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HomeMy WebLinkAbout0013 LAURA ROAD i A w } . ti7 cif x " i � I I �, 11HE lQ� Town of Barnstable *Permit# " I -W% 1•G Expires 6 moerths from issue date Regulatory Services ® Fee Z 13ARNSPABI.E. v� 1659.MASER. `0m° Richard V.Scali Director Building Division Tom Perry,CBO,Building Commissioner 1 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us / ti Office: 508-862-4038 F�-�, -6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press hitprint Map/parcel Number 5�f- // 3 f Property Address /,3 jL4u -a -Ave_ Ce41&�v1t//if /Rsidential Value of Work$ 9 3 — Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address iZ 4 e/ (Ieru l t 1 / Z- ✓e. Ce,,fie ,,,t(P tl A 2— Contractor's Name W D W wOf �lGFF > > ,� Telephone Number 7 ff/ of 3asZ7A_1� Home Improvement Contractor License#(if applicable) 1(0(002. Email: Construction Supervisor's License#(if applicable) 87 Z7J 2 YNorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name frf&Krr01L ` j j?,= IIUSCtZi4� M Y1A�y Workman's Comp.Policy# ZZ VJ F-C1-T Z4 34� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value 3 O . (maximum.32)#of windows $ #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note:. Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is equired. SIGNATURE: dows\Tempoary Internet Fles\CbC:\Users\Decol i • cros t i ntent.Outlook\2Pl01 DHR\EXPRESS.doc Revised 040215 Massachusetts Department of?ublic Safety Board of Building Regulations and Standards _ic_nse: CS-072772 JEFF C STEELE 24 SHERWOOD AVE DANVERS MA 01923 4 .-ommissioner 04/07/2018 ��Y-- Office of Consumer Affairs&Business Regulation ., HOME IMPROVEMENT CONTRACTOR Registration: 166025 Type: " = Expiration: 4/12/2018 LLC WINDOW WORLD OF BOSTON,:LLC. JEFF STEELE 24 CUMMINGS PARK SUITE.15-A WOBURN,MA 01801 Undersecretary License or registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 ;Not valid without signature i tie Comma,zrtveat,'n. of Massacfttse s Department of Indus-frla"4ccident; F rJf face of bnvesiigatrei?s 600 F ashington Street 4 Boston, MA 02111 nrcczss,gov/dia Workers' Compensation l s'�rance Aiffzdavit: guilders/Contractors/EZ ease Prvat Ledbi;� Applicant Information N1am-(Business/Orga=ation/L dividual): E �� Aaar�ss: I t M/A/- S City/Slate/Zip: Are you an employer? Check the appropriate boss: Type of project(required):, a. Lam a general contractor and I am a employer with V ❑ 6. El New cohstruc ion have hired the sub-contractors employees(full and/or part-time)." listed on the attached sheet. 7. [❑Rzmcdeling 2.❑ I am a sole proprietor or partaer- These sub-contractors have 8. []Demolition slop and have no:ermployees. P Io em ees and have workers'. Building addition t . Y 9. [ Bui]diz b worgng for me in any capacity. comp..insurance [No workers' comp.insurance 5 We are a corporation and its 10.❑Electrical repairs or addit?ons required-] _; officers have exercised their 1I:El Plumbing repairs or additions IT I am a homeowner doing all work rift of exemption per MGL 12.[]Roof repairs myself. [No workers'comp. c. 152,§1(4),and vie ha°je no ins'rance required]t employees,po.workers 13• ther ZZ comp.insurance required_] *Aay applicant that chicks box rl must also fill ot2 the se rion below showing the=.*workar'co�pensa�on policy;nfoima�on.' Ho eowner who submit this aziidavit mdicatmg they are doing all work and am of the Buhen hue lb contractors and sta±e whether or bmit no those men ties hav�ch. Contractor that check this box muss attached as additional sheet shQwin� ohc number. employees. li the suxontractors have employees,they must provide their workers'comp.p ' Y - th policy and job site I am an employer that is providing workers'compensation insurance for my employees. Be£ow is e information. -//� � j� o Insurance Company Name: G Expiration Date: Policy or Self-ins-Lic. r_ W , � Job Site Address: � Lot✓r r= City/State/Zip: Center✓� c 1M✓� of the workers compensation policy declaration page.