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HomeMy WebLinkAbout1402 BUMPS RIVER ROAD t, x . Fir k 0 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 'Map' Parcel Application # Health Division Date Issued oZo �., Conservation Division ���•- Y1 Application Fee Planning Dept. i Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address 7- '6UA4 PT LCI-P.-. Village 1012.ti'-611ZVI l,l. - Owner Address Telephone Permit Request 3vIII-V N42-1. D$C4e_ bAJ QAIN-2 Df_ NOQSE_.' I,ANVI �Q S tt- o F A&.,raC- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 'roject Valuation 264 0&9, onstruction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ ,Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) NurrIber of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor m Cour --i Heat Type and Fuel: ❑ Gas ❑ Oil ' ❑ Electric ❑ Other fi n.. a < Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woo ;coal stovse: ❑"fbs ❑ No 01 ; Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barr): ❑ xisting --4 nev . size Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: C� Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 10Q6i. U�1 � Telephone Number s -'2 �`" Z PP C Address,()i , IZ 7 License# l�nq N MIL 1 L/A 00 Home Improvement Contractor# 1-1 5 3 7 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN SIGNATURE ALIn DATE ` FOR OFFICIAL USE ONLY f x LkPPLICATION# DATE ISSUED MAP/PARCEL NO. ' x ADDRESS VILLAGE OWNER ' DATE OF INSPECTION: FOUNDATION (' ),h os a �53013 FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ` F PLUMBING: ROUGH FINAL GAS: ROUGH FINAL `T FINAL BUILDING /L`UI I :i • DATE CLOSED OUT F 4 ASSOCIATION PLAN NO. . - ..•�• - •y' k rti The Commonwealth of Massachusetts Department of IndustrialAccidents. Office of Investigations r . 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/Organimtion/Individual): �Qy(t1 M U L Address: P.O. City/State/Zip:-. 5TZ)AJ5 M/Wd MA- Pto Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer.with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.[91 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 t3' 9.. ❑ Building addition [No workers'comp, insurance comp. insurance. 10. Electrical airs or additions required.] S. ❑ We are a corporation and its ❑ .reP 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 ��CiIG 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. xContractors 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'camp.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$1,50.0.00 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 dayagainst 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 nder the pains and penalties of perjury that the information provided abo is true and correct -Signstore: Date: Phone#: Sdo'7 37 Z,V 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 J 6. Other Contact Person: w' Phone-#: I i Information and .Instructions Ivlassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or-written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing-employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house' or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be'an employer." MGL chapter.152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a Iicense 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 cant'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 entertheir self-insurance license number on the appropriate line. ------- City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only,submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city.or. ' town)."A copy of the-affidavit that has.been officially stamped of 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.