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0307 PHINNEY'S LANE
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" , , � , ,,, , �I " , , , , " , ,;I_ .! , , j, ,,,,,I- , ,, , I , .,. 4-" !L' , , ,�_�"�� . , �,,���%� " "� ,�,��,, I, - �'_ ,,1 - --I : �. - � � ,__-s,,'��-�"�I ,64 , , , 00� ', " _� , " - -`,� , 'i,�,!,,, -I. -, LL�,Z:"_,,,�_-,,' ,- � ., _��" � , 1 , ��,��,�, is� , ������:_.,!__I�.;_ �,.��'._���-._,,LL _j�,. ,�, , ` �" - JL -,"�I,", - I ..� _,�I,�,�, _�� .___...,iY, , - - -� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Maps Parcel CaliflLE Application #t:�: /j 0 7 S Health Division Date Issued Conservation Division Application Fee t( Planning Dept. t`:�µ M � Permit Fee �"35 .00 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address �)61 "0mviWAS Village A l VI Owner Y v�C�1 kl, Address Telephone 4 2 Z, Permit Request �/� ���k. �lJ Pia UL a ��� a l j +ew" bmvvv I h J I I Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �6d ' Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family U(/ 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 O No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name (iV�U Ciao Telephone Number !�d - 8 Address Vd t,- License # a U AV WM Home Improvement Contractor# �Lj Email Worker's Compensation # fl1 ALL CONSTRUCTION DEBRIS R SULTING FROM THIS PROJECT ILL QE TAKEN TO AWP SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. 4 ADDRESS VILLAGE OWNER ti DATE OF INSPECTION: FOUNDATION r FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Massachusetts Department of Public Safety /- r Board of Building Regulations and Standards License: CS-100988 Construction Supervisor I IN HENRY E CASSIDY,\ 8 SHED ROW ��° �1�` , . WEST YARMOUTH MA{ .2' .�►^^^ Expiration: ' commissioner= 11/11/2017 Office of Consumer Affairs and Business Regulation. 10 Park Plaza -'Suite 5,170 Boston, Massachusetts 02116 Home Improvement Cbbtra.,ctor, Registration Registration::,153567- Type: Private Corporation. Expiration: 12/15/2016 , Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE, --_- SO, YARMOUTH, MA 02664 UpdMe Address and return card. Mark reason for change, $CAI 0 2OM•05i11 Address. Renewal Employment LostC'nrc �ce�par�rwza�uuea.�G/t a�C/�lcWacro�ccdeCt� ' . Office of Consumer Affairs& Business Regulation License or registration valid for Individul use only (TOME IMPROVEMENT CONTRACTOR before the expiration date, If found return to; egistratlon; -1.53567• Type; Office of Consumer Affairs and Business Regulation j xplratiom ; 1V-.i5.j20,:16 Private Corporation 10 Park Plaza -Suite 5170 4: a� Boston,MA 02116 . CAPE COD INSUL0.tI .N,iNC HENRY CASSIDY 18 REARDON CIRCLE''''': S0.YARMOUTH,MA 02664 Undersecretnr — Y N valid wi ut sign e The Commonwealth of Massachusetts Department of Industrial Accidents ;j Office of Investigations 9 -:' 660 Washington Street. Boston, MA 02111 i www,mass,gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizationAndividual); �l ' t ' t n Address: Cih/State/ZiP� V OAMMa, A- Phone #: �� iI.v Are you an employer? Check th appropriate box; J of project (require ` l, ,I am a employer with �� � 4, ❑_1 am a:general contr Type actor and I - d): _ employees(full and/or part-time).* have hired the sub-contractors 6, C New construction 2, 1 am a sole proprietor or partner- listed on'the attached sheet, 7, 0 Remodeling shipand have no employees These sub-contractors have 8. [] Demolition �- working for mein any capacity, employees and have workers' [No workers' comp, insurance .` comp, insurance,t � 9• [] Building-addition - required.) 5. ❑ We are a corporation and its 1.0.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 l,[] Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL r c, 152 4 1.2•0 Roof repairs insurance required,) � , §1O, and we have no employees, [No workers' " 13.N'Ll Other comp. insurance required.) :A a t *Any applicant that checks box NI must also fill lout the section below showng theirw work ers'compensation on 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, tContractors that check this box must attaFhed an additional sheet showing the name of the sub-contractors and.state whether or not those entities have employees, If the subcontractors 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 „�nfo.rmation, Ing Insurance Company Name: � �' Policy # or Self-ins, Lic. #: t �i 06' JI I Expiration Date:` Ij I149 job Site Address _ "-��" � K