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0109 EMERSON WAY
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'_ ,-v,_: , "' " ,- ',,�, --`,_�L'_' ', -,_,,,,�,��......��,.�,,,-:;�,�,���,,�,,����,�,:, , , , � ,,;��!�; , oon,j_ ;QQ',�,�1� ',,!� � : ,:,-,��,��,�,��"".", � , -, -;,L ,���t,�� _ "" � " �r �_�,,. ,,,�,, ,,,�4,�,�*,i'��,�,�,-",Z,,.4,�,,--,��,,�4,-���4'�",�,',_,, ,,, TOWN OF BARNSTABLE,BUILDING PERMIT APPLICATIONd. ~' { l Map Parcelr 1 0H ; Application # '.0690 ')4 V Health-Division Date Issued O� Conservation;Division c Application Fee 6"1.Crib Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis E Project Street Address 10 G VVNQ-R Stir-1 Village C ('1-t i c=fw i 1112 `� =; Owner 7'140MAS N. C0,4A0&_S Address 16 !( AC.R, 0A Telephone 02 6 el- gL10�5" V11- J Permit Request �=W Fx 1 E N'0— U CK Square feet: 1 st floor: existing I,`1Q�proposed N LA 2nd floor:existing VP s proposed N v Total new I, 4G cy Zoning District Flood Plain Groundwater Overlay Project Valuation$ Construction Type Fr,A1411, Lot Size 101000 _vs r T Grandfathered: 0 Yes Q-IQ'd If yes, attach supporting documentation. Dwelling Type: Single Family R-- Two Family '❑ Multi-Family (# units) Age of Existing Structure IS 10-5 Historic House: ❑Yes U-No On Old King's Highway: ❑Yes 4dNo Basement Type: mull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) b Basement Unfinished Area (sq.ft) 1C)0 `7b Number of Baths: Full: existing f new 14 0, Half: existing 1 new 4l A Number of Bedrooms: 3 existing 0 new Total Room Count (not including baths): existing C0 new N A First Floor Room Count Lf Heat Type and Fuel: was ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes 21qo Fireplaces: Existing 1 New O Existing wood/coal stove: ❑Yes49-No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size#L&Shed: ❑ existing ❑ new size _ Other: 14vWi- 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 714 Telephone Number �d 9 6Y-' 100 Address Aw4 S R License # O®v 1 Q.C1 P-® Home Improvement Contractor# 100(O q 5 -- 'jAR t+S f'of3i F_. MA Q'X,3v Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO No SIGNATURE DATE L7' �`�-'cciw- I FOR OFFICIAL USE ONLY ,,APPLICATION# DATE ISSUED J MAP/PARCEL N0. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. THE COMMONWEALTH OF.MASSACHUSETTS Registration: 1,00699 Board of Building Regulations and Standards Expiration: 6/23/2008 Home Improvement Contractor Registration Program p One Ashburton Place,Room 1301 Received: a Boston,MA 02108-1618 Application for Renewal of Registration Home Improvement Contractor or Subcontractor MGL Chapter 142A, 780 CMR R6 (PLEASE READ INSTRUCTIONS CAREFULLY) -- --- -- --- Business name can not change on renewal form! 1. JAMES K. SMITH James K Smith 2. P.O. Box 124 3. Barnstable, MA 02630 Please note changes to mailing address. 4. Street Addresss(if different): (tsetS t`I, A1'14i'S AG, 26 Beale Way Barnstable MA02630 ncly c Please note changes to street address. g. Applicant type:I Individual 6. Federal ID No See Instructions to change Application type. 7. No.of Employees: F O�No.Employees 9. Individual responsible for Home Improvement Contracts: James K Smith First Mid Last 10. Title of Individual responsible for Home Improvement Contracts: OwnerlContractor Please note changes to title. Phone No: (508)362-9624 11. Does the applicant or responsible person hold any other construction related,state,city,town licenses or registrations? Yes No Construction Supervisor License: 51901 Expires: . Motor Vehicle Repair Shop: Expires: 12. List all partners,trustees,officers,directors and major owners(10%or greater of ownership)of an applicant partnership or corporation below. Use additional paper if necessary. Check here if you wish to receive an application for additional ID cards for key persons. Last First- Mid. -Title it Applicant.Business %Owner Address . 