my employees working on this job. id s cot nhonc#� insurance co policy# 1 am a sole proprietor,general contractor,or homeowner(circle one)and.have hired the contractors listed below who have the following workers' compensation polices. company name- addresse phone#• policy# tU`' — vcn z-.L sa�ec-eerti-z i^T.� "S7.y.•4--+nr.�neaaa.-r�yr �3 tom am•name--- address, - cit phone#t insurance co policy# .Attach additional'sheef if'necessa •�� +"•^'�"" ..+�..: { r` '°"�""' Failure to secure coverage as required under section 25A of 111GL 152 can lead to the imposition of criminal penalties of a fine up to Si.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a cope of this statement may be forwarded to the Office of investigations of the DIA for coverage verification. I do berebr certify under the pains and penalties of perjun•that the iafornwtion provided above is true and correct. i ISi_nature Date SJ �2 Print name L�L✓rZfi�yG T /l�Gr]rYI01/(/� Phone r ofiid2i use only do not write in this area to be completed by city or town official, city or town: permit/license# riBuilding Department C3Licensing Board check if immediate response is required O5eleetmen's Once �liealth Department contact person• phone#; r•IUther�_ 4 (wised 3,4)3 P1A)