City/State/Zip: Attach a copy of the wo'r" ers' 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 WORKORDER and a fine of up to $250,00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insuraQ4overage verification, I do hereby certify d ' the pal art penalties of perjury that the Information provided a ove true and correct, - Si nature: { Date, Phone#: Official use only, Do not write in this area, to be completed by city or town official, City or Town: Permit/License# Issuing Authority (circle one): 1, Board of Health 2, Building Department 3, City/Town Clerk 4, Electrical Inspector 5, Plumbing Inspector 6, Other Contact Person: Phnna f!. p CAP•ECOD•27 BDELAWRENCE A�ORO'Tj DATE(MMIDD/YYYY) — `.� CERTIFICATE OF LIABILITY INSURANCE 6,30/2015 THIS CERTIFICATE I ISSUED AS .A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE,DOES NOT CONSTITUTE A .CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED,the policy(les) must be endorsed, If SUBROGATION IS WAIVED, sub)ect to the terms and conditions of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s), PRODUCER CONTACT.NAME: Rogers&Gray Insurance Agency, In PHONE Faz 434 Rte 134 aC Ne; (877) 816.2156 South Dennis,MA 02660 EMAIL -. - — ADDRESS: INSURERS AFFORDING COVERAGE NAIC n IN$URERA;Peerless Insurance Company•see LIBERTY MUTUAL INSURED INSURER B:ATLANTIC CHARTER INSURANCE GROUP " Cape Cod Insulation,Inc, INSURER c 18 Reardon Circle INSURER D I South Yarmouth,MA 02664 INSURER E I. INSURER F I 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. INSR _ LTR TYPE OF INSURANCEJam POLICY NUMBER MMIpD E MMIDDm P LIMITS A X COMMERCIALGENERALLIABILITY t CLAIM$.MADE OCCUR CBP8263063 04101/2016 04/0112016 EACH OCCURRENCE $ 1,000,00 PREMISES Eeoccurrence $ 100,00 MED EXP(Any oneperson) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: X PRO. GENERAL AGGREGATE $ 2,000,00 POLICY a JECT LOC PRODUCTS•COMPIOPAGG $ _2,000,00 OTHER: AUTOMOBILE LIABILITY el 0 I G III $ Ea ec Fenn ANY AUTO BODILY INJURY(Per person) $ ' ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Par accitlenl) $" T NON-OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per ec ident UMBRELLA LIAR EACH OCC URRENCE CE $ OCCUR - EXCESS LIA9 H'CLAIMS-MAOE � � $ AGGREGATE $ CEO RETENTION$ WORKERS COMPENSATION " AND EMPLOYERS'LIABILITY STATUTE OER _ B OFFICERIMEMBERANY ,EXCLUDED?ECUTIVE Ya NIA WCE00431901 0613012016 0613012016 e,t.EACHAccIDENT $ 1,000'00 (Mandatory In NH) If yes,describe under E.L.DISEASE•EA EMPLOYEE $ 1,000,00 pESCRIPTIONOFOPEFtATIONS.below E.L.DISEASE•POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES'( CORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers Compensation includes Officers or Proprietors, Additional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS, South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION, All rights reserved, -- ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD . Al - mass save, . PART[C,pATIJIG swings ilroc,,¢r.�srgP etbefier,ey CONTRACTOR PERMIT AUTHORIZATION FORM I, MARY MELESKI ,owner of the property located at: (Owner's Name,printed) k7 Phinneys Ln CENTERVILLE (Property Street Address) IGty) hereby authorize the,Mass Save Home Energy Services Program assigned Participating Contractor listed- below to act on my behalf and obtain a building permit to perform insulation and/or weath_erization ` work on my property.. X owner's Signature Date. FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy.Services Participating Contractor,to the.above referenced project: Participating Contractor . Date 4 vle $` For office use only Rev. 12132011 r.. �f YKE Tpr,. Town of Barnstable Expires ti r?iaitlis jro�n„issr{e date B, , ,B1 ; Regulatory Services Fee `��fl � M"S& $ Thomas F. Geiler, Director p i639. �� ] rF16.39 � Building Division Tom Perry, CBO Building Commissioner g 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax. 5087790=6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number3 Property Address E 1 6A n e S VResidential Value of Work '� gyp.Co Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number I I400� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) [v}workman's Compensation Insurance Chef am a sole proprietorPERMIT ❑ I am the Homeowner ®PRESS ❑ I have Worker's Compensation Insurance JUL 1 0 2oog Insurance Company Name �VtN1 P1 J BARNSTABLE Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on tile. Permit Request(check box)- ❑ Re-roof(stripping old shingles)All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ` �Re-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: r petty Owner must sign Property Owner Letter of Permission. omen Improvement Contractors License& Construct Supervisors License is required. SIGNATURE: Q:\WPFIL:ES\FORMS\Express\EXPRESSPERMIT.DOC Revise06O4O9 The Commonwealth of Massachusetts Department of Industridl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): YDfit. Address• LL y �n City/State/Zip:'\� M R 02f0_1 i Phone.