13. Is the applicant claiming exemption from the registration fee?(See the instructions) Yes ±"No 14. Registration fee enclosed:$ U Guaranty Fund fee enclosed:$ If necessary,include two separate certified checks or money orders-one marked"Registration Fee";one marked"Guaranty Fund". See instructions for amount of fees.Make all certified checks or money orders payable to"Commonwealth of Massachusetts". NO PERSONAL'OR BUSINESS CHECKS WILL BE ACCEPTED UNLESS THEY ARE CERTIFIED. Pursuant to Massachusetts General Laws Chapter 62C§49A,I'certity under the penalties of perjury that I, to my best knowledge and belief have filed all state tax returns and paid all state taxes required under law. ZOC, Signature of applicant or appliciu0s representative Title held with applicant Date A false answer to any question in this application constitutes grounds for suspension or revocation of the applicant's registration. Board of Building Regulations and'Standarcls Home Improvement Contractor Registration,Program One Ashburton Place,Room 1301 Boston, MA 02108 °( (617)-727-3200 PLEASE READ COMPLETELY To All Home Improvement Contractors:. INSTRUCTIONS FOR COMPLETION OF>RENEWAL FORM IMPORTANT'NOTICE: 'AppUcations are no.'longer processed ona wally-ui basis Please'mail your renewal to the above address&allow tharty'days for processing All a . lieations will be roeessecl in the,order in which the are reserved. It has come time for you to renew your Home Improvement Contractor Registration.'In order to renew your registration, you must complete the enclosed application and return it to this office as soon as possible to prevent your registration from lapsing. The renewal application contains the information that was submitted to this office. . Please make the necessary changes on the lines provided. Please read through this application.completely. Please pay particular attention to the items listed below. DO NOT FORGET TO SIGN AND DATE THE APPLICATION. ` Item 1: This MUST be the current name of the business that is listed on the'contract." If this has'`changed, you must obtain an application for new registration by sending a self addressed stamped envelope to the address above. (a) If the business name does not include the?last name of the responsible person, and you are registered as either a DBA or PARTNERSHIP, you MUST also submit a copy of the'DBA certificate from the city or town clerk (b) ALL corporations MUST submit a copy of the Annual Report, registration as 'a'foreign''corporatiari from the Commonwealth of Massachusetts Secretary`of State's office. www.see.state.maus Item 2: This is the mailing address of your business. If you have"a Post Office Box or,RFD'address as the mailing,address,you MUST indicate a street address on line number 4. Item 5: The following is a list, in order, of possible applicant types: Individual, DBA,"Partnership, Trust, Private Corporation, Public Corporation, Limited Liability Partnership, or Limited Liability Corporation. The``only.way to apply as an individual is when using the name of the responsible person. Although the name of the business must.remain the same, the applicant type may change with the appropriate documentation(i.e. DBA certificate, incorporation papers,etc.). t Item 7: If you have more than one employee, there MUST be a federal identification'number listed for question number 6. For the purposes of this application and 780CMR R6, the number of employees shall include:all construction related employees who worked 20 or more hours on the payroll in the weekly pay,period prior to the filing;of this renewal.form. Item 9: If the name in item 1 is anything other, than Ian'individual, (i.e., a corporation, partnership, etc.) the name of the individual person responsible for the home improvement contracting,work of the entity,must be entered-on-line-9—If the-person so named