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0363 BUCKSKIN PATH
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Director BU�ding Division Tom Perry,CIRO'Baildhzg Comm�lsslaner ` Z00 Main Street,Hyannis;kA 92601 Office: 508-862-4038 Wwwtowabantstgblcmtns EXIPRE55ZUMLAPP AT,14N - R +S]D Fax.:508 790-6230 Ma$/parcel Number���/� Not v��our.RedaCp�lp�,1r�j �QN—LY _ Property Address ( �� ��-�-�5��� �j9-. • R iae al Valve of%&$ Owner's Name,&AdderARM mm fee of$35.00 for work under$6000.00 yct- �(� 0�3 Contractor's Name O Home bmprovemif Telephone Numnber Contactor License#( applicable). � Constrncxion Supervisor's License#(if applicable ) 1c)Ioa7 Wow-s cozupensation 7nsnrance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have WOWS Cation Insurance Insurance CompaoyName /(J Worknoan s Comp.Policy# W (� Copy of[nyy nce Compliance C"Meate writ accomp y each Permit: Re- f(hu ricane nailed)(stripping old shingles) AU constatcdon debris I`2 wilt be taken to C� ❑ Re-,Side Of(hurricane na0ed)(not stripping. Gamgover — g layers ofroo ❑ RePhc'nwnt Windows/dOaWsliders,.0 Vaine roof) ' (maximum 35),#of windows . -❑ SmokJ #of doors: Carbon Monoxide d .Where iatie Electrical&Fite Permits" s marked with red S and inspections required. �� Lssaancauft�apermndu�aotesempc Note: wah otba town d La ffrscaric Conservation,etc er gn prof Y Owner Letter of P A copy of g ermissioo. required. hwrovement C ti'actors LicenSe,&Construction Supervisors License is SIGNATURE; T*%EVIN D)Bunftg 1ERP Revised 061313 RHSs doe The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 e� www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):THE HOME DEPOT AT-HOME SERVICES Address:9D8 BOSTON TPK City/State/Zip:SHREWSBURY, MA 01545 Phone#:508-962-6942 Ar4ou an employer?Check the appropriate box: Type of project(required): . IQ I am a employer with-24M employees(full and/or part-time).° 7. 0 New C011struCUOn 2. I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required-] - $• Remodeling 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t Q addition 4:a I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.�ROOf repairs ese sub-contractors have employees and have workers'comp.insurance? 6.[]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:NEW HAMPSHIRE INSURANCE COMPANY Policy#or Self-ins.Lic.#:017731493 Expiration Date:3/1/2016 Job Site`Address: 263 aeK5KON �/lF'r w City/State/Zip: Attach a copy'of the workers'compensation policy declaration page(showing the policy number and expilration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as w as civil penalties iu-tho form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy th' statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tl ns and pef lties o iat the information provided abov is tru a/nd correct. Signature: Date: ; �b Phone#:401-714-6399 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 J Contact Person: / Phone#: �*rr tfi HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by: PLEASE READ THIS CONTRACT THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike Unit 1,Shrewsbury,MA 1545 Branch Name: Boston North Date:1/23/2016 Toll Free 8779033768;Fax 8009863610ME Lic#C 02439 RI Cont.Lic#16427 CT Lic#HIC.0565522 MA Home Improvement Branch No: 33 Contractor Reg.#126893 Federal ID# 75-2698460 Installation Address: 363 Buckskin Path CENTERVILLE MA 02632 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: Mr.Adam Denoncourt (508)958-5438 Mrs. Petya Denoncourt 508 958-5438 Home Address: 363 Buckskin Path CENTERVILLE MA 02632 (If different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates):adeno736(a,gmail.com Marketing emails will not be sent from The Home Depot. Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,and THD At-Home Services,Inc.("The Home Depot')agrees to furnish,deliver and arrange for the installation("Installati on")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary(where applicable)attached hereto and any Change Orders(collectively,"Contract'): Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount 8936507 Roofing 8936507 $16,394.76 Minimum 25% Deposit of Contract Amount Total Contract Amount $16,394.76 due upon execution of this contract Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns, pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary# 8936507 ,included as part of this Contract,sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). 06/17/14SA Page 1 of 7 s,1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS CONTRACT NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time of sign.Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor, expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law.THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVER OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Contract is the entire agreement between Customer and The Home Depot with regard to the products and installation services and supersedes all prior discussions and agreements, either oral or written,relating to.said products and installation.This Contract cannot be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. You are entitled to a paper copy of this Agreement if you choose. If you consent to an emailed copy,your consent applies only to this Agreement.By contacting sales office (R77)903--176g ,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement at no charge. By signing