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Town of Barnstable Building
Post ThrstCard So„T.Mat rt,rs Ursrble From the Street Approved Plans Must beRetarned on Jo,b and this Card Must-be,Kept _
�: MARATSY'AtILC. • 'Post
• F
M Poste Until Final°Inspection Has3Beer IVlade f,� _ �„
Wh'ere a Certificate of O,ecu anc ys R� wired °such Burldrn shall Not'beOccu red u;ntrT.a=Flnal.lns ectro�has",been made , : ', 1 el lijl 1
Permit No. , B-18-999 Applicant Name: John Vreeland
Approvals
Date issued: 04/13/2018 Current Use: Structure
Permit Type: Building-Solar Panel-Residential Expiration Date: 10/13/2018 Foundation:
Location: 31 HIGHLAND DRIVE,CENTERVILLE . Map/Lot 189 119 Zoning District: RC Sheathing:
Owner on Record: MATTHEWS, KATHERINE A TR ;FUntractdif Name``, JOHN VREELAND Framing: 1
Address: 31 HIGHLAND DRIVE torsi
Contractor License CS'107947
�a 2
P� a
CENTERVILLE, MA 02632i�� _ <. Est Pr
oJectCost: $21,292.00 Chimney:
Description: Roof mounted PV solar installation.This system will consist of 23- Permit F. e: $ 158.59
Insulation:
290w modules with microinverters.The totalisystem-srze Is 6.67 Fee Pai411
d $ 158.59
kW. Final:
t Date 4/13/2018
Project Review Req: incorrect code reference cited in engineers letter f
Building Official Plumbing/Gas
Mm
Rough Plumbing:
• &
This permit shall be deemed abandoned and invalid unless the work authonze i &&J"e
h.�'s permit is commenced withinm six months after issuance. Final Plumbing:
All work authorized by this permit shall conform to the approved apple to ion a rapproved construction docuen forts whichthis permit has been granted.
All construction,alterations and changes of use of any building and stuctures al be in compliance with the local zoning,by laws nd codes. Rough Gas:
This permit shall be displayed in a location clearly visible from access street or oad and shall be maintained open for puo1m;Inspec ion for the entire duration of the
Final Gas:
work until the completion of the same.
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and,Eire Officials are provided on thi—permit. Electrical
Minimum of Five Call Inspections Required for All ConstructionWork
1.Foundation or Footing k Service:
2.Sheathing Inspection �, y
3.All Fireplaces must be inspected at the throat level before firest flue lrn rs,nstalled.' .•'. Rough:
mg
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Rough:
7.Final Inspection before Occupancy
Low Voltage Final:
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. Health
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
c.�
Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
JAMES A. CLANCY
]PROFESSIONAL ENGINEER
601 AS] URY AVENUE
NATIONAL PARK, NJ 08063
(856) 358-1125 ]FAX: (856) 358-1511
Construction Code Office
Date: April 12,2018
Re: Cotuit Solar LLC,3800 Falmouth Rd.,Marston Mills,MA 02648
Subj: Katherine Matthews,31 Highland Drive,Centerville MA 02632
We have provided an inspection and review of the residence roof'construction of the above named
property in regards to verifying the capacity of the existing roof for installation of a new Solar Panel
Array.
We have found the residence to be of wood frame construction bearing walls with a rafter framed roof
system. The main roof is of 2x6 @ 16" o.c. and is sheathed with 1/2" ext-ply sheathing and a single
layer of composite shingles. The existing roof structure bears directly upon the exterior stud framed
wall system. The existing rafters as installed meet the required load/span ratings with sufficient
capacity to carry the minor additional load of 4 #/sf imposed by the proposed solar array per the details
below.
Installation of solar rack systems shall be as follows:
Each panel row shall, be 'supported upon 2 mounting rails. Rails shall be screw anchored
through roof and directly to rafters below.
Rail attachment points to rafters shall be staggered each row with exception to the first fastener
row from the gable end which is attached to two adjacent rafters.