holds a construction supervisor license and owns 10% or more of the business,°lithe applicant is exempt from the' registration fee. Item 13: If the responsible person holds a valid Construction Supervisor license;.no feeds required. If you do not have a valid Massachusetts Construction Supervisor License;,you are required to,pay the registration fee of$100. No Guaranty Fund payment is necessary" for this renewal, unless you have increased`the number of employees and have found your business in`a new payment grouping based on the`chart listed below. If the number of employees now places you in a new category, subtract the amount previously paid from.the amount due and submit,a CERTIFIED CHECK,or MONEY ORDER for this amount. Guaranty Fund Contributions` Zero to three em to ees` .• p Y $100 00 u Four to ten'employees - $200:00 ' Eleven to thirty employees $300.00 f r M .. ' ore;than'thirty employees $500.00 Be sure to include all the proper,documentation or the processing will bedelayed. Alltpayments must be made in the form of checks or,money orders to the Commonwealth of Massachusetts" and returned with this form. Payments for the Registration Fee and the Guaranty Fund must be made with separate checks. f TYNCAL COMPONEN TS FOR CAN I ILC VEF a DECK I I I I ' I 3 I � I -- - VJT X V RAIL IL. CAP I. ! FV l �t/�1 �a� A f+Trn �. ' 2X2 03A1../1t7 1 LfI�V.C. 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SE A A ��-= �` ,. __ ____: , ----- . ''�XI ,� -t( . - :. r(...,r� 1�:.. . .... , . , , , . _ �, . -, ,,,r -�'" : r � )�- �'91 {� . .y- -� . ... � .... ._,. u, .Kali!.'.,e R.....n .. -. .. - `, 9.. 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 Ledbly Name(Business/Organization/Individual): 3Vlvr4 S. S i Address: 109' f`iyjSt14t41_s RA PC)- k lark City/State/Zip: Phone.#: SWR 0-19- t00 9 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 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 10.❑Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myselL[No workers' comp. right bf 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 infomnation. 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. lam 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 crirmrial 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 _ Investijzations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Si mature Date: Phone# SU . fo�l — l o 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 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 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 confiimation 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 nurrtber 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 necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le.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 C6mmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617=727-4900 ext 4.06 or 1-877-IvIASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia °FTHE r Town of Barnstable Regulatory Services BMWSTASLe Thomas F. Geiler,Director ArFoA Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.toWn.bArnstable.ma.us 3 " Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, i lkl 1-7A S ' /Y CCUNNv a S , as Owner of the,subject property hereby authorize J IN)L S S/`'1 /4 to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) b o b Signature of Owner Date �/�i�,7 S h �Cil1/1 LDS Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. rl•F'l1R rAC•l1WNFR PFR1vfi.CCIf1N - Town of Barnstable OF1HE Tp� " Regulatory Services s M t;axxsrAar> Thomas F.Geiler,Director MASS. 1659. ,� Building Division jFvr A Tom Perry,Building Commissioner . 200 Main Street, Hyannis,MA 02601 vww.town.barnstabl e.ma.us Office: 508-862-4038 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 person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page 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. - J�P�O.7Yt-)11411fIJClCG�JI, (=j•.