below,you confirm the following: • You consent to receive only an emailed copy of this Agreement • You have access to a computer that can receive and open emails and PDF(Adobe Reader Version 10.1.4 or later)formatted documents. • Your email address is correctly listed on the Home Improvement Contract Submitted by: Accepted by: Mr.Adam Denwcourt(Jan 23.2016,2:48 PM) Sales Consultant Christopher G.Read Customer License Name. Signature: (877)903-3768 Customer Telephone No. Signature: Accepted by:Christopher Read(Jan 23,2016;2:48 Sales Consultant PM) License No. (as applicable) CANCELLATION:CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT.THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE 06/17114SA Page 7 of 7 r ® F DATE(MMIDOIPYYY) .4CORCI CERTIFICATE OF LIABILITY INSURANCE o2r?5r2o1s d... . 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 MARSH USA.,INC. NAME: _ PHONE --FAX TWO ALLIANCE CENTER -tC ,EVIL— 3560 LENOX ROAD.SUITE 2400 EMAIL ATLANTA,GA 30326 ADoa���.�. IN$URER(s)AFFORDING COVERAGES---, y� NAIC 0. 100492-HonteD-GAW'-15-16 INSURER A!Steadfast Insurance Cornpany 26387 INSURED ZurichAnlericanInsuranceCo �16535 —� THE HOME DEPOT,INC. INSURERS:B: _ _ HOME DEPOT U.S.A.,INC. INSURER C:New Hampshire Ins Co 236<+1 245S PACES FERRY ROAD,NW INSURER D:Illinois National Insurance Company 23817 BUILDING C-20 —-- -�— ATLANTA,GA 30339 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: ATL-W3156127.07 REVISION NUMBER:I 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 POLI CIES:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ 1N RR — TYPE'OF INSURANCE IN OL POLICY NUM9ERw~T ^^ POLICY EFY h DDIYYYY,- _- LIMITS ti A GENERALLIAsturY GLO4887714.05 03101)2015 0310112016 EACH OCCURRENCE f S' 9,000,000 X DAMAGE T�RERYED —1.0!?O,OO/. COMMERCIAL GENERAL LIABILITY PR IV", ESES(Eagccunence)_ S,_,r„_-___. _ -� L J LIMITS OF POLICY XS, EXCLUDED CLAIMS-MADE 17— l OCCUR- MED£XP(Any one person OF SIR;Si M PER OCC PERSONAL a AOV INJURY s 9,000 060 GENERAL AGGREGATE .S-.,-.w.....�—. 9,00.000 G;E�N'L AGGREGATE LIMIT APPLIES PER; PRODUCTS•COMPIOP AGG $ 9,000,000 _ JECT I—] ^,I POLICY PRO- ( LOC I S 8 AUTOMOBILE LIABILITY BAP 2938863.12 03101/2015 0310112016 COMBINED SINGLE LIMIT 1,000,ox '. Ea aaident _ `S . . X ANY AUTO - BODILY INJURY(Per person) S ALL OWNED jSCHEDULED SELF INSUREDAUT'OP.HY1DMG BODILYINJURY(Per.accideng 'S AUTOS AUTOS - I - .' NON-OWNED PROPERTY.pAN1AGE - �HIREDAUTOS AUTOS �. '; (PeraccidentL S UMBRELLA L1AB ,_�OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-Mr OE AGGREGATE DED RETENTION S M C WORKERS COMPENSATION iWC017731493(ADS) 03101/2015 03101016 X WC STATU- OTH. AND EMPLOYERS'LIABILITY T5.— EB_ ANY pROPRIE70R1PARTNERiEXECUTIVE y r N WC017731495(AK,KY;NH;NJ;VT) 0310112015 0310112016 E.L.EACH ACCIDENT 1,000,000 5 C OFFICERIMEMBER EXCLUDED? 5 LA — D WC017731494(FL) 0 I(Mandatory In NH) 3:10112015 03101?2015 E L,DISEASE•EA EMPLOYEE S 1 000,000 it yes,describe under Conitnued on Additional Page 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE.POLICY LIMIT S- f , I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORO iO1,,Additional:Remarks Schedule,Amore space is requiredl CERTIFICATE HOLDER CANCELLATION TOWN OF ABINGTON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 500GLINIEWICZWAY, THE EXPIRATION DATE THEREOF, NOTICE WILL BE, DELIVERED, IN ABINGTON,MA 02351 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ManashiMukheriee ,Mauco�% T4+ti-tnar�s� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i y I r r - 3 7 — ry e ..-- efr:'YU1�Lf�Zl-L'21:GG�lZ Office of j Consumer hairs and Business Regulation ` - i 0 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home improver enf Contractor Registration Registration: 128893 - - - Type: Supplement Card THD AT HOME SERVICES, INC. . - _. = Expiration: s/3i2016 ANDREW SWEET 2690 CUMBERLAND PARKWAY SUITE=300 `.�:_ ATLANTA, GA 30339 - - - - Update Address and return card.hark reason for chance. scA t 2oN-osni Address �_� Renewal a Employment f j Lost Card C��e C�a�icaun�ccrre�clf�.0��0/�lrcrs�cr,�u�etdi =Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ' before the expiration date. If found return to: — go IMPROVEMENT CONTRACTOR p �Re istrationType: Office of Consumer Affairs and Business Regulation . 9 126893 TYPe 10 Park Plaza-Suite 5170 Expiration g)3/2016 ;';: Supplement Card Boston,MA 02116 THD AT HOME SERVICESINC` THE HOME DEPOT AT HOMESERVICES ANDREW SWEET,... 2690 CUMBERLAND PARKWAY S 7 �— A"f11 ,GA 30339 Undersecretary No4iwitut signature Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avolicant Information Please Print Legibly Name(Business/Organization/Individual): 01L _qCjQd 4 p —.6 Address: lva0erly . City/State/Zip: l A 61'V Phone#: 909?-3 Are you an employer?Chec the appropriate bog: Type of project(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.XI 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' insurance. 9:: ❑Building addition comp.[No workers' comp.insurance p• required.] 5.-❑ We are a corporation and its ME]Electrical repairs or.additions 3.❑ I am a homeowner doing all work officers have exercised their. 11.0 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. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance verage verification. I do hereby c u e t e pains a44j&alties o er ug that the information provided above is true and correct Sionature. _ Date' _.. Phone#: Official use only. Do not write in this area,to be completed by.city or town offcciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: 4"lite off Mitts i� piarfinerit of�Puts{�c� <tfety Boat�l�t`�$�it�t�t�f2egi�latt�r�5 aia�i 5tarrdard5, acense CSSL 904Q2T Cons Mcf100, " i T63 WAV12!Y STILE , r H FRAMM HAM MAC Q171f2 �} „ S yya wff,�} i Of THE Try, Town of Barnstable *Permit# jI Expir s 6 months frorn issue date BARNSCABLE, ; Regulatory Services Fee v� Mass Thomas F. Geiler, Director . AlfD `�� Building Division / Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 �f'�31D9 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-79076230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address���( 3wc,���.i�.. � ✓✓ ' ["Residential Value of Work G 3 UU Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address tic.—, �1_ Contractor's Name C- Q 1NL�C,c. ✓1 Telephone Number �5_0b7'74- 10D 0 - r Home Improvement Contractor License#(if applicable) %U U -2 G Construction Supervisor's License#(if applicable) C U � ❑Workman's Compensation Insurance ®PRESS PERMIT Check one: ❑ I am a sole proprietor 'JUL 10 2009, ❑ I am the Homeowner [ l have Worker's Compensation Insurance �-®wN OF BARNSTAKE . Insurance Company Name Workman's Comp. Policy# / z Z t: U 0 S 1 ' U Nf6� �U c Copy of Insurance Compliance Certificate must be on,rile. Permit Request(check box) ❑ Re-roof(strippirig old shingles) All construction debris will be to ❑ Re-roof(not stripping. Going over existing layers of roof) . to-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License& Construct Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\Express\EXPRESS PERMIT.DOC Revise06O4O9 `i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 sJ•y, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): G,v` c,. Address: City/State/Zip: •-. taw^^ NSA—c>2 G 3Z Phone.#: 5 U �77L C��C� Are you an employer? Check the appropriate bog: Type of project(required): 1.M- am a er y emP to with .2_ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-titn.e).* have hired the sub-contractors listed on the attached sheet. T. ❑Remodeling 2.❑ 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 ❑Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its '10.0 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.EM0ther 1 z- w . , comp.insurance required.] *My 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: -Z w✓L,z4 A1.1.e,i C—e-, _ Policy#or Self-ins.Lic.#: (9 Z Z to V Q If f 10 Expiration Dater 5113 10 Job Site Address: e3 L -5 l�sd�Y. �� City/State/Zip: C,,,I ,,bt. 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 penalties ofperjury that the information provided above is true and correct. Si ature: Date: y ) _ Phone#: '5-6) -7 2 L o2��CJ 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#: 41 ,f 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 tiustee 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«Zth 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-contiactor(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 confirm lion 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 necessarv)and under"Job Site Address" I.he applicant should write"all locations in (city or town),".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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 ln.dustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia JUL-10-2009 12:26 LOUELY AGENCY P.02 ACORD,. CERTIFICATE OF LIABILITY INSURANCE o7r�o�2oos ,. 508-543-3131 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 40DUGFA ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE THE LOVELY INSURANCE AGENCY, LTD HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6 RA!LROAD'AVENUE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 BOX 374 NAIC# FOXBOROUGH,MA 02036 _ INSURERS AFFORDING COVERAGE ___ - "' INSURERA: ZURICH AMERICAN ISURED MOGAN 8 CO„ INC. IN6URER B: 68 JOYCE ANN ROAD INSURERc; CENTERVILLE.MA 02632 INSURER D: INSURER E; 'OVERAGES THE POLICIES OF INSURANCE LISTED BCONTRACT OR OTHER DOCUMENT WITH ORESPECT TO WHICH THIS CERTIFICATE MAYVE FOR THE POLICY PERIOD INDicATED, O IEIISSUEDI AN OR ANY REQUIREMENT,TERM OR CONDITION OF MAY PERTAIN,THE INSURANCE AFFORDED 0Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED 6Y PAID CLAIMS, ____ •—• ..__. -- —— -- ' -- POLICY EFFECTIVE -PO LIC EXPIRATIO . LIMITSJSR 0131 POLICYNUM9ER EACH OCCURRENCE I GENERAL LIABILITY d S " PR ISES otCure 4° COMMERCIAL GENERAL LIABILITY MEDEXP Anyone arson) S CLAIMS MADE 7 OCCUR PERSONALJ4�DVINJURY 6 GENERALAGGREGATE S PRODUCTS-COMPIOPAGG 6 GEN'LAGGREGATE LIMIT APPLIES PER. POLICY PRO) LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT . (E a eeeldenq ANY AUTO ALLOWNEDAUTOS BODILY INJURY g (Per person), SCHEDULED AUTOS HIREDAUT08 BODILY INJURY g (Pervcidant) NON)OWNEDAUTOS PROPERTY DAMAGE S ' (Per auidmi) AUTOONLY)EAACCIDENT S QARAGE),IAWLITY EA ACC S OTMERTHAN •• ANY AUTO AUTOONLY: AGO S EACNOCCURRENCE 6 Fxgd$$JUMGRELLA LIABIUTY AGGREGATE S OCCUR CLAIMS MADE DEDuc7IDLE �^ ........