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 Massachusetts Department of Industrial Accidents - Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ex't 406 or 1-877-MASSAFE Fax#61 727-7749 Revised 4-24-07 WWW.mas OV/C1ia y 1 Town of Barnstable Regulatory Services y� mass Thomas F.Geiler,Director 1659,69 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.townbarnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, C/ as Ownex of the subject l property hereby authorize DIN U 4A V L l,rc3;,,J to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. §ignatu&f Owner Signature of pplicant Print NaLe Print Name AVO I ' If ( ZU` D Q:F0RW.0WNERPERb0SI0NPOOLS 62012 a 4, i Town of Barnstable PROF THE T�ti • Regulatory Services f Thomas F—Geiler,Director 16 a,�� Building Division ' FD Tom Perry,Building Commissioner s 200 Main Street; Hyannis,MA 02601 ` www.town.barnstable.ma.us Office: 508-862-4038 Fax:•508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print 1 DATE: . JOB LOCATION: number street village "HOMBO WNER": 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(g)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.L 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 perfomung work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibrlities,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. i Q:forms:homeexempt r Office of Consumer Affairs &Business Regulation-Mass.Gov Page 1 of-1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) �` Consumer Affairs and Business Regulation r. Home Consumer Home Improvement Contracting HIC Registration Complaints z Registration# 175317 _Home Improvement Contractor Registrant MULLEN BUILDING & REMODELING, LLC. Registration Home Page Name DOUGLAS MULLEN Address P.O. BOX 1274 City, State Zip MASTONSMILL, MA 02648 Expiration Date 05/03/2015 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search �f� '»°"""a"��Pa�C/ Z"� or re` a istratwn val►d for nd�v�du use oni Office of Cbffsumer Affairs&$dsmesy/ atton �v� g x HOTS��h.JiEw r CONTRACTOR the expiration date Ifa return to Registrations 3836 Type. 3 Office `Consumer ti ffa►rs and Business Regul�toq Expiratron 3121G2073 D"BA ! 10�Park:Ptaza Suite ' Boston;MA 02116 M EN BUILDINiREItA(3ALING a DOUGLAS MULLEN-­" - 59 N6BBY LN {. WESTYAR0OUTH,P*0267.3 A ersecretary f Not VaRgwit out Signature =� http://services.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=77213 5/6/2013 Massachtis'etts ;,Qep.artment:of-Public Safety Board of B:u.ildt!$ Regulations,and Standards F.. Cunstruc,46n Surcri"iwr License: CS-081995 `�\�� DOUGLAS WTLLEN\ 87 HICKORIIII�L i OSTERVILa 1 02655 L � 4\ IC`J ` Expiration Commissioner 01/23/2014 � , ' I j. 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Application Fee Tax Collector Permit Fee "s-0,0 Treasurer f SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE °F Planning Dept. WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address Village Owne,ODWA rA �CK-?� Address l`1 Q` �.1, 9--TJ Telephone 50�r 9r) ' I Permit Request A-D D 1 ilo* &Lar �IVo Ct�o�k &-i►4 vv /W) Q T &, )6 L41vz AAPa06 P',1R o if) Square feet: 1 st floor: existing proposed. 2nd floor: existing L4f) proposed Total new �tP Zoning District Flood Plain Groundwater Overlay Project Valuation 6110 000 .q=V' Construction Type Lot Size Grandfathered: ❑Yes Cl No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Struc ure Historic House: ❑Yes /No On Old King's Highway: ❑Yes ZNo Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 12 new Half:existing new Number of Bedrooms: existing_ new Total Room Count(not including baths): existing new First Floor Room Count / Heat Type and Fuel: ❑Gas /Oil ❑Electric ❑Other Central Air: ❑Yes /No Fireplaces: Existing �_ New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing Cl new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing O new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes /NO If yes,site plan review# Current Use ( ta� *JV1,Y1"- Proposed Use r BUILDER INFORMATION Name 1110MG- -CO 1�y—Telephone Number FEE-`3(Y Address License# 3 x�D 1 i�t— ' Q)Q, -11 Home Improvement Contractor# Worker's Compensation# \/ TyU G° �( � Tabby ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE yy a 940 Y 1 FOR OFFICIAL USE ONLY PERMIT NO. _ w DATE ISSUED ' MAP/PARCEL NO. - y w - ADDRESS VILLAGE F 4 OWNER G - ' DATE OF INSPECTION: FOUNDATION O FRAME _< o INSULATION `T /3 — 5 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH 'co > L FINAL_ .r: FINAL BUILDING h1 c 5 DATE CLOSED OUT d ray C) x . •t m ASSOCIATION PLAN NO. <- co �SS py1 1 �. j � RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET :)-°7 NEW LIVING SPACE square feet x$96/sq.foot= 13 n`1 X-903t- plus from below(if applicable) ALTERATIONSIRENOVATIONS OF EXISTING SPACE root(( -square feet x$64/sq.foot=_ r�'33`� x AH)3-i— plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq. ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) 2 Deck x$30.00= J 0-00 (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee projcosc ��� °� ratttW�ta ditt ge��ed x1W `csx11 'ur1� T'Ahlc • g�erlptiYK yarkxS a tar qua�acd T o-•k'tmity P,Idetttw Huit &� • kffN1Mt slzb •gasing/Ccaling 14iAX M Yldt Roar 1U."=ACa p daObcdn% q�{pmant Cfici�ncy� VA(Itn9 Sl Y�1 WAR tudt • tr a riot to 6500 ga 1ting n m nxy: Namvsl t� o Ka,rm�1 <, 0.�0 31 S3 I9 10 15 AFL75 S2% a.i7 30 19 19 10 A xarm�l � 1�.'/, 4.50 31 yr t�VA xonr� r 0.36 93 13 19 t0 8 15 Am T t5f. 0.hd 31 19 NIA VJA • 15 AM i5 h 13 10 6 X=4 15'h 0,44 1 VIA 15 I9 y I j,A 041 30 13 NIA 140tm�t ti4�l. a.52 31 19 25 NIA H/6A Qo AFU9 0142 31 S3 19 10 6 g0•I,FtT Y 0.42 31 19 19 to x SHv�, 0.50 30 a jm �v�� • A l)vas9 0P MOPER'I Y, i• vl vt-� ABSFOOTAGE OF ALL ETEROR ,rp,I,LS; 0 3. SQ�A 'FOOTAGE OP ALL c�LAz G; �� NO ' A #3 n ►II]ED BY #�) , GLAZING ARE 5 sea chart abava}; OLVKD 0 A �aT�: OTHER�a�'� TiOri ARE AYAILARLL'I ASy''US FOR' S LttFORMA �,,DI3�G IKSPI;C 10R APPROV p�L: ,Y.1;5, . q.fcrtn=•fl80303s , T`�c ,Cointrian veaIth bf.Massachusetts ' e , • _ - Department of IndustriarAceidents' baO'Washington Street _ Boston;Mass. b2IX -J Workers".C ensation.bsurance Affidavit-Genera]Bus4nesses 52 IN alp / •, / .'. �:oi'I'u" "'Mrrr�r*' Sr`�'«+ . _ , rl•t},1", , ' ' �•l/ r rx Ir• address: ,, s' •- zI :v h e •_ _. . _ state' • tlBai/$atirig Fstablisbmeat ocatiort full address :' ; ' s e. []Retail❑Rest�t�� etc. work site 1 d leave no one $R,- . g Real'$sta Auto ) 01 El Is .a sole proprietor an ` . []price[�SaTes(includin Y,rorYdng M,`capacity. I am to er with: etn��lo ees full Sc' azt time /// %/y oI]an' on this job., , �/ erspensation for my employees w ,it g .�+�•,' an•brr•,_V10Ve[r P�o�`. g.'^ t r„ 1(�•�S ...�"y.• '' :. t'S '? ,�i ,j .} ,•St�r• l S free'=•� r ,:.y t•.•'''.��Y? ..."1 t 51`,• •�' t ,.d st S , .. .. ,. i r.':1•,:.=;{rt':17::{'"t i:'i: !i S,.j.'• y• .r•� tf Siy�-C• .. 7i • I '' •.sr,l,,,s��s�a:'F}j,•rr.•,�•,'•r•• . 'J'{�{y�.'.l t`:r v. tw s�S r5''�� ,r. ii1•as''' S r�. 33i'p,6t. sr,: :'tip- Y.gii'i' ... t. ,ti t JI"S:1 trf.;�'r•.t'-Y.:.�il••ryr. fiII Il ,:.Y•.•J j; ! t:;.;'... , 1 t••••:t T �i;'1 to4 ts.r:. com 1: ,•;•.. t<'xs,: ^. .t�`�. 'i b is v •L;•.r' . , ':.3••r :f'.•>. .• •' L ' 4ii. 5 `r ' :•Rq' ' J i;l jtr.*C •f.t••; s�.d:'-„ . F..ra ,. . T, r j •h�vr' ` ''' '•.r. , •:�'•' '••r t J 1.7,J+ :r':i!r•J•?t., .+• 1.•. yi5'ti y,^ yy,. s J,w:'4 .!�'�'•, _ do 'Yi�J.'•''i 1• f ,tL••,i >rrr7'••h''•r; r."'•. 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':!Y Vie' (;,:;L.,,t•:;:i,.Js,;:. : : oo.Do su or fiisur ' osition of crlmin ySenaYttrs of a fine up to 51,5 ailul a to secure coverage as required underTS Section io 2 of NiGL15Z TO can lead to the�'era a Verification. J0. F ant as wall as c�P the foe m of a STOP WO7tK ORDER and a fine of�1o0.DD a'day against ma, X understand that X years'imPrbou"1 g one be forf+azded to the Office of Investigation+of the DTA for coY r copy o f this statement=may , erti under the psi and strait' b rf iry at the information provided above is Erie and corXec� v a fin' r do hereby e fy Al hone# CS ,Print nam8 5 official we only de not writeIn this areatobeeoxnpletedby city ortawnafficial OBuildingDepartcaent permitliicensa# QLicensing Board city or toTvw, ❑Selectmen's Office (]EealthDCpartment , C checkif immediate response is required phone t, contact p!ra0: • Infoz'noiatioit and Znstructions• . r eral Laws chapter]52 section 25 xequires all eu lovers to providb•vvorkers' eompensgtidh far .their•. usetts Gezl � .. .