#: 6`1- Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. am a sole proprietor or partner listed on the attached sheet. T. 0 Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers 9. ❑Building addition [No workers'comp.insurance comp. insurance.$ required.] 5. We are a corporation and its '10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.dOther N' (' comp.insurance required.] *Any applicant,that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. XContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees.. If the sub-contractors have employees,they must provide their workers'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. Ida hereby certi the.pains and penalties of perjury that the information provided above is true and correct Signature: ,{ Date: Phone#: _ �'O'� " l 0 L'f" Official use only. Do not write in this area,to be completed by city or town officiaC 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 em loyee is'defined as"...every person in.the service of another under any contract of hire, express or im plied,oral or wri ,en." ex r d, P mP An employer is defined as"an imA ividual,partnership,association, orporation or other legal entity,or any two or more of the foregoing engaged in a join enterprise,and including the le•al representatives of a deceased employer,or the receiver or trustee of an individual, :artnership,association or o er legal entity,employing employees. However the owner of a dwelling house having nmore than three apartrnen, and who resides therein,or the occupant of the dwelling house of another who employ persons to do mainten ce,construction or repair work on such dwelling house or on the grounds or building appurtenan thereto shall not bee, use of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that `every state or la al licensing agency shall withhold the issuance or renewal of a license or permit to operate a usiness or to J onstruct buildings in the commonwealth for any applicant who has not produced acceptable Ividence of e� mpliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states1Ieither th commonwealth nor any of its political subdivisions shall . enter into any contract for,the performance of pub 'c work ntil.acceptable evidence of compliance with the insurance requirements of this chapter have been presented to a co tracting authority." Applicants Please fill out the workers'compensation affidavit co m le ely,by checking the boxes that apply to your situation and, if necessary,supply sub-contiactor(s)name(s),addresses, an hone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Li r ed Lia ility Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers compe tion insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this a1 davit ma be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. j so be sure to ign and date the affidavit. The affidavit should be returned to the city or town that the application fo the permit or he nse is being requested,not the Department of Industrial Accidents. Should you have any questions egarding the law if you are required to obtain a workers' compensation policy,please call the Department at tp.number listed belo . Self-insured companies should enter their self-insurance license number on the approp ,riate lin . City or Town Officials Please be sure that the affidavit is complete'and pr ted legibly. The Department as provided a space at the bottom of the affidavit for you to fill out in the event the 01h" ich fice of Investigations has to con ct you regarding the applicant. Please be sure to fill in the permit/license number will be used as a reference n ber. In addition,an applicant that must submit multiple permit/license applications in any given year,need only sub 't one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should writ "all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or to