` $ RETENTION S / T X WC STATIU) OTH) . WORKERS COMPENSATION AND 05/14109 05114/10 E,L.EACH ACCIDENY 6 1 OO OOO A EMPLOYERS,LIABILITY 6ZZU80510N35-2.09 ANY PROIPRIETORIPARTNERJEX-ECUTIVE �a _ E.L.DISEASE I EAEMPLOYEE I 500.000 OFFICERIMEMBER EXCLUOED? Ify ea,deeclpe under E.L.DISEASE)POLICY LIMIT S 100,000 6PECIALFR VISION eeloyJ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUBIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS. USUAL TO THE OPERATION OF THE INSURED CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCR18E0 POLICIES BE CANCELLED BEFORE THE EXPIRATION 4TEREOF, HE 186UING INSURER WILL NOEAVOR TO MAIL 1 O DAYS WRITTEN TOWN OF BARNS7ABLE BUILDING DEPT. ERTIFI 7E MOLDER NA D TO TH T BUT FAILVRE TO DO SO SHALL BOO MAIN STREET TION OR LIA61F A IND UP THE IN9URER IT5 AGENTIi OR HYANNIS, MA 02601 IS N FAX 608-790-6230 'AC CORPORATION 1988 ACORO 25(2001108) TOTAL P.02 6usrd'of Bw!uiog.Regu{aiionslnd Shndards .,iceusc.or i egistr.ation valid for indi idu,{use only HOME IMPROVEMENT CONTRACTOR before the expiration dale. Il found return to: '.+ 134ard of Building Regulations and Standards lug f egis ration 100718 pne Ashburton Placc Rm 13U1 ExprraUon 6/�3/2010 Tr# ,267851 }tostcn,im3 .02108 Type Pr4ii Corporation. j MOGAN CO 'NC Francis Mogan jr.:, C; ':)l CE-AN" R�, W►i s:=Lst ur. a tt MA C263 mims 2 Adtrato 'foul rat >~ � g ',' te'q k Xi`Sk A FU `...• ._._ �FM ,t. `4 ' q iBoard bf Budding Regulations and'S,tandar ds �� Construction;Supervisor License'= License CS x 26071 ' ! Birthdate 10/3/1947 �Ezpiratio 0/3/2009 , Tr# 5081' i Restnction�4y m� �S _ + r. 68 JOYCE�ANN RD��,�,�� {. i CENTERVILLE,MA 02632"r a Commissioner" t i , sro � Town of Barn-stable ` Regulatory Services BAIMp MM.s,& $ Thomas F.Geiler,Director 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 509-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �„)�,,L� � , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. 36-3 (Address of rob) Signatnr of Owner Date a G- C '� Print Nam If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Town of Barnstable Regulatory Services - - Thomas F. Geiler,Director RARN9UBET,IN = Building Division plFD µA{ Tom Perry,Building Commissioner 200 Mairi Streeter Hyannis;MA 02601 _....._.. w".town.b arnstable-ma.us Office: 50 8-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for`homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to- be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned."homeowner"certifies that-he/she understands the Town of Barnstable,Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such work,that such Homeowner shall ad 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 hints unlicensed persons. In this ease,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 ofhis/hcr rasponnbiilitirs,many communities require,as part of the permit application, current] used b ' that hdshe understands the responsibilities of a Supervisor. On the last page of this issue is a form y Y that the homeowner comfy rerp up several towns. You may can t amend and adopt such a form1certifi cation.for use in your Community. Q:forms:homccxempt Fv l dCs��Z��� f �-� • Tp�� Town of Barnstable *Permit# Expires 6 moat .jrom PROF THE i e dale Regulatory Services Fee , y i BARNSTABLE, y MASS, g Thomas F.Geiler, Director �t�ll69 039. �� ATED MPy A Building Division Tom Perry,CBO, Building Commissioner 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 Imprint Map/parcel Number Property AddressL. ❑ Residential Value of Work c��� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address w Contractor's Name vvux. Telephone Number y U b -77L 2 V 70 I tome Improvement Contractor License#(if applicable) / D U —7 15 Construction Supervisor's License# (if applicable) 0-7 7 ❑Workman's Compensation Insurance Check one: ❑ 1 am a sole proprietor. ❑ 1 am the Homeowner []J-1 have Worker's Compensation Insurance -PRESS PERMIT Insurance Company Name 2,....,n_r In "09 Workman's Comp. Policy# G L-13 9 S' 7 1-/6 b/ O �) _FBHRNSTABLE 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 (V/Replacement Window door 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: c. A i,i-II.t.S\I.olZMS\buildin ermit forms\EXPRESS.doc Revised 100608 I e The Commonwealth of Massachusetts rA Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): •w1 g4 4't- Address: 1 0�1 TkLQ City/State/Zip: L),; z VVk_pC_()zG3Z Phone.#: 'SD 7 Z ;LU-10 Are you an employer?Check the appropriate box: Type of project(required): L❑ 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:❑ I am a sole proprietor or parttler-' 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' 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'compansatim policy information. t Homeowners who submit this affidavit indicating they are doing all work and than has outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. if the subcontractors have employees,they must providt 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: —Z Policy#or Self-ins.Lie.#: l Z 2(,( 3 �j' 7 t/ -,9`0 Expiration Date: Job Site Address: '36-3 City/State/Zip:'CG L,,-I A OZO� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure io secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a find 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 Inves gations of the DIA for insurance coverage verification. I do hereby certify and r the pains•and penalties ofperjury that the information provided above is true and correct. Signature: Date: ..? _ Phone# (' 7 7 L Official use only. Do not write in this area,to be completed by city or town offccial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health'2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone M Information and Instructions f 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 fpregoing-engaged m ajorn n rpr�se; =ine-lu�nfle le represen�aliVef- dease�-empiarthe= --.