•t:it. Nlassach ;• quoted'fromthe f 1[tH ', an employee is.defined as every person in the service o another under any contract emplaYY ' the or Written. ' of hire;express orinol?Iied; , a ers ' , association, corporation or other legal entity, or any#wo or mare of i er yS defied as an individual,p eased to ex or the xeceiver or ,An em'p �' in a 'vsnt enf nse,and including the legal'representatives of a dec ynT y foregoing engaged ] erp , •, to ees. 'However.the owiter of a e g entity, e l �' ar6o.ersbi association or other legal en ty, rup oymg� y ,trustee of an individual,P • px oce� ant bf the,dwe house bf avyelling house having.hot'inorethdn three apartrnents an&who resides thereon, or the. up l spersoiis to do mainte wce,constrkiction or repair work on such clwellnng'6ie•c'tr on the grounds or another who.e�•°3' 'hall ' mf suchtheretosl -building, nt ;employmentbe deemedto be ari err�loyer. ,., ZGL chapter 152 section 25 also''states fhat'every state or local licensing agendy shall withhold they PP co or renewal of a licens6 or p �•nnif to operate a business or to construct buildings in the.cdirimonweaIthfnr an a licant who has not produced acceptable'evldence of-comp liance w enter into anthe y otitracgfar -heerfonnancc of y Nc work unt�,�, p cf its political subdivisions shally coirmaonwealthnor.any. P acceptable evidence of compliance with the insurance requirements'of thi,s'chapter have beeuprescnted to the contracting authority; ' Applicants • • •. • t a lies to our situation., Please Please f nI � eonvensa c ems' fim�idavit cori�letely,by checking the box the pp : y supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the p� ment of industrial Acicidents•for confirmation of insurance coverage. Also'be sufe to sigh and'date the affidavit• The�dav-'t should be retumedto the city or town that the application for the perniit or license is being re nested, not the pepartment 6f'7rtdustrial A.ccideu'ts. Should you have any questions regardirigthe'"Iaty"or if you are q #eW ensgtionpQlicy,please call theDepartiuvt at the number listeA,below- .s required to obtain a ' „•comP� . '. City or Towns . that the affidavit is cbnlplete andprinted legibly. The Aepartmenthas provided a space at thdbottom of the P1easebe sure t affidavit fo you to fill o-at in'the event the Office of Investigations has to contact you xegardiug the applicant. Please e t/liaense wbich' �M be used as a reference number. The•affidavits maybe xetiirned tq, besuxe to f111; p - ,. • . anti' "b'mad or p•A unless othe'r'ari mgemsnts have been made, the p ep , : eration and should you have any questions, The Office of SnYe�gations would llle to t yo hank you in,advance for you coop • . please do nothesitate to give us a'calL' ' ' i The rVartntnfs address,telephone and fax number: ' • - The Commonwealth Of Massachusetts Aepartment.of IndustrialAcdclents , . Bice>ai 11�esena . 600 Washington Street Boston,MR. 02111 fax#: (617)727-7749 1. . Town of Barnstable y�F I"E rog� b , o� Pegu].atox'y Services Thomas-0.Geiler,1)Irector, ArFD �k Tom Perry,Building Comnilssioner 200 Main Street, Fiyannis,MA 02601 • Fax: 508-790-6230 Office,, 508.862-4038 ' permit no• Date OR LAW A�AVIT CONTRACT }TOME MERNT O ERMLT CATION SUP . • conversion, MGL c.142A requires that the"reconstruction,alterations,renovation,-repair,modernization, demolition,or construction of an addition to any pre-existing owner-occupied •improvement,xemoval, units or to structures whicb. are adjacent to containing atleast one but not more than four d'�'eninB p th other