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0062 THISTLE DRIVE
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Ix :�h_'�.: .._�.Wit_: Permit No. B-20-783 Applicant Name: Ryan Lane Approvals Date Issued: 03/20/2020 Current Use: Structure Permit Type: Building-Solar Panel-Residential Expiration Date: 09/20/2020 Foundation: Location: 62 THISTLE DRIVE,CENTERVILLE Map/Lot 171 066 Zoning District: RC Sheathing: §gj, 7z .z. Owner on Record: FOUNTAIN, DAX M Contractor',Name SKYLINE SOLAR LLC. Framing: 1 Address: 62 THISTLE DRIVE Contractor Lieese� 172284 2 CENTERVILLE,MA 02632 f Es6,Project Cost: $8,000.00 Chimney: Description: Installations of a safe and code compliant,grid tied, PV solar system Permit Fee: $90.80 on a residential rooftop. _' € Insulation: E Fee Paid: $90.80 Pro ect Review Re 3/20/2020 Final J 4 y Date Plumbing/Gas 3-�TCM- ^� .; Rough Plumbing: clal This permit shall be deemed abandoned and invalid unless the work authoraed by this permif is commenced withinxsix months after issuan Final Plumbing: All work authorized by this permit shall conform to the approved application and the�approved construction documents'for,which this permit has been granted. All construction;alterations and changes of use of any building and structures shall b"e in compliance with the local zoning by laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. $ F Final Gas: The Certificate of Occupancy will not be issued until all applicable signatures by the 8w1ding and Fire Officials are provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work: 1.foundation or Footing Service: 16 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lm�nggs installed , 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Low Voltage Rough: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: 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: Building plans are to be available on site Fire Department t All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: F 1W Application numbe .. 1. ''. .1 .. ILIyo 8 ._ Date Issued...................�. ..!/..F � .................. AS& `0 Building Inspectors Initials...... .................. 16 9. JUL 0 5 2018 . /7/ - 0Map/Parcel................................ .............................. TOWN OE BARNS ABLE TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: If - r. NUMBER STREET VILLAGE Owner's Name: lie ((�y ` Fojr�c-fac✓, Phone Number-7-7 IF L 36 2- Email Address: Cell Phone Number 7 7!t/-' S Z/- 7 ?S Project cost$ 8*7 5 Z — Check one Residential ✓ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Gct,--fre c-4 Date: TYPE OF WORD ❑ Siding t 0 Windows e # /Z ❑ Insulation/Weatherization (no header change) ❑ 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 s 4 e a..t ye 6 r,-, M A CONTRACTOR'S INFORMATION Contractor's name ' Home Improvement Contractors Registration(if applicable)# j (attach copy) Construction Supervisor's License# 07 Z 77 Z- (attach copy) Email of Contractor Phone number 7?1 - 1 3 Z- LIPO5 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR.IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *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 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 LICANT'S SIGNATURE Signature _ Date All perms a 'ons are subject to a building official's approval prior to issuance. Wil1d0VIf.Wo.