- receiver or trustee of an individual,partnership,association or other legal entity,employing employees.'However the owner of a dwelling house having not mare 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-Conti-actors)name(s),address(es)andphone number(s) along with their certificates)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 is the permitflicense number which will be'used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit cap 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 pitizen is obtaining a license or permit not related to any business or commercial venture (ie.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to-thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone-and fax number. The Commonwealth of MassachuseM Department of Industrial Accidents Office of Investigations 600 WmMngton Street Boston,MA 02111 TO. # 617-727-4904 ext-406 or 1-977-MASSAFE Revised 11-22-06 Fax# 617-727-774R www.mass.gov/dia t: T Wrti Town of Barnstable . F Regulatory Services y $, Thomas F.Geiler,Director ��EDµ9- 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town-barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder ��J wL- as Owner of the subject property hereby authorize C VVLo!cJ to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signa of Owner Date Print NaAae t. If Property Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. O:FORMS:O%WF-"ERMISSION Town of Barnstable , N'�P�o4 zttE r�~� Regulatory Services Rl R Thomas F. Gaer,Director r NCr�RT P • � 0.19..16 Building Division prED Tom Perry,Building Commissioner 200)vf -Streeter Hyannis;M -02fiD 1 www.town.barnstable-ma.us Office: 508-962-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE JOB LOCATION: - number street village "HOMEOWNER": name home phone# work phone# CURRENT MAMING ADDRESS: cityhown state rip code The cmTent 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 siructures accessory to such use and/or farm strictures. 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 resgonsib}e for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"asst es responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned.."homeownee'certifies that-he/she understands the Town of Barrastable,BuildiugDcpartment minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any bomw"cr performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Liccnsbrg of construction Supervisors);provided that if the homeowner engages a pason(s)for hire to do such work,that such Homeowner shall ad as supervisor." Many homeowners who use this exemption art unaware that they art assurr7ng the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Constroction Supervisor,,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires rmlicmsed persons. In this case,our Board cannot proceed against.the unlicarsed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultirnateJy 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 hdshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by care t amend and adopt sueb a fmaileertification.for use in ur community. several towns. You may op Yo tY Y Q:forTns:homocrccmpt -" IDATE(MMIDD/YYYY) . CORD, CERTIFICATE OF LIABILITY 1NSU'RANCE 1/22/2009 RooucER 508-543-3131 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE LOVELY INSURANCE AGENCY, LTD. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6 RAILROAD AVENUE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 BOX 374 TNAIC70FOXBOROUGH INSURERS AFFORDING COVERAGE _— NSURED MOGAN&CO., INC. INsuRERA: AMERICAN=ZURICH INSURANCE CO. I _ — 68 JOYCE ANN RD. wsURERB: --- CENTERVILLE, MA 02632 wsURERC: -- -- INSURER D: INSURER E:..- . COVERAGES ANY ROEOUIREME TSTERMCORICONDITION OF ANY CONTRACT OR OTHER DOCUMENT AVE BEEN ISSUED TO THE INSURED EWITH RESPECT TO WH CH THIS CERTIFICATE MAY BIE I(SSUEDIOR 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. LIMITS POLICY EFFECTIVE POLICY EXPIRATION NSR DO'� _—r_---- POLICY NUMBER - EACH OCCURRENCE GENERAL LIABILITY - - 6AFfi�GE.TO-Ft�NTE6— $ PREMISES(Ea occurence)-�^� — COMMERCIAL GENERAL LIABILITY MED EXP(Any one person) $ _— CLAIMS MADE OCCUR PERSONAL&ADV INJURY - :GENERALAGGREGATE 1!$- - -- - -- PRODUCTS>COMPlOP AGG: � 6 APPLIES PER. - GENLAGGREGAT (�j I POLId4':I PRO:. .7 -711 LOC . '.-... - _ f .... .. .. - _. . _ _ ..... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO r ALL OWNED AUTOS j 60DILYINJURY $ (Per person) j SCHEDULED AUTOS HIREDAUTOS BODILYINJURY $ (Per accident) NON•OWNEDAUTOS PROPERTY DAMAGE $ (Per accident) .. -..... _.. .:... AUTO ONLY•EA ACCIDENT-- $ GARAGE LIABILITY EA ACC I$ - OTHERTHAN J— ANY AUTO AUTO ONLY: AGG $ EACH OCCURRENCE $ — I EXCESSIUMBRELLA LIABILITY i � AGGREGATE $ I OCCUR CLAIMS MADE - - - $ DEDUCTIBLE - $" RETENTION r I _ . X TORYtIMITS �_ _ WORKERS COMPENSATION AND gZZU6-9574A81-8 08 O5/14I2008 O5I14/2009.. ;'$ 100,000 E L EACH ACCIDENT AEMPLOYERS'LIABILITY' — ANYPROPRIETORIPARTNER/EXECUTIVE I, EL DISEASE EAEMRLOYEE $: �SOO,000 OFFICER/MEMBER EXCLUDED 100,000 1 It es,describe under l E L DISEASE POLICY LIMIT $ ISPECIAL PROVISIONS below_ ..- ------I� I,OTHER I. _ .. ... - I•. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ON ALL OPERATIONS USUAL TO THE BUSINESS OF THE INSURED. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEE XPIRATION TOWN OF BARNSTABLE. DATE THEREOF,THE ISSUING INSURER WILLJQDEAVOR TO MAIL DAYS WRITTEN 206 MAIN ST. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL HYANNIS, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR FAX: 508-790-6230 REPRESENTATIVES. r' p AUTHORIZED REPRESENTTJVE L PORATION 1988 ACORD 26(2001/08) jK.,. Board of Building Regulations and Standards ¢ .. ° x Construction Supeisor License ry l License:-CS -,26071 ° ! BirthdateL 10/3/1947, x,^ tEzpiratio 1n 0�3J,2009 Tr# 5081 cRestric'tio�0 { FRANCIS E MOGA 68 JOYCE ANN RD yak s CENTERVILLE,MA 02632 Commissioner " a B oia r d of liwld ne°Regulations and Shndards 7, L iceus�of icgist ..tiun valid �oE 1:1mQnidul use only d HOME IMPROVEMENT CONTRACTOR uefo!a the expiration d.te II Cound rctui n to: t'eOisYration 100718 s1391i d of aui.lduig ltegdl kit, au.i Standards 5. E'piiration 6/�3/2010 `Tr# 267851 Unc As1�Lur.on Place RIP 1301 71." QStGil .lNla 0. 108 7 11, Tpe `Prvale Corporation MOGAN GO 'NCB; t , . F, n c i Mogan .ir�Y V tUa'' - �� -q CE-ANi'E,R6,,"K- enw 026?2 �:u MA - _ f�dltiiOlStratO `� ``. itiC:.. d�17 ilQUt Slii3tLLrC �pFIKE r Town of Barnstable *Permit# Expires 6 months om sPe�date Regulatory Services Fee r -, anaxsenatr;, Thomas F.Geiler,Director 9�A1639. 16 Building Division ploy �L+ lFD MA'I /I Tom Perry,CBO, Building Commissioner V 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number rProp Address 1U_� I,`�.����5�+�.` �.�.�. �.-..� ✓�1-L Residential Value of Work ),00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number , Ob 7 7 i2 y7C> Home Improvement Contractor License#(if applicable) /LJ('> .7 U*/Orkman's Compensation Insurance Check one:❑ I am a sole proprietorX-PRESS IT❑ I am the Homeowner a'I have Worker's Compensation Insurance FEB — 6 2009 Insurance Company Name —,71 TDI IN OF B n RNSTABLE Workman's Comp. Policy# (. Z L 13 9 5 7 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side [�]" Replacement Windows/doors/sliders.U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. .A copy of the Home Improvement Contractors License is required. SIGNATURE: G I t y Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: G 0 City/State/Zip: C.�— �� Vl, L Phone.#: 3 L.���U Are you an employer?Check the appropriate box: Type of project(required): 1.21 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors .2:❑ I am a sole proprietor or partner- listed on the attached sheet. 7. .❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'•comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its "101] 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. tContractoms that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,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.#: (-,.`Z-Z 5.S-7 ` A-b/ y-vv Expiration Date: J 1 I -i� L)� Job Site Address: .It, 3 City/State/Zip: Ct •(P4&;� 1"A-A- 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 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 Investigations of the DIA for insurance coverage verification: I do hereby certtt&under the pains and penalties ofperjury that the information provided above is true and correct Signattue: 2 ���//� Date: Phone#• 2.61- 4,) 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 ofhe foregoing-engag in joint-enferprisee a d melu�m`g=the legal-representatives of de aced mpio�er,urrthe- ----- 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 azth 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-contractors)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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense 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 maybe 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 fo 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 o€Massachusetts Department of Industrial Accidents 0mce of Investigations 600 Washington Street Boston, MA 02111 TO. #617-727-4900 ext-406 or 1-977-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass gov(dia CA zl�ti Town of Barnstable Regulatory Services r s BAANSTARM • y MAB.9. $, Thomas F.Geiler,Director 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 ABuilder I, :UJ2,-n ��, � , as Owner of the subject property hereby authorize V*"Vc04 to act on my behalf, in all matters relative to work authorized bythis building permit application for: (Address of Job) Siknatqie of Owner Date Print N If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RMS:O WNERPERMISSION Town of Barnstable Regulatory Services Thomas F.Geiler,Director MASS. Building Division Tom Perry,Building Commissioner _ :....._.._... - -200 Maid Streets Hyannis,MA 02601 _..__.... ...._.. __...- .. _ ._. ..... . . __.______-_... .. _. www.town.barnstable-ma.us Office: 508-862-4038 " ' Fax: 508-790-623,0 HOWOWNER LICENSE EXEMPTION Please Print JOB LOCATION: .3 L+ 1 .e._LL .L ,'J �`��-✓1✓ .. �number street village "HOMEOWNER": '�y�'�I In 1,c. G... ✓ `�L�s Zz J17 name home phone# work phone# CURRENT MAILING ADDRESS: J Ceiba t L 1. �o.,• 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 Persons)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 hermit. (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 'o rocedures and requirements and that e c procedures d minimum inspection p 4u he/she will comply with sand pine ur s an 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 ad as supervisor." Many homeowners who use this exemption art unaware that they are assunring 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 hirrs unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt j ,p� ✓�te i0omvmoozcuect� a�✓l�LrzQduc�u'Board of Building Regulations and Standards l License or,rcgistratu,u valid for indisidul use only HOME IMPROVEMENT CONTRACTOR ucfore tLe espiratioir date.:lf lowid return to: " f;e�istratton,ay 1007,18 111 d of Building kegul,itions and Standards Expiration,__6/23/2010 Tr# 267851 One Aslibm•.on Placc Rin 1301 :Tyner F'ivaie Corporation 13ustc n,i17a.02108 - MOGAN&CO, 1`6�ncis..Mogan Jr - 08 OYCE-AN"c RI? 7-7 g` I -- Cen.c ,e,MA C2632 r — -- Adrninistrato� \ ai d wi tout sig utum x Co6'I!