-/`'Lf1:YrCGCfIfIJBGs6 Board of Building Regulations and Standards _ Construction Supervisor License License: CS. 5190 Expiration 3/21/2010 Tr# 20071 Restriction 00 JAMES K SMITH PO BOX 124 BARNSTABLE.MA 02630 ` Commissioner ----------------- h . a - � 1 'T ow�He rq�� own of Barnstable � *Permit# p -- Pires ti months» •-atix rrsirnsr-�;:. -' from issue aUte Fee C latoySevtCeS::Reu rg - •• �� i63 r��� 7 NO :,...,� = � ' Director �la�la Jl� :.: ,T.omas'F Geiler,Dire �c Fo Mn Building Division TOVVi'v OF BA a N ST,A:.�E •--Toro Perry, Building Commissioner 200 MainStreet,_ Hyannis,MA 02601 • .• Office: 508-862-4038 '• Fax:•508-790-6230• . .. _ ,.:.. .._ ............ . -. '"RESIDENTIAL -EXPS�:PER1Gr[TI� YCA'Y'Y.ON - ONLY. Not Valid without Red X-Press Imprint Map/parcel Number Property Address �UlCSO1�.J Wf+� C'�✓'7Et/t�L� Residential Value of Work'f 4;U 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address _r 0 M4M '; Contractor'sName (—•A-17 /i�C� Telephone Number 9 V, 4?� � Home Improvement Contractor License#(if applicable) , 3 S Construction Supervisor's License#(if applicable) 27 3 Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name 44(Z- 0�D 6 0,�"u e — Workman's Comp.Policy#�CA� Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) q , ❑ 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. 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 is required. (` Signature (r< Q:Forms:expmtrg Revise063004 • • -- The Commonwedlth of Massachusetts _ Department of Industrial Accidents Office oflnuesUnUons 600 Washington Street, a Floor -- Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit: Buildin /Plumbin /Electrical Contractors 3e name address tv l_.�(i1 I T state: Ad d-- zip 0262 Rhone# 74" work site location(full address): ❑ I am a homeowner performing all work myself Project Type: ❑New Construction❑Remodel I am a sole ro rietor and have no one Working in any capacity. Build* Addition I am an emUToyer providin workers'compensation for my{employees working on this job. fir s ;. s.c t<; .�. Jar„ .f{ :e • �� s ,.�^.r� + -cT �Fl,h+'4" ';Y}r�.7'fl'-.."'y7C, •ii-eff'i:t�S'9• 7,4 e mr'': -�;...T t 1 i � '-S•'. .-+4 'h. ..i=' ..h,y � ,.n.w•�F..v. 1. ,. s.�`V :,=1', `i.,.. .t.�. "SJ�zS Y :? _j d,lu!' ✓ '� �svt .�?,c�!'���tL i4 ,�":i.r.it>:;'�':j- t'^.:a� G: ...s, i"i i 'i- 9 �y..j..:.. :a�d�•eS§WAS•'i ::�'�•t r;� �S::F -;x,�i4+��s i� µ v�^r'Ky t�a'i..r,v'`4ai a, as.7t{ i # y J't +..:._ :F�;. .v.- 'J'. ;`'� tt Tir< -•" rt c'. ��'` k74 ,w. s. y y- d , VW,yr +Y�?l � -7 �f� �, �,}�£.{" �' @ n=.aF+'�' ��,,gg��YS.ua .teee �'w�,,,ic°S•�''�•�'>,,s.•at.cF�aw+s i i s v f ; ,�:' ,Zfi k.:F•t�+'Y+."�i -c"'Y ,��.11�' .{�`G,'�'#t�p'T'� 'wrtr +�d7f�i" c ' •. �✓� "el :..,c i�^t`v t,a? �,. ��, s'�"B� •�34.7:.u.�x17k ''s,7y �Pt2y�,� ?,i3'sK a o bJl� �.� ; + . u,': Y:R' +Y¢.. �, v �.."P �, R p ry i6 "4y ..S i- .:f•��::rl:s.u,...^ ..... :�4 ..:�:; {rsyt `-,.• ta.,�;'c,-fir lks' � .,s �A. �'r?a7 �,4 ti�a•� r-�iaf� s t• ,w '>_.'�"'w h5.t1ra.n W!c Offimmew Am-arn--a sole proprieto ,general contractor r homeowner(circle one)and have hired the contractors listed below who have e following workers' co _ p. "�:x,• s. fa 8 ='tI�IDE.d. w,-Via'?::N. � �•'s.;[ -.. T A 1 '+," e,�,�.t,PH'tr 7�{t. Ur OTIP .,a �i.... �s:•7 s J G• ,. .., .i :,�.: r�. C,% a </Fri` M1 'F •:r { �`Y!.52 k ty" .,t r t.:` "r.'{/,4" iristfra'nea fie. •�� A.. - - .d . .3 +S. ,1..:_..::. .... -. ,._,, ...:.: :........... :. .,.,'6... .. .:•.a` ia!Ck%' pia ti .1 ;�dt��egS°;�s..;:::;-:i?s:.nk „-:, -" .. f-' ..!.'.:;a{h3F..