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HomeMy WebLinkAbout0017 HIGHLAND DRIVE u N a r W " a ° T r .. a .�. d , 6 r „ .. '. a ': • �. ,, 1 Application number............................................. .. Date Issued............ . ............. ................... KAM Building Inspectors Initials.......MIN 0� OHM I .. ............................ ABLF Map/Parcel................................. er TOWN OF BARNSTABLE 00- 66 EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBEW STREET VILLAGE Owner's Name: 6^4,2 Phone Number T� _ -'fg7 , 'Zo76 S Email Address: �� Cell Phone Number j',gap e Project cost $ ?aoU, ®O Check one Residential _ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize Pcgy /Z x to make application for a build' permit in acco dance with 780 CMR Owner Signature: Date: TYPE OF WORK 1Siding 0 Windows (no header change)# 0 Insulation/Weatherization Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to T � CONTRACTOR'S INFORMATION Contractor's name o C Home Improvement Contractors Registration(if applicable) # /��,� '���` (attach copy) Construction Supervisor's License# — (3 ����''�' (attach copy) Email of Contractor liw p 65 e7Phone number \"01�- > ALL PROPERTIES THAT WVE STRUCTURES OVER 7S YEARS OLD OR/F THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER ............................................................ • � 3 *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X ' 5 X Additional tent dimensions can be attached on a separate piece of paper. Check.one: this event is a: for profit non-profit event Check'one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. ` The Commonwealth of Massachusetts Department of IndustrialAccidents - - 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): o R Address:�( S�41 It r t L.4-) City/State/Zip: e,✓ eJ-V,'6/'C_ o_J&LPhone#: Are.you an employer?Check the ap ropriate 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.gI am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workin for me in an capacity. employees and have workers' g Y P tY� 9. ❑Building addition [No workers'comp.insurance comp•insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 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.❑Other �. 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. #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 coverage verification. I do hereby cerd nder the p ' and nalties of perjury that the information provided ab a is ue�and correct.Si afore: Dated Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License#' Issuing Authority(circle one): 1.Board of Health 2.Budding 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.m the service of an 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 for the performance of public work until acceptable evidence of compliance with the insurance enter into any contract p 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 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 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 ' lapartramt of Industrial Aeddents office of Znvestigatiow 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-8 MASSAM Fax#617 727-7749 Revised 4-24-07 wwwmass,govldia R' 1 9- Commonwealth of Massachusetts Division of Prolpssional Licensure Boar,0,,.gk0 iiidi�i f egulations and Standards Constmjtl 6r�ltbpervisor CS-073885 EkDires: 03/1212020 ROGER T COX 19 SOUTHEAST LANE s CENTERVILLE Nff1 Cammi$sioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR a TYPE:Individual 6' Resist ' tin Expiration '133775 r 08/06/2021 ROGER T COX ROGER T.COX 19 SOUTHEAST LA1JE"= `%'� � GG•�rG�otok 1 CENTERVILLE,MA 02632 Undersecretary R Town of Barnstable Buildin : Post This Ga''d Sq;That rtasU�sible�From,;the�Street�Approved,-;Plans Must be Retained on Job�and this Card Must�be Keptz Posted Until Finaf Inspection Has�6een Made � v �,., R Where a Certificate"of,Occu anc -��s,Re u�retl�such�t3uldm shall Not-�bec�ied.nti#„a Fna#`Ins ect�on�has:been£made, , � Permlt Permit No. B-16-2365 Applicant Name: CROCKER,CARLTON B& PAMELA Map/Lot: 189-120 Date Issued: 08/22/2016 - Current Use: Zoning District: RC Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 02/22/2017 Contractor Name: Location: 17HIGHLAND DRIVE,CENTERVILLE , Est Project Cost: $0.00 Contractor License: Vv Owner on Record: CROCKER,CARLTON B&PAMELA ¢ Permit fee ' $35.00 Address: 17 HIGHLAND DR k Fee Paid $35.00 ,r€ Y , Date 8/22/2016 CENTERVILLE, MA 02632 . . . h Description: 12x16 Shed } Project Review Req : 12x16 Shed ` Building Official This permit shall be deemed abandoned and invalid unless the work autho{ized by this permit s commenced withm�six�months after issuance. All work authorized by this permit shall conform to the approved application and the approved construes ion documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be'in co'mpl ance waith�the ocal zone g by laws,and codes. This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open for p""u41ic inspection for the entire duration of the work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Bwlding and Fire Officials are provideonthis permit. . ` Minimum of Five Call Inspections Required for All Construction Work:. 1.Foundation or Footing 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is'instalfed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection,,,. Sig � V 5.Prior to Covering Structural Members(Frame Inspection) •�; 6.Insulation ° 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT cK Town of Barnstable Regulatory Services Q' Richard V. Scali,Director MAMELMMSTA1314 Building Division s6;p. ♦� iOtEp s Paul Roma,Building Commissioner 200 Main Street, Hyannis,MA 02601 F. www.town.barnstable.ma.us 9,Ag S- Office: 508-862-4038 t / Fax: 508-790-6230 PERMIT# LA FEE: $35.00 SHED REGISTRATION u.