may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affrda it must be filled out each year.Where a home owner or citizen is obtaining a�license or permit not related to any busine s or commercial venture (i.e.a dog license or permit to bum leaves etc.)sai person is NOT required to complete this a davit. The Office of Investigations would like to thank yo� 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 numb The Comm,nwealth of Massachusetts Department of Industrial Accidents Office f Vestigati.ons 600 Washington Street Boston, MA 02111 Tel. #617--727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia Mame MelerA 307 Phinneys Lane Centerville,MA 02632 July 8,2009 Town of Barnstable Building Department As owner of the property at 307 Phinneys Lane, Centerville, MA 02632, 1 hereby authorize Harry Eisener to act as my agent in applying for a building permit to replace siding on gable end of house for said property. Sincerely, Marne Meleski 307 Phinneys Lane Centerville, MA 02632 I ___ �. _ and Standa�d� Ltcrls�o t cg��fratrcu a'id for mitl idul use on�� \ Board of Building Regulations` HOME IMPROVEMENT CONTRPLTOR b�lor;c the a `ptraLot:date .If found: cttlrn=.to Registration:::149263f ''nerd of[iuildutg Reguhtions nd Sts tdarls Ex iration , �: csltb irton TK'`ace Rmk 13b1. p 12/1.6/2009 Tr#,:;264 85 M. a ,> Bost i hl.t 02108,< ifl Type Individual, ' HARRY EISENER� SW =! fs. • t HARRY EIISENER ' I 4 HOLLY LANE � — I W HARW ICH,,MA 02671" '~ Administrator �f i f valid r .ftZaoat sicsa#ur ; iNlassachusetts - Department of Public Safeh Board of Building Re,yulations and Standards: Construction Supervisor License Licen;se:.CS 85469 Restricted to: 00 bw - HARRY G EISENER 4 HOL LY LN W HARWICH, MA 02671 # ~i Expiration: 5/4/2011 ('ununissiunci'" Tr#: 15498 l , �04 ► � Town of Barnstable *Permit#C�6996300(:) P Expires 6 mo jr is V.date Regulatory Services Fee � = enxxL , mas F.Geiler,Director ® PERM O K ro'Igf as� 9qp 163�. .� Building Division J U N - 4 2008rom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 TOWN OF BARNSTABL4ww.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EMPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number o O 1i — Pro a Address 1( 1 ✓l V1 1- U� t ( l` P tty � �S � C ��il/LT`�V`(J 1 e ❑Residential Value of Work ��c7, Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Lrl Contractor's Name p . (,S�� ?`R— Tele hone Number Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Check one: R?1-1am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name agA PA(iK CQ , �V,,A 1 Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. 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) 2"Re-side ❑ Replacement Windows/doors/sliders.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. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:buildingpermits/express Revised 123107 r r Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR License or registration valid for mdn-dul use only tio\n before the expiration date. If found return to: Registrafion: 149263 Board of Building Regulations and Standards Expirat n 1y16/2009 Tr# 264385 One Ashburton Place Rm 1301 . Individual ! Boston Ma.02108 HARRY EISENER HARRY EISENER i 4 HOLLY LANE W HARWICH,MA 02671 Administrator Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents RUT 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): 41 , AAA F:7 i e VJ`4- ' City/State/Zip: t �,Fttiwt�.� , 02b�1 t Phone.#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction pmployees(full and/or part time).* have hired the stib-contractors 2.UZI 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. . ieq�e&] - S. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myselL[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required-]t c. 152, §1(4),and we have rio employees. [No workers' 13.�Other 5 t t to P comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their work='compensat$on policy information. t Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tConhactors that check this box must attached an additional sheet showing the name of the subcontractors and states whether or not those entities have employees. If the subcontractors have employees,they must provi dt their workers'comp.policy mmdber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: NVIA VAn -42,r U— Policy#or Self-ins.Lie.M / 15 22 Expiration Date: Job Site Address: 3 UT p k t to y1 qe�4 L'-v\ City/State/Zip: 0,P V,,L 7 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ' Failure to soctae coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip 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 Investieations of the WA for m' s rance coverage verification. I do hereby certifru .