(showing the policy number and expiration date). Attach a copy ' on zcriminal penalties of a' Failure to secure coverage as required under Section 25A ofaMG�• Il5���es�ea�det owe�STOP WORK ORDER and a tine ire up to$I,500.00 and/or one-year raprso�ent,as well p of up to $2�0.00 a day against the violator. Be advised.that a copy of this statement maybe forwarded to the O,ice of Lnvestgations of the DIA for insurance coverage verification. jdo hereby certify and the aims and p es of that the information provided above is true and correct Date: Si tare: �3 Phone 9 r official use only. Do not write in this area, to be completed by city or town official PermitUcense 9 City or Town: Issuing Authority(circle one): eparbnent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing T 1.Board of Health Z.BuildingD itspector 6.Other Phone r4-• r`nntnet Person: WINDO-2 OP ID:W► (MMIDDICERTIFICATE OF LIABILITY INSURANCE °01125/20 7 1/25/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Carli Witcher CISR,CBIA,CIC Senn Dunn-GSO NAME: O 3625 N.Elm St A No Ext:336-272-7161 A No:336-346-1397 Greensboro,NC 27455 ADDRESS:cwitcher@senndunn.com C.Timothy Ward,CPCU,CIC INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Citizens Ins Co of America. 31534 INSURED Window World of Boston,LLC - INSURER B:All-erica Financial Benefit 118 Shaver Street North Wilkesboro,NC 28669 INSURER C:Hartford Fire Insurance Co. 19652 INSURER D: INSURER E: . i INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN;THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1EXP LTR TYPE OF INSURANCE ,ANSI SWVD POLICY NUMBER MMIDDY EFF MM/DDPOLICY YY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE OCCUR OB6790252707 04/01/2016 04/01/2017 PREMISES Ea occurrence $ 500100 MED EXP(Any one person) $ 5000 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,00 POLICY PRO- JECT LOC PRODUCTS-COMPIOPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB • Ea accident) $ 1,000,00 l3 X ANY AUTO AW68767615 06/16/2016 06/16/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - HIRED AUTOS NON-OWNED PROPERTY DAMAGE ' $ AUTOS Per accident $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS LIAR CLAIMS-MADE OB6790252707 04/01/2016 04/01/2017 AGGREGATE $ DED RETENTION$ + $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETORIPARTNERlEXECUTIVE YIN 22WECU2635 01/27/2017 01/27/2018 E.L.EA ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? � N/A . (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) r' CERTIFICATE HOLDER CANCELLATION -, 'FORINFO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Info Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD df�Osu °Window World of Boston,LLC MA HIC Registratlon Offices&Showrooms Number. 015A GUmmings Park 0295 Old Oak Sired 166025 6UWoburn,MA 01801 Pembroke,MA 02359 Federal Ip$ (781)932-4805 (781)826-6281 27-14131605 "Simply the Best for Less" www.WandowWorldof6asto n,com Customer: /s7'�C �L L✓LL/ Phone(h)// =Z30 Install Address:13 GAUrAIf�E Phone(wrjlf•2' —3�3�� •J tuM MA Tap 2?A 3 E-mal !� WINDOW WORLD GLASS OPTIONS _1000 Series Single-hung AINNeld $169 12—SclarZone Elite $1192�z6/ 2000 Series DH Mech/Wetded Sash $215 _Triple Glazed T021 $y9s 7&4000 Series DH AIWVdd $225 ("Sides 6=Wy) _6000 Series OHAll-Weld $260 WINDOW OPTIONS �2 Lie Slider $354_35fe lass Breakage Warranty s15INCLUDED _31.295lider (vs,lra,,n pµ,va,up $545 2Screens l $91EWDED Picture/Fixed Lite $354, am insulation an Jambs and Head $11 INCLUDED _Awning $tap Double Strength Glass $15 INCLUDED _Casement $tip DoubleLoris.,tn26°) $51NCLUDED 2 Lite Casement $595 _Full Screens $22 3 Lite Casement nra,ae,rat ru+,,rz vy $880 —Colonial Grids(ComouredlFfat) $45 _Prairie Grids $51 _Basement Hopper $334 _Diamond Grids $69 _Bay Window-Soffit Mount I INS Seat$266p Simulated Divided L0e $182 Bow Windom-Soffit Mount/INS Seat$2785 Tempered DH Sash(BSO)(TSO) $65 Garden Window $2040 Obscure Glass(BM)(TSO) $35 Specialty Window $ —_Oriel Style(40160 or 60/40) $30 _Beige/Almond "a _Foam Enhanced Frame $35 ____,Wcod Grain Interior fSeAes 40M 16000 ally)$100 PRE 1978 BUILT HOMES(EPA LEAD SAFE RENOVA770NJ (UghtOakl Dark