Geocell 4500 roof bonding sealant shall be applied between the aluminum foot of the mounting
system and the existing roof shingles at each foot location.
Typical mounting detail sketch attached.
When installed per the above specifications the system shall exceed 140 MPH wind&30 PSF snow
loads as required by Massachusetts 780 CMR table 1604.11.
Should you have any further question or comment please feel free to contact our office.
Respectfully,OF,
MES A Gc
Ncy
48775 �+
.a
Ja es A. Clancy
Professional Engineer -
MA License#46775
Assessor's Office(1st floor) Ma
„^T p ��/ Lot �J� �' Permit#
Conservation Office(4th floor) Date Issued
Board of Health(3rd floor)(8:30-9:30/1:00- 2:00) Fee
Engineering Dept. (3rd floor) House# 3'� , , ®� ��
Planning Dept.(1st floor/School Admin. Bldg.) 3t �Ze
} RNSPABLE.
MASS
Definitive Plan Approved by Planning Board 19
TOWN OF..BARNSTABL0,1� ��q#• ,�
/ Building/Permit Application
Project Street Address -X 13 l t �7l 2
Village ,� eUl` �° �®
Owner Address
-Telephone �7 7�-V�/��/
Permit Request ✓ pS�a/� Gc.,O ��,/ ���dll� //I,SGf�d � C�2��4 .� �CS
Total 1 Story Area(include 1 story' es&decks) ✓: square feet C� &�n4kc:,m5�
Total 2 Story Area(total of 1st&2nd stories) square feet
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ?
Zoning Board of Appeals Authorization Recorded
Current Use Proposed Use
Construction Type
Commercial Residential
Dwelling Type: Single Family ✓ Two Family Multi-Family
Age of Existing Structure y1?_5 Basement Type: Finished
Historic House &11) Unfinished
Old King's Highway &f o
Number of Baths o2 No.of Bedrooms 3
Total Room Count(not including baths) First Floor
Heat Type and Fuel Central Air Fireplaces
Garage: Detached. Other Detached Structures: Pool
Attached Barn
None F Sheds
Other
Builder Information
Name ���/ �� �CLJS 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
SIGNATU DATE
-
BUILDING PERMIT DENIED FOR THE F LLOWING REASON(S)
FOR OFFICIAL USE ONLY _ - -- -
~ f
PERMIT NO.
June 5� 1995
DATE ISSUED `-• -- � •
MAP/.PARCEL NO. 189. 119
ADDRESS 31 -Highland Drive ' VILLAGE Centerville, MA 02632 r
OWNER Katherine. A. =Matthews
DATE OF INSPECTION: _ +
FOUNDATION `
FRAME
INSULATION `
FIREPLACE.-
ELECTRICAL: ROUGH FINAL ,
PLUMBING: -ROUGH,- ' FINAL
�e�'e�i ..are: ' f + .. •
GAS: ROUGH" FINAL _
FINAL BUILDING
� h 1
DATE CLOSED OUT
ASSOCIATION PLAN NO. c`�. ,
° The Town of Barnstable
tee$ Department of Health Safety and Environmental Services
116
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-775-3344 Building Commissioner
For office use only
Permit no.
Date
AFFIDAVIT
HOME EffROVEMENT 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 pre-existing owner occupied
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.
G6 �7i,�1o� kF IacLsu6 Flno¢�� °<
1
Type of Work: N �• Est.Cost JdO• x,< I,
Address of Work: !7/ h�a�Cl } � i�y/ � ,X0,
Owner Name: ��/�/.t��
Date of Permit Application: 1a
I herebv certifv that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000
Building not owner-occupied
70wner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT 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:
Date Contractor name Registration No.
OR
Date Owner's w6e
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB. LOCATION
Numb r Street address Section of town
"HOMEOWNER" , ZCIZ,
Name Home phone Work phone
PRESENT MAILING ADDRESS �� ifl f��� �i�• ., .
Q26/132.
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 Officia.
on a form acgp-ptable to the Building Official, that he/she shall be responsibl
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 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.