► RESIDENTIAL ONLY M 200 square feet or less cm H, !'$S � Cr Z Q Location of slkd(address) Village D ® U_ 0, � z C�2��®cam R x�� (�i��-re�, - ���.�'r� 7,f� �8�-��Z 1�,�" o .• Property owners name Telephone number Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? You must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION,FEE. PLEASE SEE THE APPROPRIATE COMMIISSION FOR DETAILS. .. . THIS FORM MUST BE AC COMPANIED CCOMPANIED BY A PLOT PLAN Q-forms-shedreg r REV:06/20/16 Town of Barnstable Geographic Information System August 16,2016111 190121 #40 t 190120 #64 190052��" #43 190108 ; yy` 189119 #31 6q�®off 189120 #17 b 189121 01309 190257 V� #116 44 14 189045 #4 U V% �` 190107 �..► p �14v #345 189041 #21 Q 22 F t #5 7- DISCLAIMERS: z -� . This map is for planning purposes only. It is not adequate for legal Map:189 Parcel:120 LLJboundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel 1"=100'may not meet established map accuracy standards. The parcel lines on this map Owner:CROCKER,CARLTON B&PAMELA Total Assessed Value:$297900 are only graphic representations of Assessors tax parcels. They are not true property Co-Owner Acreage:0.34 acres Abutters W boundaries and do not represent accurate relationships to physical features on the map• Location:17 HIGHLAND DRIVEf such as building locations. • Buffer -_ pr--�n..-..--�- _�.-.�.-.--�...�rt.,...-.--•---•-..,...- ..--... ..rr\r .r.�`^"`-_.--......�,--.-..�..� �w...r-..++'-.._. �... �.....�-�r..--^,..-- . . � - �.`. ter.�- -... -,.�.--......r-....�-.-..--..,/ 7 Assessor's map and lot number ...!' .. ;.L�... h Vt#�T B, 3 Sewa"e` Permit number ..:. ..... INSTALLED y` C 1 O P ANCE g J. .Q..' .....,. #tl 1 d A 9 t 3 l U E 11 STATE � . Sr'ri ITARY CODE AND TOWN O�PyF7MErQ�o' # }: TOWN OF;� BXRNSTQ tAIMSTABLE, 9,o M6 9. ,,� -� RUI:LDING ; INSPECTOR. 0 MPY 4 APPLICATION FOR !PERMIT TO ..... ..................... !..' :.. ......................................... ............... ....... ..... TYPEOF CONSTRUCTION ....... �J:��f.........................................................................:.......:....................... `.. ........ ...`...... � ...:.../7. .l 9 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the .following information: Location .......1.3../...7..!... .?�.L ✓ ....... ���. ...............................� �. ............................ ProposedUse ..... f. .g........ " !���/ ...................................................... ............................................................ ..................Fire District ®��Zoning District ........ ........................... ......... / .....-............................................ Nameof Owner ... /w .Address .....'................ ...................................... .................. Name of Builder ...-'(1'.�! U�L�®.....:�/C'�/�'?Vss Nameof Architect ..................................................................Address .................................................................................... FT Number of Rooms ...................15 - �ST�/v� ............................................................................... Exierior ..............4��,.a........................................................Roofing ....... /' ............................................ Floors + C -It.[ ....................................Interior ................ Heating ....Plumbing Fireplace .............Approximate Cost Definitive Plan Approved by Planning Board -------------------_-----------19--------. Area a... .. :R f1...0 Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ............. ............................... .... grwckmr» Carlton ` No — itfor —.49%JMOK.------ ' - ' --------------------------. . . . - Location ........lI. .I.tive------ ----_--..Centerville................................ Owner --.1�a��koz�'[rockez--------. � . ' Type of Construction ...........frame------.. - � . ` ---,`..~-------------.------- ' Plot ............................ Lot ................................ ` \ �Permit Granted .� —.—.] 7� g � � Dote �� lg � ^ of Inspection^ ^—��---'' � . Date Completed .-�------]g ` ' � . . ' / ^ ^ . PERMIT REFUSED - ` ^�?---,_'r—.---�-------. l� ' ` i ............................................................... , � —.. � �� � �,.. ....................... ....................................................... '---------------.. lg � ,^~ � . � --�'---------------.------- � 4 , --------------~---------^^— � � � Assessor's map and lot number . .... ........ . ...... SevJag'� Permit number ...` .....4 ..�..��................................ E.T°�° TOWN OF .BARNSTABLE ii i I-A"STADLE, i # "69 BUILDING' INSPECTOR -� -- �0 waY a•0 w APPLICATIONFOR .PERMIT TO ....:.-.............................................................................. ..... !.•.. .......:: ............ TYPEOF .CONSTRUCTION ........................... .. ................................................................................................: ................. . ......... 04 ,Z64- 3 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: > Location ...... ..d... . .L.��.! .L `L .......1 � .....................................••, •.,,;(/./ ............................... ProposedUse ..... .... 1�. ` ..................................................................................................................... Zoning District .......... ........................................Fire District Name of Owner1 . ' ....................... ...�C .Address .... '^ ... �. ............................ Name of Builder .......... r ........Address ......... .............................................. Nameof Architect ....................................:............................Address .................................................................................... Number of Rooms .................. ..........................................Foundation .. .......T�/..... ......................................... Exterior .' ...Roofing `a "-' Floors •..:................................................Interior ..