bu�l�g be done by registered contractors,with certain exce bons,along wi such residence or building ' requirements. � L Estimated Cost Type of Work - L(,{� .01 0 Address oLID f Work: ::L Owner's Name: Date of k licition: to D 1 Y hereby certify that: Reotratioa is not-required for the following reason(s). [],Work excluded by law ' []lob Under$1,000 , C]BUn ng not owner-occupied []Owner pulling own permit Notice is hereby given that: ORDEALTNG WITH.UNREGISTERED 0V gS PULLING THEIR OWN HERMIT CONT�• CTORS FOR APPS1CABLE HOME IlI�P OR GUARANTX FUND UnER M L c 142A� ACCESS TO THE ARBITRATION PRO GRAM SIGNED UNDERPENALTIES OF PERJURY Ihexeby applyIfor apermit as the agept of the ovr4er: RegistrationNo. Contractor Name OR . °FIMEToy, Town of Barnstable Regulatory Services BANS'ABM Thomas F.Geiler,Director 9 MASS. 39. a�0 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Fax: 508-790-6230 Office: 508-862-4038 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize c o v�I J1 to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) j w 2 a �� ate Sign e o e �d Print ame F Q:FORM S:0 W NERP ERMIS S I0N Oct 26 04 12 :24a P. t Y Ta-d i101 ` >- f) Q ® m Z IL ItlAitry �` fo M I JONN !AURETTAg1! i ` 1OTL LCi CONFIGURATION tS DASEO ON ��4as�sSjor`� MED.ANWR ASSESSWS MAP,&OCCUPA. suPrlrP~ - TION. A MORE ACCURATE KPRESENTATXW WIU REQUIRE A NSTORRVEW SitRiF?. -�' -� � i9� _ Scats: JOHN S. LAUFIETAM PROFESSIONALE CERTIFY THAT THE AMERICAN SURVEYING COMPANY 3OVE MORTGAGE INSPECTION 77 RUrrdord AVenue, WallhaM MA 021S4 {617)$43-G477-AN WAS PR��EPAR D fggOR 3NNECTION WI TPI A NEW MORTGAGE #� M �+ a�s }� ! 10 IS NOT INTENDED OR flEPRE- •� o t ge Insp ctiod!! �8t�tf ?NTEO TO BE A LAND OR PROPERTY a CC NE SURVEY. NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDED AT C¢uNTY REGtbTRY OF OEE613 IT CatvNr�T BE USED FOR ES- DWELLING SHOWN HEREON EITHER 9OOK-y++ +'r3 FACE-�d� L.C.Cart 0._ ♦GUSHING FENCE, HEDGE OR WAS IN COMPLIANCEWiTH THE LOCAL PLAN REFERENCE: 3ILDINGUNES.THE I.ANDASSHOWN APPLICABLE ZONING BYLAWS IN.EF- DRAWN PER TOWN OF A1sSE$SOFNS °PEON IS BASED ON CLIENT FUR. FEGT WHEN CONSTRUCTED WITH RE MAP# Lam _PAriC �! aTED SHED INFORMATION AND MAY BE $PECT TO HORIZONTAL DIMENSIONAL ADDRE$g: l2%V IOUECT TO PUATHER OUT-SALE:s, REOVIR6MENTS ONLY),OR IS EXEMPT .KING$..SASEMENTSAND RIGHTS Of FROM VIOLATION ENFORCEMENT AC- BORROWER: v✓0� SY• = RespoNSISILITY IS EX. 'nONLINDER MASS,G.LTITLEV1l.CHAP. NOEOHERONTOTHELANDOWNEq 40A, SEC. 7, UNLESS OTHERWISE 'SUBJECT DWELLING LIES IN FLOOD ZONE I OCCUPANT,IT tS NOT INTENDED _NOTW OR SHOWN HEREON.A CON- AS SHOWN ON NATIONAL FLOOD IN RAN R0f3RAM FLOQQ w Bit RECORDED, FIRIyMATORY INSTRUMENT SURVEY INSURANCE RATE MAP p L + IS ADVISED WH EN daTAUC TlJRI"r.8 ARB COMMUNITY PANSt i.� ;T SHOWN TO B13 V OR LEGO Mom � ..��., I !@NT PROPERTY OR REQUIRED ZONING By I D D FlAfTED HFC tElbT Rt=_a ��jj JJ ^^�M SETBACK LINES. r 0 LO l-D 1 11 NJ O� /�wTc ...+t v++ 9 --08�tfo:)I awto" woad Sb:Go66i-8�-fllltl ' J .,,_�, .d,., bJ'!h+•,a.++ t.+.'3�w-a t..a nIYL:F��QNJ °' ^s•=. j s rc�% '�' r =S � T� 3' _ x "tea FawSkr w t w K • FORES4T4/1�E`IVGq .d�• �� �-, f -ate. . Commissioner r ' �� ✓/ze i�anv�rtovuirra� a� _`_- �uQel�\ . Board of Buildin !1�_ c�1it'tti�s and S lords = HOh1c ROVEMENT CONTRACT R gi •stration: 129598 Expiration• 10/1/2005 Type: Private Corporation Fitzpatric Home Building Co. Inc. Michael itipatrick 8 Jan Sel stion Dr. Sandwich, MA 02536 Administrator F t L_ CA-ZA\C)W o F P rao P E RCFY i N Es MA o-r BE AMC u R,.-rE STANDARD LEGEND 1 1 NOTE:not all symbols will appear on a map # 24 � ( ��=:�7 GOLF COURSE FAIRWAY EDGE OF DECIDUOUS TREES ^ EDGE OF BRUSH ORCHARD OR NURSERY EDGE OF CONIFEROUS TREES s MARSH AREA a - EDGE OF WATER DIRT ROAD E DRIVEWAY PARKING LOT M 18H I�E PAVED ROAD 02 MAP188 _ _ _ DRAINAGE DITCH )22 050 MAP 188 # 1390 0 ,51 PATH/TRAIL _ PARCEL LINE t # 1402 ,' MAP 326 � MAP# I I 021E PARCEL NUMBER I j MAP 208 #367 _ HOUSE NUMBER I I o11 2 FOOT CONTOUR LINE ( # 1 4 1 0 }o 10 FOOT CONTOUR LINE 1 Elevation based on NGVD29 j `,•/4.9 SPOT ELEVATION f STONE WALL . - 1/ l _X__...