�r_�.. b,t. _ -h.. ,r s: r„ 1 - •, i t� n r # p t Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500,00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify un the pains and penalties of perjury that the information provided above is true and correct Signature Date Print name CAhq3&2 Phone# f( 4 ZK 4U 2}l official use only do not write in this area to be completed by city or town official city or town: permit/license#' []Building Department' ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office []Health Department contact person: phone#; ❑Other (revised Sept 2003) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an 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 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 commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. , Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance.coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested;-not the'Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. 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. ilgg The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Inuestioations 600 Washington Street,7«Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 s AP .�3tA�.aa,.r,n^L•�w,-�� BOARDOF BUILDING REGULATIONS ¢ CONSTRIJCT�ION SIJR PP �' �cen n 408 t +�a Nuumb�r C� -�089273, '° `r r `'.'' � : 17�-f';07- 'Tr�n`o•�-8�92.73 F j ` F y RICHARD M 5CA r { 205,BLACKTHOR ,/ {� ��MARSsT,O,NS M4 LS,� "b26`�$;' ~�amrr►is§lo�e� 1`�' 1 iyr�, y��xi�€+.ea�'{ fa -` .yy �9� _�'?d�•'I' q � ..;,r•t ^.1�--ems.-�,.: -:::,t. ___ _ . /ae C�Jomvr�aariureal�i��aoa�.uaeCCa � "£ Board of Budding Regulahonstand Standards„ HOME{IMPROVEMENTOONTR ACTOR ` Registration 443358 \ �xpirat�oh 7/8/2008 >t Ltd Liability Corporation , r CAPENUIDE ENTERPRISES L L'Ct RICHARD CAPEfS ' 205 BLACKHO.RN RDt � ;` MARS7ON MILLS .MA:02l;4$ Deputy Adm�uistrator r FR011 I FAX N0. :9086899431 Oct. 15 2007 11:01AM P1 t FROM :CAPGj[ G i t ,w tdC1. :51�842939::6, Oct. 12 207 02:48PM P1 f� : i 'own of Barnstable �! $af�d3A�Di'Jiom , zAIffil, Wftj CQM=hdouer �� . �rwn►.iox�bbi�ipa�us t . l p ►city Cwwr Must i iCot Viet and 53�gn Section IfUslngABader A r a a i �d nid k's } t C 'e:0 tie iut►je�k pz i ., to*Ct VA r r j 41 c�exs mudve to pro k�utbot{xe i b7+ boyld pens ppl ton for, f ' �6 � �Wf�'YSd?'� .WAS �f?►�•f-f'rV r �l� j Iljljlj 1 j i i l RightFax H2-3 8/31/:2007 3: 13 :39 PM PAGE '003/003 F'ax, Server Y ACORD. CERTIFICATE OF INSURANCE DATEcMMiDD►Ylr7 08-31-07 ^"ODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ROGERS&GRAY INS AGENCY HOLDER.THIS CERTIFICATE DOES NOT,AMEND,EXTEND OR 341 COURT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 3700 COMPANIES AFFORDING COVERAGE PLYMOUTH,MA 02360 COMPANY 72WFB A HARTF'ORD GROUP INSURED: COMPANY B CAPEWIDE ENTERPRISES LLC COMPANY PO BOX 763 C CENTERVILLE,MA 02632 COMPANY D COVERAGE THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THEINSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING .ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN,MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMWDIYY) DATE(MM%DD1YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY: PRODUCTS-COMP/OP AGG. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $ OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE $ - FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Anyone person) $ ,AUTOMOBILE LIABILITY. ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Person) $ SCHEDULEAUTOS BODILY INJURY(Per Accidenq $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $. GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE OTHER THAN UMBRELLA FORM $AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY . UB-9845A033-07 04-14-07 04-14-08 STATUTORY-LIMITS X THE.PROPRIETOR/ EACH ACCIDENT $ 100,000 PART IVERS/EXECUTIVE INCL DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLES/RESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP.COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TOMAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TOMAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVE3. AUTHORIZED REPRESENTATIVE Ramani Ayer )RD 26-5(3193)