HOMEOWNER'S SIGNATU
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35, 000 cubic feet,, or larger, will be required
to comply with State Building Code Section 127. 0, Construction Control.
. _ APPLICATION FOR PERMIT TO INSTALL AND REQUES
FOR ELECTRICAL SERVICE
Inspector of Wires 0!fQ/!"V/�� Wiring Permit.# COM/Electric#
Town of '`n'°" n ' `�j Massachusetts Building Permit# Date
If
Customer. -� rr on(Street#) /f�fa �A•V� �:�C
Lot# in-the village of e� utility pole number or underground number
Customer's billing.address
Temporary New instgliation Change of service Starting Date
Job descnpt ion
y
,`- Serviceenttance Voltage Amperage Phase
Wire size;.(cu.or al.) Conductor per phase
Number of meters. Water heater Off peak:Yes— No—
: Estimated_load:Electric heat kw,lights kw, Range . dryer .Motors, H.P.&Phase
Ready for,first inspection Ready for final inspection
Electrical Contractor ��iA"'� �� 82f}l�'�r ��° Lic.# ae) .'7y A Telephone#6l?g 7,r ,a 9a7
Address SuAliH i S 1^� tdG'1�� �
Additional Remarks:
Do Not Write Below This Line
ELECTRICAL WIRING INSPECTION CERTIFICATV00MUN
INSPECTOR OF WIRES
INSPECTIONS. :. DATE FEE CHARGE
Temporary Service
Roughing:in
Service and Meter
Off Peak Meter o '
Final Approval
Disapproved 6
.`For the following reasons
CERTIFICATE OF INSPECTION DATE
r.
To the COMMONWEALTH ELECTRIC COMPANY.The installation described above has been completed,and_has this day been inspected and
approval granted for connection to your service.
Inspector of Wires .
WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit Good For One Year From Date Of Issue CA 46-1
White--COM/Electric Green—Inspector Canary—Town Receipt Pink-Inspector's Copy Goldenrod-.Electrical Contractor
to COM/Electric
ate\ Of m Use Only
The Commonwealth of Afassachusctts PcrrrAtNo. 0 77
Department of Public Safety O=up=y&Fat Cbedwd
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12.•00 3#90 (1mveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All Work to be periormed in accordance WUh the Massachusetts Electrical Code. S27 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORHATION) Date 6 S — 7,j",—
TOWN OF BARNSTABLE To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street 6 Number)
/ 3 ��ci
Owner or Tenant /���� i �� C�C -e l.✓S
Owner's Address 4-
Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box)
Purpose of Building ���y e'���'� / S e Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total
KVA
Above In-
No. of Lighting Fixtures Swimming Pool grnd. ❑grnd. ❑ Generators KVA
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting
Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
No. of Ranges No. of Air Cond. Toone tal No. of Detection and
_ Initiating Devices
No. of Disposals No. of Heats TotalTons otal No. of Sounding Devices
No. of Dishwashers S ace/Area Heating KW No. of Self Contained
P Detection/Sounding Devices
No. of Dryers Heating Devices ' KW Local❑ Municipal ❑Other
�Y B Connection
No, of o. o Low Voltage
No. of Water Heaters Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Li lilt Insurance Policy including Completed Operations Coverage or i substantial
equivalent. YES Li
8 I have submitted valid proof of same to this office. YES NO ❑
If you have c eked YES, please indicate the type of.cover ge y cnecking the appropriate box.
INSURANCE BOND ❑ OTHER ❑ (Ple Specify) ���� 7
(Expiration-Date)
IG Estimated Value of Electrical Work S 'mod
Work to Start �j r 0 s Inspection Date Requested: Rough - / - ?,S
S Final
Signed under the penalties of per,Jury:
FIRM NAME Gy�l�i�`"7 J ��� `f 2 /- / LIC.-VO__3o a�
Licensee -S�� SigratureG� LIC. NO. S `�
C/ i Bus. T o. `/7
Address /b
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or is cu -
stantial equivalent as required by Massachusetts General 14W39 and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S
Signature of Owner or Agent
oFzT�, j� :°Town-of Barnstable *Permit# (�
-,11 u L Expires 6 months from issue date
l
swxrrs-r.+er.E, ' dart% y Services FeeMASS.