__X_ FENCE I MAP _ 1 88 RETAINING WALL [ j — RAIL ROAD TRACK 1 j ; = STONE JETTY . # I378 jj i 'Pow SWIMMING POOL Jj X 1 ` PORCH/DECK ! I 0 BUILDING/STRUCTURE I DOCK/PIER ..�. _..............._. � HYDRANT e VALVE O MANHOLE o POST O" FLAG POLE T O W N O F B A R N S T A B L E G E O G R A P H 1 C I N F O R M A T 1 O N -S Y S T E M S U N 1 T .o- SIGN ® STORM DRAIN x PRINTED SCAtE:IN FEET *NOTE:This map is an enlargement of a **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimetrics(man-made features)were interpreted from 1995 aerial photographs by The James n TOWER I=100'scale ma and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topographyand vegetation were interpreted from 1989 aerialphotographs b GEOD o UTILITY POLE e — P V P P hl' eY P Y• P Y 0 30 60 National Map Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Planimetiics,topography,and vegetation were mapped to meet National Map Accuracy Standards : 1 INCH=60 FEET* enlarged style. on the map. of a scale of 1"=100'. Parcel lines were digitized from FY2004 Town of Barnstable Assessors tax maps. ¢ LIGHT POLE O ELECTRIC BOX f _ The Town of Barnstable 1 P`pp tME Tp�� • BA MARS-LE. MASS. g' Department of Health Safety and Environmental Services t63q. �0 plfo Mpg° Building Division 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection c 1 Location ! r>7 P , ? Permit Number SS r) 4 l { Owner Builder - , n n 4 4 r 1(, One notice to remain on job site,one notice on file in Building Department. The following items need correcting: I ' n 0 Q n : ( ate�� VA --To- rr) (1 �� 3 n 0 { i On I IA C' � � � G / • ?. t�c� S —1 10.()0 � c )—C r V\ �,)t) � C� c T' �� i t � c7A Lo '^ 1-7 6C 1 { \rC' 1 f1C' r n44 1\11 'I VV\ (1, -r- Q r, 1-4 C G [ L)i+ 1 [ I 1J .V i J Please call: 508-86.2-403 for re-inspection. Inspected by \ l\;I Q a,d Date e Map" Parcel Permit# Conservation Office(4th floor)(8:30-9:30/1:00--2:00) '� k Date Issued Al—96 Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) a l Fee ��,av Engineering Dept.(3rd floor) House# ` a �iNE►p,,_ .SEPTIC �{ UST SE 19 INSTAL. PLIMME ��VCRON , E L CO®E AN® TOWN OF'BARNSTABLL 70T REQULATOT,�A Building Permit Application Tjetwets 11402- 6vfteS 9Md-ti_ R.eA-P Village CeW77CW Ul Owner Address ''�`� Telephone Permit Request ,QC�IOVA710-,,A � C-Y_JA��► STP-VZ-1'1 � Ll M t 1Z�D 7-0 /6 x �2/ L_. 2_x(o3 zx(,=, HvSfl First Floor square feet Second Floor square feet Estimated Project Cost $ Zoning District /Z0 —/ Flood Plain Niq Water Protection Lot Size T Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use &5S�C MN_L- Proposed Use 4&:51 of- n.Ai— Construction Type U/Uat) Commercial / Residential Dwelling Type: Single Family ' ✓ Two Family Multi-Family Age of Existing Structure Affr!4 , l Basement Type: Finished Historic House All., Unfinished L,� CR4�AzC- Old King's Highway AM Number of Baths 2 No.of Bedrooms 3 Total Room Count(not including baths) 6 First Floor 4 Heat Type and Fuel 6A-7s Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn ✓ /fix 40 None Sheds Other Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO R&Owc-o Ar7�4 ffZ)OVQ 6v-r AAWrtf, SIGNATURE DATEy�/l BUILDING PERMIT . WM'FOR(THE FOLLOWING REASON(S) ' e FOR OFFICIAL USE ONLY • PERMIT NO. # 1 D ISSUED f M' /PARCEL NO. 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F +- +- -t + +++ :-r +- + :.., y..+ -F �...t +t+. t +-+ +-+ + + t - { + + +. t-+ -�- + +-+ +- r+t + ' + + *- t + + + +,- + , + t r • + t +-t 44 t + t + { J + + r + } -4 4- + + -+ i 4 + + r + + T , + jt + r} j tj +-+-+ -+ �- -t t- - } +._-}-. +_w ,._« +-�- + -+ +-i-1m-f- + + -+ + -�-+ t-+ I-t t-� }+ } + +.{ :- ..-: +- +-t t�- T +- t-* * +-+ + + , + -'•-+ +-r + r-+ +. .} _, +- -} +- + +--+ t -+ r-r t t + t r r -+- t +-+ + t +- -+-+ + + ++- + + + + L + t } t + + + r--4..r + r +T + + ++-+ + t+ ++ a + 3 � + + 1 + + , + r + +t .