OW Chanit/Fox Wood 1$Lead Sate Practices Required $30 i5vt7 Mch Maple) MY HOME WAS BUILT IN THE YEAR,&a Initial _Brown Exterior(Arch,Bronze/AmerlcanTerra)$1CO Designer Color Exterior $175-7 MISCELLANEOUS . f aCU5tom BdEr'norAluminum Cladding Window Color 'IJL� O T lured$75 I ion $75 $11 L— MsWe' Outside Facing Color NON CUSTOM FORS —Me�Window Removal $50 _Vinyl Rolling Patio Door 51 or bit. $1095 New Cons7urdionV'aryl Removal $175 Yrnyl Rolling Patio Door aft. $1195 —Spedalty Window Exterior Trim $ Mdto base priaeicr Custom Rolling Para Door$1250 Mall to Form Muffl Unit $so _French Rail Sliding Patio Dour 51t or lib. $1395 Install IntenodExlerior Stops $50 _French Rail Sliding Patio Door lift $1495 /Install Interior Casing Starts At $95 French Rail Sliding Polio Door sift $1595 Irisulate Weight Boxes $20 _CustamBdadorCladrding, $160 _Root for Bay/BawWindows $500 Salaizone Exle or ETC Glass $205 _Extsting New Corsi.Ext.Retro Fit $150 _Grids Patio Dorn $149 _Removal of Existing Bay/Bow $250 _Woodgrain Interiors $295 _Repair Sill,Jamb or replace sill nosing $50 —E,derior Designer Colors $995 Z Fug Sub Sill(Single)replacement $150 ARoo _Interior Casing 2nn 3tre $176 / Mullion Removal $W--aa _Harrdeset Options $_ _BayfBow Conversion Ext.Retro Fit $350 (New Siding Will Not.Match) Door Color j a, �rFAYi VIlINQQIK'�( {yS, i >nrrae o„ade �a� -,; '�uoe'�nlrher�ah�daei��N.�r �-� � li Customer declines exterior wrap and understands painting and/or repair may be required InatlaL Customer declines grids ci `\ winclows/doors Initial `kR_," [NELAIMER,Diatimer is responsitiefor the following In cormiction with this corbect pajoik Staining,Alum System disscannectlieconnect Building Permit fees In excess of$25.00,Npneamer and or Condo Assodathm Approval,Hlstodc Dis9lctAppmral City of Boston parking&sidevalkPerinkfess N ornnecfronvrign Instal ation NO EXTRA WORK IF NOT IN WRITINCa1 Customer agrees to the terms of payment as follows: Bdra Labor&Materials $ R L7l"/— Site Set Up,Permit,Disposal&Delivery Fees$ $36g.D0 Taal Amount $ 03- Cuslcm Order Deposit 50% $ 1 Ck•#ZDW Balance Paid to Installer upon Completion $ 6JZ Amount Financed $ Windrow Warid of Boston au*pates sbrtingth s work on '6� being substantially completed�aays.Securely Merest Yes No Any deposit required in advance oft ostartof the work SHALL NOT exceed 331/3%of the total contract price or the actual cost of any material or equipment of a " speclal order oreustam made nature,which must be ordered in advance of the sUt orthe wad;to assrsethatlhe project wiA proceed on schedule.No llnal payment , z shag be demanded unit the contract is completed tothe sailslacgon of both parties. r All home Improvement contractors end aubcerdracmrs shag be regisleredandMat arrytripulres abouta contract or subcontractor relatingio a registration should be dlrecledtp.ounce of consumerMairs and Business 6eguhllann,11ed Park Plata,Sulie 5170 Boslan,NA 02116.Phase:(617)9Td-3709 No work shag begin poor to the sigding d the confuted and transmittal to the owner of a copyaf lull conlrasf. Window Word of Boston under provision of Cuter 142A of the germal taws is regWred to applyfor and obtain all consbnidion-related permils.Window World of Boston shall not be deemed responsible for allays Tuttle work desonbed in this agreemendcaused byregulatory,permit granting agencies,autharit"or Individuals. Noffae:If thePURCHASERIB)oNainc his awii conaNurdian related perm0s farina work desed0ed under lbHI agreement or deals whh umegbte red cmdractors, Ilia PURCHASER(S)Is beretr+advised that In the evael of a dispute,judgement and nornpaymeM,Me PURCHASER(S)will not be et�led to make a clatm at collection ham the gin 9fundegablishedbydnapte142A,M.G.L. YOU the buyer awy cartel this transactrott at any fibre prim to intdn4m of Me Ihird bodoess day after Me dale a]INS transaction. Notice of emellatiani most he in writing postmarked no later gran midnight of the following third business day. This window VM-Frambse is inde endenQ owned and o enkd by window weld of Boston.I.I.C.under hcense