r.;1
�
Thomas F.Ge �T Di rector
0
i639' ��
Building Division
Tom�1� oner
200 Main Street; Hyannis,MA 02601 3 j
Office- 508-862-4038
Fax: 508-790-6230 °��� � ` ���4
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint I UVVN Ul- BARNS_ABL
Map/parcel Number 9 If 9 Lo+ I �
Property Address n r 4_1 V t-(�e , (Y)q col(.03�
,*esidential Value of Work �GC�
Owner's Name&Address KOA ev- n 2 rn L,)S V i rz�104 � case V
Contractor's Name f�nr1 n Il �ume- --Telephone Number '7 des ' 7 75 - (7 7 K
Home Improvement.Contractor License#(if applicable) 3-7 S
Construction Supervisor's License#(if applicable)
orkman's Compensation Insurance
Check one:
[] I am a sole proprietor
am the Homeowner
ave Worker's Compensation Insurance f
Insurance Company Name
Workman's Comp.Policy# -7 Oy `f 'T y 3(.)► a 00,3
Permit Request(check box)
❑'Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
_ e-side'
❑ Replacement Windows. U-Value (maximum.44)
f
*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 JTprovement Contractors License is required.
Signature —
Q:Forms:expmtrg
Revise053003
, a
.LT �.ax,
31, lllgblanll�r'^ a
Centerville,MA 02632
RE: Vinyl Siding
January 12,2004
CONTRACT
SIDING
■ Strip&Dispose of shingles from sides and rear of house.
■ Apply Tyvek House Wrap over existing sheathing.
■ Furnish and install Mastic Barkwood Triple 2 2/3 Colonial Yellow vinyl siding.
x�
�µ s�
r
Approximate Start Date: Week of January 26`h, 2004
Approximate Completion: Week of February 91", 2004
Cus er's Si a e� Date
Contractor's Signature Date
'✓ �` .�xaa�, ii�'x �'4 �` � v*=`, r� M ;sr Ft "_^ � k W�" aY" 9� � ^��
*r
,� o 2u
�B�OARD �:OF ;B` � I,LDING�REG.� TIONS
License: .COI=STRU{ =TIO`N S'UiPE+Rl`SR
°` Number; 0.6� 3 A
x
�` Expire : 10/08/200'5 Tr. no 51-1 {
t Restr�ced: q0
PRINLE r3
BRADK S 4I
Ng1ARNSTALE, AMA 0268 riainistraor {
1
A mad
i
x:w
- Board' a :B=uiidng Regulations an�ct�Stan�dard
z f° a4 !
n
HOME IIIIPRlVEM'ENT CONTRACTOR # = <f
M
Ec�ItIQt: ?/9L °.w 04 j
l r r oraton
Type. Pr,*ate Copp
:
SPRINKLE HOME IMPIOVMtENT
Brad Sol nkle
99 Barnstable Rd.
1
yan.0 MA 02�01 }
Adininis ra,
, toI
00 38,Qo0 cf enclosec _space p
4'
(MG;L C:1 12 S6OL)
1A - Masonry only
1 iG- 1 :&;2 Faintly Roes
Facture to possess=a,Cu -ri:edition of the
Mas achusetts Stete B'uiltling Code
is cause for revocation"-of this=license.
fW
DIG SAFE CALL CENTER: 44Ij
�7233
Y #
.rv4 }Y.td..t.
sy,'YwM.. '.�+"E:m, w4 t ..lbw"ti. +w �•Yc4Wxw."4'cN..-;4 H _
M
f ..
r
License or registration valid for ind�ivdu use onl
.before the expiration date. If found retu3rn to Y
` Board of Building Regalations and t-andards ^F
OneAsh$burton Place Rm 13'01 :.