--.........:........................................................................ ` ....................................Plumbing '_ i............................................................ = /'`�` � Fireplace ............... ................................................................... Cost .................a..........................A.... ................... Definitive Plan Approved by Planning Board _______________________________19________. Area /.....d..,.. !�: ... A?-.�. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH t I I hereby agree to conform to all the Rules and,Regulations of the Town of Barnstable regarding the above construction. 4 Name �.................. .....-..... . ....................................... Crocker, Carlton 19q— C"wne, ---.���l.t.on..Cr.ock.e.r...................... Type of Construction .............fXA1444.................. --------------------------' Plot ............................ Lot ................................ � Permit Granted .............July...l8............ A-74 Date of Inspection ....................................l9, ~ . �� Date Completed ------------'lg � � , � PERMIT REFUSED .----.'---------------.. lA --------'^---~------------'- ------'—'---------------~--' - � —,---.—..-----------....------ . � � ----.---------------.—..---.. - Approved ................................................ lg � ^ ---'------------^----'~----'' ' � ' ------------------------.... ' � ��� TOWN'OF BARNSTABLE BUILDING PERMIT'APPLICATION Map 1 1 Parcel Permit# 3 Q, t o, Health Division Date Issued Conservation Division - Fee Tax Collector tl�Treasurer Cr�f �'a J✓ . Planning Dept. ` Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis F , Project Street Address A t Village C,-41k Owner Address VY1 P k Telephone -1 Q b ► Permit Request t> Square feet: 1 st floor: existing proposed 2nd floor: existing proposed •Total new Estimated Project Cost '31 0 0 0. D) Zoning District Flood Plain Groundwater Overlay 1 Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House:;❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including 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 ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If.yes,site plan review# Current Use Proposed Use ` BUILDER INFORMATION' Name N��:�� 1�ec Telephone Number Address 4ci -(\Iw A\ron License# ©(4015`f (n Home.lmprovement Contractor# t a �c ll g o Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO DATE SIGNATURE l . - FOR OFFICIAL USE ONLY , s PERMIT NO. : - rT DATE ISSUED MAP/PARCEL NO. r ^' ADDRESS VILLAGE � OWNER '�� • � � ^ - - - � _ _ . w ! + r DATE OF INSPECTION:; FOUNDATION - . t FRAME s INSULATION - FIREPLACE ELECTRICAL: ROUGH - FINAL r _.PLUMBING• ROUGH FINAL _ GAS: ROUGH FINAL 1 FINAL BUILDING t DATE CLOSED OUT t ASSOCIATION PLAN NO. - , U b �Ali1V�i,A=.� Department of Health Safety and Environmental Services Fo ' Building Division _ 367 Main Street,Hyannis MA 02601 J Xffice: 508-862-4038 Ralph Crossen Fax: 508-790-6230 r Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,.modernization,conversion, improvement,removal, demolition, or construction of an addition to any g owner-occupied ied P building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: a Estimated Cost �71 Address of Work: z e2 ✓ Owner's Name:r "-el l Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 ❑Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MIPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. V- Q b-CQ YY\mm �- ,-,\.A1WX41t- VW1oi �o Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav .___ The Commonwealth of Massachusetts _.� Department of Industrial Accidents =- Office olfmvestigaMons 600 Washington Street Boston Mass. 02111 ""•� on Insurance Afavit / /�r�j�%% %%%% sari % %name: NYI19,0L,\60VA ocation: 0%-i .t'C s �L fl nhone# Ag deb ❑ I azn a homeowner performing all work myself. I am a sole roprietor and have no one tivorking in any capacity %%/%% %/%%%% /%%/%%//% /////% %/%/G%//////�%///%////%/%%%%%%%%%%%�%//////�%%%%%/%%/%:;;;�',; ❑ I am an employer providing workers compensation for my employees working on this job. compnnv name: address: city: phone* insurance co. nolicy# ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the folloning workers' compensation polices: company name: - address: city: phone#: ...... insurnnce co. oliev# comnanv name: address: city: phone#r ...... > :: Insurance co, oiicv# .....:..,. /G / / / / Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a tine 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 One of 5100.00 a day against me. I understand that a copy of Oils statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. 1 do hereby certify der the p and pe i of erjury that the information provided above is 1 :and Sorrel Signature C Date / _ Print name Phone# oMciai use only do not write in this area to be completed by city or town official city or town: permit/Ucense# []Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (ie+vea 9;95 P1A) 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 conicz. 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 c: 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 1.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 and supplying company names, 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 rctrrned io 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. FENI The Department's address,telephone and fax number: The Commonwealth Of Massachusetts . Department of Industrial Accidents Office of In lasugaucus 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375