from Window Wald Ire. . , 7 sm Oer;Do sat sign nfheraare any blanR ¢aso sp . vice 7 hZ G Sedesman:lac not s are airy bleak 3pacew Data Owner Do not sign R Ihm are any brink apace*. Data eoao„orn White Copy-Ofiginal; Yellow Copy-Fls Pink Copy-customer ifft-glMaae4-11le X _PRESS PER iTTown of Barnstable *Permit# ol Z AUG2007 Expires 6 months from issue_date Regulatory Services Fee CQ1 TOWN OF BARNSTABLEI'homas F.Geiler,Director Building jivision Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.toWn barnstable.ma.us Office: 508-86274038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY. Not Valid without Red X Press Imprint Map/parcel Number 51 Property Address ,.3 t a a ya, Roo Cea+eVu A-P 111 C_ 0Q (1P 25IQ [Residential Value of Work /J, 000 O Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 0l C t I do [ 1 O L,( S 4e_ Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable)' ❑Workmen's Compensation Insurance Check one: 0ra sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must-be on file. Permit Request(check box) []1Re-roof(stripping old shingles) All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof) E3"Re-side ❑ Replacement Windows..U-Value (maximum.44) "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. SIGNATURE:- Q:Forms:expmtrg Revise071405 The Commonwealth of Massachusetts Department of bidttstrial Accidents Office of Investigations • 600 Washington Street ' Boston,MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Butiders/Contiractors/Elect#dmislPumb r 3 licant Infflrmation Please Print . StOrPMiZ""'oUftlM • •��° �t `�Y� \ ^ten—) O ,e--Addtess: VA ' te/Zi 4vie City/5ta p•: ' , ;Type of project(required). �,re you an employer?.Checkthe:appropriate box:. . •• , .❑ Z am a Cmloyer with �4. ❑ I an a general contractor and I 6, ❑Navv eanstraction employees(fall and/or part tun)e * . have hired the mchedntractors :'7. ❑ Remodeling actor�p�._ listed'on the attached sheet.$ • •❑ I am�a sole proprietor These sub-contractors have S. Demolition • ship and have no employees. working forme in any'capacity, workers' comp,insurance. 9, ❑ Building addition. [No work�� COMP.inwanco 5. ❑ We are a corporation and its 10.[] Blbctrical repairs or.additions officers have dxcreised their r1 --- r ad of exemption per MGL �1Y.❑ Plumbing iepaas o ditions �_ I-am a homeowner do�pg all:work . .. . . . • c. 152,§1(4),and we have no.. 12.❑ Roof repairs \ �N leers fi�am�p; employees.(No worim �--� 13';❑ Other ._._ comp.insurance required ,may applicant that checks box#1 must slag fill outthe section showing their workers'compensation policy information: , '► ._ _ Flomeewaat5 who subatitthis affidavit indicating they are'doing all-work and then hire outside cabactoq must submit anew affidavit iodic a Uh. Contract=.that check Sus ben,crust attached an additional sheet showing the alma df the sub-contractors andtheir arorktas �= eF' C am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and Job site Information. " [nstiu auce•Company Name' #or Self-ins.Lic.#: Expiration Date•• - Policy . • � • •. ' . Job Site Address: Cityista*Zip: Attach a copy of the workers' compensatfon policy declaration page(showing the policy number and•expiration date). Failure to,seeate coverage as requiredunder Section 25A of MGL c. 152 carileadto the imposition OfcnmmalPcn2ltlez of a fine u' to$1,500,,00 and/or one-year iraprisoIIment,as well•as,civil penalties in'le form of a ST0?V0RK ORDEIL and a fine of t4$250.40 a day against the violator. $e advised that a copy oftlris statemenf may 6e forwarded ta,the Office of Inv estigatidns of the DIA for insurance coverage verification. under the airs and enaltces of pe►yury that the Information provided above is true and correct I do hereby rt<;fy p p / stare Phone#: 77ilt nly. 'Do not write In this area,to be completed by city,or town of Cityn: Permit/License hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.ElectricalInspector S.Plumbing Inspector rsou. Phone#: ' t1o]�.s' Information and Instruc ' . . . 