Boston, Ma.. 02108 u
Not _
valid' without sig
ature
.. .M
V
1
P'fCY
CERTIFICATE OF INSURANCE .ISSUE DATE(MM/DD/YY)
PRLODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
Bryden&Sullivan Ins Agency DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
Inc POLICIES BELOW.
88 Falmouth Road COMPANIES AFFORDING COVERAGE
Hyannis, MA 02601 t-- ----------- ---
INSURED
Sprinkle Home Improvement Inc COMPANY A.I.M. Mutual Insurance Co
199 Barnstable Road LETTER A Mutual.
Insurance
MA 02601
I 1
COVERAGES _
THIS LS 7 O CEICI IF?IIAl THE I OI.CIFa dF INSUkANCt L&T BEL:1W NAVE 8E-r- :SSUEU'tU W E URED r AME5 A:;OVE FOR POLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REQUIREMENT,T'ERM OR CONDA'ION OF ANY CON T RACr OR OTHER DOCUMENT WITH RESPECTTO WHICH THE
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. , t
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXMRATI LIMITS ( r
L D,CTE(MM/DD/YY) DATE(MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE S
MMERCIAL GENERAL LIABILITY PRODUCTSCOMP/OPAGG. S
'LAIMS MADE[ —�X'CUR PERSONAL&ADV.INJURY S
•
WNER'S&CONTRA(TUR:S PROT. EACH OCCURRENCE S
FIRE DAMAGE(Airy om fire) f
MED.EXPENSE(Any one person) S
AUTOMOBILE LIABILITY I COMBINED SINGLE f
ANY AUTO ` LIMIT
ALL OWNED AUTOS
BODILY INJURY f
SCHEDULED AUTOS Per peon)
i
HIRED AMUS
' BODILY INJURY I S
NON-OWNED AUTOS Per swideoq
ARAGE LIABILITY
PROP ERTY DAMAGE S
LESS LIABILITY EACH OCCURRENCE S
MBRELLA FORM AGGREGATE f
HER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND x WCSTATU- OTH-
EMPLOYERS'LIABILITY
7004943012003 05/13/2003 05/13/2004 S —7�Uw
A THE PROPRIETOR/
PARTNERS/EXECUPIVE INCL E DSE E-- LICY IMIT S SOO O00
OFFICERS ARE: RIEXCL EL DISEASE—EA EMPLOYEE S 100 000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
- 'PIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
III. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
FT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
\BILITY OF ANY KIND UPON THE COMPANY. ITS AGENTS OR
PRESENTATIVES.
THORIZED REPRESENTATIVE /�
The Commonwealth of Massachusetts
( Department of Industrial Accidents
office.MONSOON=
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city
phone#
❑ 1 am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
am an employer providing workers' compensation for my employees working on this job.
1'
comoanv name> SD f (1 J;1 t 0 M e, VVN n rO V-P
Q.r MCI MCIL b I�C_
co an in i S 00 A O a o()l phone#• C 01 -175 - 1`I-1 S:
insuranceio' A�T M m L-J U&I T.�(- C poi y# 1 OLD ,A 9 4 r7 La M as
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who hs,:-
the following workers'compensation polices:
.......,..
comnaex tram:'
::..::..::.:.
tttl�r'.ess:.
S.lt . ..
phone#.;..::; :;::;..:.::: ;•:::..,.;:. ., .:
adtityess�
mo-t�..: .... .... .. ..
tnsnrsneefo's. policy
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 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 under the pains and penalties of perjury that the information provided above is true and correct:
Signature Date
. ..... Print name Phone
Ccheck
ly do not write in this area to be completed by city or town official
permitAicense# nBuilding Department
pLicensing Board
mediate respo a is re uired oSelectmen's OfficeoHesith Department
n: phone#; �7 7 5-- �7 7� Other .
(revised 3/95 PJA)
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 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 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.
The Department's address,telephcre and Fax `._.....___ _. ..._.._ . . .. .. ._... ... ...
The
Dewart'r ..rat fie 6.ndt3J fil .t.uxm
difice of Investigations
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone #: (617) 7274900 ext. 406, 409 or 375