� + t t r ++ + + + 1 t + {t t + $ + ++t T + t--I-}- -i + + }- $-} f -i- t--t + t t- - - t -t t- t -t ' - r+ :-T-t + + +-+ s + +++ -r r-t + ? + + t - - + + + + + + + + r + + * + t + + + � + +-t f' + +-+ -I- +�+ , + t+ � +~ + « + + +_+ + + +-+ + i - 4 + + + T- + { + I + + + fi + + rr t ( t + + +- + + - +-+ + r++ + ++ ++ +- + t + + 7f + +-rt + ± t , + T + ter + , +- + r+ t + r + - - _ + {- t_h. + {-t + +� tt + + ++ ...+ tFtr-t t fiit + t 1tt'tttttt * -t + tt itr + t +_ + ( } frit - -�-t- t�--�- _ t-+ t i-+ f- r-t--+-t t + + r T-r +--+ t---+ t-t t-+ t-+ t *-i-- + t + +- + +-+ r..,. + t +--+ + � + +--F -+.- + t +- + + + fit +� +tt + t ... + +. + + tt + t + 1 + + atrrrt +-++ t +- t t tit t + + +- }- � t + + + + + +-t--�- -i--+ - t - ++--+-fi- -i + ++ +-t-++---•- rt + +-+-t +-}-;.. t+ i--r t-+ + +t- +-+ + + r ++++ >-- + T ++-+ +-+ + + r + +-++ T 1t t tt t ♦ 1f$rt+ } tt + rt + I-t '-tt + T + + tt -. - - - a--+- + -t + + + r -+ -++ �+ t -+-1-+ -+ + t }-r- i- { + i--+-�- + + }-+ +--} +-�- -�- i- +++ } t t h t + + t + + + $ +- r + + + i t t j + + - + + +-t t- i- -r +-r t+ +} t t t t t t + i + t tt f t + T t + + -r-t+ + t. + t.F t + t + + + + t + t +++ t + + t+ + + t + + + 1 + + + + + + T + + + G + + I + + 4-t 4- t-i . + -+ + ++++ ++ + + + +a + +-+-� +- r The Town of Barnstable Kw Department of Health`Safety and Environmental Services °� ` Building Division 367 Main Street„Hyannis MA 02601 Office: 508 790-6227 Ralph CtOs= Building CommissiO Fax 508 775-3344 For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW i SUPPLEMENT TO PERNIIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernisation,conversion, improvement,.removal, demolition. or construction of an addition to any preodsting owner occupied building containing at least one but not more than four dwelling units.ar to,strucm=which are Aacent 'to such residence or building be done by registered contractors,with certain cXCeptions,along with other requirements- Type of Work: —Est Cast 4LW.6LO Address of Work: /`'lUZ- v�'� �`L-2. 1 i-OM CC-*1Z`12-Vi to e - Ovvrrer.Name: Date of Permit Application: I hereby certify that: Registration is not requires for the following rason(s): Work excluded by law Job under SI,000 Building not owner-occupied ` �_Ow=Pulling awn permit Notice is hereby given that: CONTRACTORS OWN ERS PULLING THEIR OWN PEP FOR APPLICABLE HOME IMPROVEMENTWORK DO NOT VMHHAVEASS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor name Registration No. ! OR n,,p Owner's name • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB. LOCATION Ru-lr� / C�7 -,2✓t c.t : Number Street address Section of town "HOMEOWNER" V 0- Name Home phone Work phone - - PRESENT MAILING ADDRESS _ S�tst�fl :s411ye1 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 such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sJ who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one to six 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 OfficiE on a form accpptable to the Building Official, that he/she shall be responsibi ' for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes . responsibility for compliance with the Sta Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies th he/she understands the Town of Barnstable Building Department m' imum ins ection procedures and requirements and that he/she will comply with said pro edures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFIC AL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 01 Construction Control. i K• L HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which a tE lding permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person(s) for hire to do such work, that such Home Owne shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for licensing Construction' Supervisors, Section 2. 