�e pains and penalties of perjury that the information p o oevided above is true and correct • Signature: Date• _ Phone#• (� - •� �� r 1 y�'`` Official use only. Do not write in this area,tb 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#: 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide w rkers'compensation for their employees: - Pursuant to this statute,an employee is defined as"...every person in the se ce of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,co ration or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the leg epresentatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or oth egal entity,employing employees. However the owner of a dwelling house having not more than three apartmen and who resides therein,or the occupant of the dwelling house of another who emtploys persons to do mainte ce,construction or repair work on such dwelling house or on the grounds or building appu4enant thereto shall not b use of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also sta. that"every state or ocal licensing agency shall withhold the issuance or renewal of a license or permit to op rate a business or ,o construct buildings in the commonwealth for any applicant who has not produced•acc ptable evidence f compliance with the insurance coverage required." Additionally,MGL chapter 152, §25 )states"Keith the commonwealth nor any of its political subdivisions shall enter into any contract for the perfo a of public ork until acceptable evidence of compliance with the insurance requirements of this chapter have been p'. sented to a contracting authority." Applicants Please Wont the workers'compensation 4 da completely,by checking the boxes that apply to your situation and,its necessary,supply sub-contractors)names ad • s(es)and phone number(s).along with their certificate(s)of insurance. Limited Liability Companies*(L 'a r Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to--1' orkers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Bc advised• t this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance cov ge. Also be sure to sign and date the affidavit:. The affidavit should be returned to the city or town that the app' tion for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any <`t stions regarding the law or if you are required to obtain a workers' compensation policy,please call the Dcp At at the number listed below. Self-insured companies should enter their self-insurance license number on the ate line. City or Town Officials Please be sure that the affidavit is compl and prntm;d legibly. The Department has provided a space at the bottom ! of the affidavit for you to fill out in the a 'ent the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit(licens number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applicationshn any given year,need only submit onp affidavit indicating current policy information(if necessary)and un er"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the aff davit that has 'e m officially tamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit' on file for>ie permits or licenses. A new affidavit,must be filled out each year.Where a home owner or citizen is taming a licens 'or permit not related io any business or commercial venture (i.e.a dog license or permit to burn leav etc.)said persop' NOT required to complete this affidavit. The Office of Investigations would like thank you in adv cc for your cooperation and should you have any questions, please do not hesitate t6 give us a call The Department's address,telephone-and numiber. Th C6mmonwt�alth of ahUSCM 1� ent tzf Industri Accidents Qffice of Lavesti 'pits Washint�a trcet Bo 2111 W. #617-727-4940 ext 4-06 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia Ma me e IVIdesW 307 Phinneys Lane Centerville,MA 02632 June 2,2008 Town of Barnstable Building Department As owner of the property at 307 Phinneys Lane, Centerville, MA 02632, 1 hereby authorize Harry Eisener to act as my agent in applying for a building permit to replace siding on gable end of house for said property. Sincerely, Mame Meleski 307 Phinneys Lane Centerville, MA 02632 1