%/pt0mwe O ✓I�GCtQ6 ivaeGCp i . i. Board of Buildm Re ulatrons"and St it dard ns Pl i Construction Supervisor License .. License CS 26071'` Blrthde� /3%1947 r 1 I E P 'Or�31�2009 Ti# 5081 f N. R strfc ton; Orb : I FRANCIS E MOGgt7 68 JOYCE ANN RD�`r, CENTERVILLE,MA 02 3 S .. Commissioner + v JAN-22-2009 09:29 LOVELY AGENCY P.01i01 � ti CERTIFICATE OF LIABILITY INSURANCE °0112212009"' DDUCER 508-543.3131 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE LOVELY INSURANCE AGENCY, LTD. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE " - HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6 RAILROAD AVENUE ALTER THE COVE AGE AFFORDED BY THE POLICIES BELOW. P O BOX 374 FOXBOROUGH INSURERS AFFORDING COVERAGE NAIC INSURED MOGAN&CO,, INC.. INSURERA: AMERICAN-ZURICH INSURANCE CO. 68 JOYCE ANN RD, INSURER B' -_ _• _,—___-,_-. CENTERVILLE, MA 02632 �-INSURERE: 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 ISSUEO 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. _ _,—_--,__, , „•,_- S- DD' -LTA NQAn TYPE OF INSURAN POLICYNUMHER POLICY EFFECTIVE POLICY X IAA71OR LIMITS GENERAL LIABILITY EACH OCCURRENCE 5 - �l/(MAGE TO p6T1TE[3-- • COMMERCIAL GENERAL LIABILITY PREMISES(Eeoccurence) , S --,,, ,. CLAIMS MADE U OCCUR MEDE..( PE Anxone ereon) S RSONA LAAOV�NJURY GENERA AGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER. I PRODUCTS•COMP/OPAGG POLICY PRO. LOC AUTOMOBILALIABWTY COMBINED SINGLE LIMIT $ ANY AUTO IEaaw cnl ALLOWNEDAUTOS BODILYINJURY S -- (Per person) SCHEDULEDAUTOS -•••• -- ---•• - M19EDAUTOD BODILYINJURY S (Pereccldanp NON.OWNEDAUTOB PROPERTY DAMAGE S --- "' (Peraccldent) GARAGE LIABILITY AUTO ONLY.EA ACCIDENT ANYAUTO OTHERTHAN EAACC $ AUTOONLY: AGG 3 EXCESWUMBRELLA LIABILITY EACH OCCURRENCE OCCUR U CLAIMS MADE AGGREOATE RDEDUCTIBLE — $ --- RETENTION 3 •G.I. STATU• H LALITVIONANG .I x. O"Tg...EML ,$A POYeR ' IBI 6ZZUB-9574A81-8-08 I05/1412008 05/14/2009 E.L.EACHACCIDENT .$.$. 100,000 • ANY PRORRIETOR/PARTNER/EXECUTIVE -' " OFFICERiMEMBER EXCLUDEO? E.L.DISE_ASE.EA EMPLOYEE $ _ 5ogjooO_ Ilyyeee deAerlaeunGer ( El,DISEASE.POLICY LIMIT $ 100 000 SPEt;'ALP I N low OTM[R I DESCRIPTION OF OPIRATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORGEMBNT/SPECIAL PROVISIONS ON ALL OPERATIONS USUAL TO THE BUSINESS OF THE INSURED, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DEBCRIORD POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF BARNSTABLE DATE THEREOF,THE ISSUING INSURER WILLIQDEAVOR TO MAIL DAYS WRITTEN 200 MAIN ST. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 00 SHALL HYANNIS, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 1148URER,ITS AGENTS OR FAX: 508-790-6230 REPRESENTATIVE% < ? AUTHORIZED REPRE T I. Aoll ACORD 26(2001/00) vcv.4141 _;5bmbvf7IPO RATION 1986 TnTOI CP nl i Hof Town of Bairnstable *Permit# S 2 S Expires 6 mbntbs fro(m�issu�e date SAWMAMA : Regulatory Services Fee 2 Thomas F.Geflers Director QED�;t► Building Division Tom Perry, Building Commissioner 200 Main Street,.Hyannis,MA 02601 PRi9S PERMIT Office:,508-862-4038 J U C 5 - 2005 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIA��Tlc� gARNSTABLE Not Valid without Red X Press Imprint Map/parcel Number Property Address 363 13 G• S 1� 3-IGesidential Value of Work E:E,(XC-. Minimum fee of!$25.00 for work under$6000.00 Owner's Name&Address wc,4jj,A 1�.II�-� ✓ Contractors-Name mQrje..vn Telephone Number 77.S— —')00 Home Improvement Contractor License#(if applicable) /� 7 Construction Supervisor's License#(if applicable) 02 G.0 7 1 ❑Workmen's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance Insurance Company Name '0 01140 W orkman's Comp.Policy# •7 2 (IL T", "U Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re roof(not stripping. Going over existing layers of roof) ❑ Re-side [l'REeplacement Windows. U-Value 3 7 ( .44). 'Where required: Issuance of this pewit does not exempt compliance with other tows dep atioas i.e.Historic,Conservation,etc. Sn Property '- - ***Note: PropertyOwner must si Pro a Owner Letter of P '` Board ofBuua,ugrR 1/ nd Steadards Home Improvement Contractors License is required. HOME IMPROVEMENT CONTRACTOR Signature R�� 100718 lug = 3i2006 QFarms:expmtrg I ` __ Corporation Revise063004 MOGAN$CO. I - j! Francis Mogan,Jr. 1 68.10YCE-ANNE Centerville,MA 02632 YAdmIRl3tr9tnr Town of Barnstable °;. Regulatory Services ysrnB , _ Thomas F.Geiler,Director 9 Building Division Tomperry, Building Commissioner 200 Main Street,IJyannis,MA 02601 www.town.barustable;ma.us Office: 508-862-4038 Fax: 508 790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder as Owner of the subject property o to-act on Mybehalf; hereby outhonzi} e:'• G `� in all ratters relative to work authorized bythis building permit application for: (Address of Job) ` S' afar of Owner Date Priat I'J !