15) . This lack of awarene often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home " wner- acti as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, ma. communities require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. The Commonwealth of Massachusetts Department of Industrial Accidents : . 011iceollalvestlgatloas 600 ff aslthigton Street Boston,Muss. 02111 Workers' Compensation Insurance.AlTdavit _ 4eRitlicant ntormation:^ /� c Plettsei1V PRT',g tbly ,� name �o/ �° wn) location• 707, X 111-At PS A1X--R--.And e � 1f�L�GChong 0 -1 am a homeowner performing all work:myself. I am a sole proprietor and have no one working in any capacity I am an emplover providing workers' compensation for my employees working on this job. company-name! address: city phone#• - insurance ce. �elity# 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: comnan3:name• address, city: phone#• iesurnncc co. nelicy# �- ^��c: �..<_ _.- - �.smr:..�.:.�-?+^�'y<"'T�'"pr+TiF' - .�7�• a�r:!^*Td!" .o®R43t4!�'+^'�':'?si Cem any name' address- city: Rhone#' insurance en policy# :Atinchadditiooal•shettifneeessary Euiiure to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of s fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded he Once of Investigations of the DIA for cinmrage verification. I do herehr'certify under t/ pains n penalties of peduq•that the information pro►7ded above is trae��and correct Signature trte T J �- Print name Phone# official use only do not write in this area to be completed by city or town official City or town: permit/license# riBuilding Department Licensing Board ` IJ check if immediate response is required QSeleetmen's Office C311ealtb Department " contact person: phone#; MOther (mised3•')S PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their loyee is defined as every person in the service of another under any entptrn ces.'As quoted from the "law", an emp contract of-hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other :z-gal entity, or am•two or more of the fore-.in engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwellin= 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 1*52 section 25 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 commomv caltli for any applicant who has not produced acceptable evidence of compliance with the in coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. t _ .,.,. ... - : .:..• �..'.'.::.;� a,l..:2'r':�� ,.:�., .;.,'.,.,. ...rW ;1,.. •.fig �,.•` W' i I• ".►:.../'!!`.7s,-.W Wit. P•.� a. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying-company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to siep gn and date the affidavit. The affidavit should be returned to the city or town that tite 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. ^w�.s�wr�ers7A/.^.i,i'�T'n V+,ew• s.�I - Y • .r.• y';m,,. .' i u'- 1't7•^M=.±,. . . Citv or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. ►�.�eanwr -.. ::r _i t...::.. i-- ••iRv•::.n<•<.•.(:'yl,.w �.�:.� r ...�,.... .�•:e- •w.I.. :i. The Department's address, telephone and fax number. The Commonwealth Of Massachusetts • Department of Industrial Accidents Office of Investigations a.a• 600 Washinaton Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 « d R N z r \ 0 2 4 Fo T70N Sig CIN MAR AM PAA�CEZ. ..s/_ � r Ed �E EieE CE e040A' 9829 IPA6 4�5 2-099. t i f 0 1 HE�C'E�Y CEsPTJ.�7' T/dAT 7?VE Z;Y/5 7"✓r'�6 ST�PUCTUWE,S � y D&P/C7`E1D ON THOJ ,fLAA.1 41C 67 -5-1-?�J AI Alen 'E ��l//tffl.97YC�/v! Bl//L to T/�EY eX/ST OrV ?iyE G/�'O UND t3As O a n/ �9 N jH �f + ash ,. P�4EP.9R�.1� For' '` • � -� oonE,rtt y( �d�t/ •9N1. .9c- �eE T �'I/O�'L7 No.33S88 r �EGIST�R Sh�Dlt�/•t/� 7-hHE �X/S?!f/�' i1lE`t/�UN13�17'�/'O/�•/ Mp SUR"iE� ' AdA )611 , .3 D M/9!c'CN /2 ID0>014 AL S Tc4 ...5,08-563 _.___. ._. ._. . .......... _._.....,_...w� .._,�_._ .....___._ _� .. ._.._._._ _..____.w �._ _ y OF IBARNsTAgt —d Towiv 1 2013 MAY -6 p€e 17 DIvj . 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