10 ees. �d ter 152 t Hires all employers to provide workers' coraPensation for their crap y Massachusetts General Laws c�ee defined "...every person in the service of another under any contract of hire, Pursuant to this statute, eP°y itten express or imp]ia drat or '�, •,' • , ar any two or more . ., . ' a tilers}ip,;assoaation,Fq=poration or other legal entity, , ,... An employer is deemed as:`4 inch►i4y - the le r resentat'ivea of a deceased employer,or the oin en a ed in a joint enterprise, and including ep �. HoVte�er:te of the foregoing, g g , , association or other legal entity,employing emp 'ant of the - receiver or trustee of as individual,per ' oww of a dwelling baus a having not more than o mamteriamc construction repair woikv such dwelling kous e ' dwelling house of another who employs pens mployer. " . :•fi or one grounds ov bu>7.ding appurteTeto,shaIl notbecause of such ezaPloymentbe deemed to be an.e chapter. §25 C(6)`�0 stag fit'"every state;or local]icensing agency shall withhold the issuance or MGL aP ' " use or permit to operate a business or to construct buildings in'thet mmYe��9�aor il., . ?aewal of a lice produced acceptable e�ldence of compliance with the insurance applicant who*has not p olitical subdivisions shall Additionally,MGL r•,h4ter 152,§25C('n states"Neither$ie commonwealth nor any of its'p ter into any contract for'the performance of putilic work until acceptabld evidence of comPkaace wi$i the insurance en �tractor authority." iequirements ofthis chapter havtitieen presented to the con g . Applicants ; ' to ur situation and,if. ensatiou affidavit'completely,by checking the boxes that apply YQ Please-n out the workers' congp address es and phone numbers) alongwith.their certificates)of necessary,supply sub-contractors)naaie(s), ( ) y�no employees other than-the ecessm e. Limited Liability Companies(LLC)or Limited Liability P artaershrps(I f an or artaers; are not required to carry workers' aompensatioa insurance. If an LLC or LLP does have members P aired. Be advised thatth�s R%davit may be•submitted to the Department of Industrial employers,a,policy is'required. ccidents for confirmation°f insurance coverage•. ' so be sere to sign aid .eiug r e este not the DepThe aartmeat of iti- A or town that the application for the permit.or license is being req ted, _ b e returned to the criY uestions regarding the law or if you are required to- - Industrial Accidents. Should xon have any q t at the nwmber listed below, �Se]f-insured companies should pater their compemationpalicY,Please call the Departmen self-insurance license number on The appropriate lime. City or Town pftldals ace at the bottom davit is complete and printed legibly, The Department has provided a space Please be sure that the a applicant of the affidavit for you to�out in the event the office of Investigations has to conttact y,ou regarding the apP licant Please be sure m••hepe=it(hcense number which wMbe used as a reference number. In addition,an aPp t submit permit/i�censo applications in any given year,need only submit one affidavit indicating cturent that must licmt should write"all locations in_._,__(city or 'on(if and under"Job Site Address"'tEie app may be provided to the poycy mformati ( davitthat has been ofiaalYY stamped or marked by a city or Y tovv�a)."A copy of te' or-la"=es..knew affidavitmast be filled out•eat h applicant as proof that•&valid affidavit is e.u.file for;fatare permits' Where&home owner or citizen is obtaining a=licduse or permitnottYel te to any business or commercial Venture year, a orvit ermit to bum leaves etc.)said person is NOT req P i.e.a dog liceas P . . bans would 1'ke to thank you in advance for your cogperation and should you have any questions, The Office ofInvestiga to give us a call. ' please do nothesitate -� ax minter. df hone an eat's address,telep , artm The Dep onwealth of Massachusetts . ' rj•• er, The��nt of ladustrialAccidents •• • • ..office 9f h1V. estigatinps '.. a !• ' �04-Washington Street . V 02.111� Tel.#617-727-4900 ext40'6 or'1-877 MASSAFE " Fax#617-7274749 zzMray.maRS.QaVI(ha