� The Commonwealth of Massachusetts •;* �- Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston,NIA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (9Cd f A� L- Address: G S ' y�A O;L e#L City/State/Zip: = ✓ v��� MA- P on : 5--©& 77 t ;2-70C> Are you an employer?Check the appropriate bog: Type of project(required): 1.U<am a employer with -3 4. ❑ I am a general contractor and I 6. ❑ New construction employees( part-time)to full and/or .* have hired the sub-contractors 7 Remodeling listed on the attached sheet. $ • ❑ Rdling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance r eqred.ui # employees. [No workers' ] 13.❑ Other �-c l.C_U 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 0Gs 19 Policy#or Self-ins.Lic. #: 7 2 Cal, CIS 7 Z/ 14 y 1 xpiration Date: Ld C' Job Site Address: L 3 _ L s� ��-. �e� � City/State/Zip: :2L n 'L 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 certi under t pains and penalties of perjury that the information provided above is true and correct Si afore: Date: O Phone#. 'Z2�;__ a "7UU 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#: II 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 me rise and including the legal representatives of a deceased employer,or the in a joint e g of the foregoing engaged ) enterprise, 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-contractors)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 n 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 ' not related to an busi ness or commercial venture year.Where a home owner or citizen is obtaining a license or pert y (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit for our cooperation and should you have any questions, The Office of Investigations would h'lce to thank you m advance o y p Y 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 Fax#617-727-7749 Revised 5-26705 www,mass.gov/dia THE TOWN OF BARNSTABLE 1639. a BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ...... ............................................................................................. ............................................................................ TYPE OF CONSTRUCTION, ......... 7*-----***--.... 19WF............... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the Glowing information: 01 Location ...... ......... ..A..eea7�4 ......... .................................................................... ProposedUse ..... ............................................................................................................................. ZoningDistrict .........................................................................Fire District .............................................................................. Name of Owner .....a��...... .............Address ..................L,...............I............................................... ................... Name of Builder ...........0b .........................................................Address ........... .................... Nameof Architect ..........%.......................................................Address .......................;,n........................................................... Number of Rooms ......Foundation .................I .............................................................. Exterior ' Roofing ..................................................R ...................;.......................................................... Floors ...........4AI-4A. -Ar.7 4. ......... ............................................Interior ....................I...............i...............................I................ j .01— Heating ......... ........... .........Plumbing .............. ....174401alop..................................... .................. ...................................................... ..../4 Fireplace ................ .........................Approximate Cost .... ............................................... Difinitive Plan Approved by Planning Board --------------------------------19-------- - Diagram of Lot and Building with Dimensions 110 Li. L Of 0 CL I Ld Ld > W > C) 0 < Cn 0 LL. 0 LL UIJ CL 0 0 r < z o (D co -L — 0 0 LLJ 1D Ld U) U) Uj 0 CL � < < r'< � aj Uj I-- I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ........................ Small, � ^ �II^ ~��^ DEC �� � ���� ' _. _ _ � ^wvu � � ~� I4208 two story, mo .--..--- Permit for .................................... | ` oiooIe fauzilY dnny ..............�*"*.-.--.--.---..��***"�~----- : &3 Buckskin Path Location --..���—.------.-.—.------.- . \ . .. �. CCenterville_ ! �^� —' '' ' 7-------''--'—'—'--------' . � JQ'an Goa]]- � Owner --------------------.—.. ' frame , | . Type of Construction .......................................... ' ----.-----_-------------.--- ^ | 2) P| � ( Permit Granted'--.. ..3l----.lg 71 ' | ` Dote of | lg � '~r~^ ' ' — ---' - Date Con�p|ete6�L. ��. ..��---]g -' ' 1y � ^ ^�, -~~ PERMIT REFUSED ^ --- —..--..--.-------.. 19 � � --.--"--.-------.—.-------.---. \ /~ . ' --~�'----'--------'-----------'' | ^ � '—^^^'—'—^'--`'`'~''`—~^~^^—~—~'- � ^^^~'~~~—~'^^--'`'-^^'^^^^---^''- / ' | ' ' / ~'-- .............................................. lg , r � . .. �^ '----' --'-'---'--~^^^^~—^^^^'~^^^—' ..............� --. . . . .� --~.-----...------..... �