��d:Of BO:St(*: Nut HIc Rewstratlon Offices&Showrooms Number. 01 5A Cummings Park' Q29S'O!d'Oak 5trem' 166025 Woburn,MA 01601' POihbfbk9,'INA 09399 Federal ID#' (781)932 4805.,.. (781)821)m6281 "B2-4090432 www.WIn0owWoddof8oston,Pom Customer. kale �1[,\l�ai X: �•Rd11>�Fax-N TPh6ne' Install Add!dre"sss�:,,..�QfJ� .tir'LJA6%W P�hOne'w) Clty W'LJt� - State MATap _EtnW(:tt>v7k� � WINDOW WORLD GLASS'OFMONS + —low Series Single•hung A mord $199 all SotarZOne Elite-Dual.Pane $119�• 2000 Series OH AI6Wetd $215 _Triple Pane/Krypton $369 4000 3afte5 DFf AlI•Weld $240 Series�00 40'00:S14$DWAII•tNe1d. gp a*? ,; (' !Y) 2 Life Slider $374 t°WNDOW OPTION$'• 3 Lite Slider oa,�m nn,+e,» 5575 —Glass Sre�(iijA W;ieh '(4 6076600) $`►5•IUM'dDED' _Picture J'M1 d 3 UI).... $956: —1/2 Screens. $91(VCWRfB �PlchttQt,�`txA0'A A41•11.0:Llif-• $44& ..:. .__Foait}liisii 1". ori'JaintiSandHead Silt INCLUDED Awrxn ::•.. .. ! � $st aass:(4o00J60110):-:.:.spy ItuciuoED :S Ceseni �'...Phie`$49`DNSeaA R r:�i:: (a 26") °••sa WET LUO ^ED ( edl)•$3a0 _DoukNa'Weks• 2 Lite Casement s695 Full Screens $2 ^3.lrtat?rasement arx.,a.,r»...I'm -sea. Woment'Hooper. ::$4 4>`> "'Pra)i 0 tiA ",r., :.;;:•:.,, ' $75' - i�Iinl3oNr=$oryit Mount i.Nd5 SA WWeK Mount/INSSea4765 Tempsfeat?NPsas((Bgo}�TSo) '" s7s^, >" `GerdeA3M(ddow �..: .., . _Say,Bov,Garden Oversize(t109 UI)SB75 ---Odel Style(4;s.' or 6 irshj ,$75`: Oriel Style{40180 or 60/40) $75 $40 Ftm"EnhanceINW.e Wood train tnterlor(3mies4W016000")$100 . (U9MO3k1DdIk0W.Chefy(.FOXWood PRE197aeuvHOMES(EPA LEA03AFERENOVA710V Rfetr'iNnpiej` LAeil83fePrai[t(—Ii4aqad,: ..` —Brown Extaft(Arch.Braize/AnnalkanTerra)S100 MY HOME WAS BUIL•TKTHEYEAR«0. tall _D9srgnaWGalotDRArlor "''$175 MISC6GIl1 E .115 alll)!'NiddOw_ 3 ' :. .,�O� Custom Frdeddr ding.(lwo�n window Color 1 Cl Textured$90 6 8rYlooth $i � +:. -�: �%✓ie4!de •:O� 6tek� Facing Color..; .. MetafWiridow`RerR)J1j $75 �_NewCcnsttueegnvtnyi.Remibrai. Vfhyif�BN�Fsh80oiSr 5iLof6k: ' ',$9d98 Multt 9eAd Cladding '$20 Vinyl Fi�,lang Ratio doM"aft 611� —ram— Addtohaseprk9.fotasfomRWlNgPalroOcat$1250 S�ITuRtoFormMtil(i0i+it $3l1 U V r a-6r�dF(dPii 1511Vjq.Foo0ao'r6a.ar6a. ®189y' 1�mil l�i4lnterlcdFxteRer;SlOpe:,.: $50�I+dQ(� �A`g' •�i li t?tloDooiB(t. SiOS." irisEeH'IntenofGli;J!fg,': _t0Roti:t�eq•S7t444Poa ell' r9h. $1595 —�InsufAte'N818EsF6afies;..: cu3topt.k Y,tGtaEdmg . gslio Root for BayMowwindows $500 R SSgEr r tSt 3lgss. 5306 T_ —_Dt6tirf40ayy,Cof E'Erit;109troFi( $3.5 ; Qridjx erGoae+ $210 Removal or8%dabng•BaylBOw $250' �' '`" obegfal'1nteK°'9 $a96 RepairSijfJ.rn cFrWacp.Vnosing,$75 t 8i1er„t�)fietgtier{�h`?ois: ,M,;, . 3545 Full Sub Sit(,($ln9la)tePlacemem 91.75.::: PPS 4• ;sa 527s �Mu111drr 0,Removal $5 ::.:.•- ;:�::;.z;:liarxllesebQOtleTI:W ,• ar, - r:r—'-..r:�•�.r,:;.v.,,:,..:�-�:r::.::.:_:•::•:�'..:e. ...:.... _8by/BAw;Conyexsion;Ezt.2'k?[4Flf,..;545tf,�. (New Siding Wit Not Match).' - �:.1)4.Pt'sl••-r:u.a S:.^�iT'' k -1t ; y. 'a_,n:::.::. lie ' � u, ,:,.rs:cbax(Etter n x OnsrCa.+,.�,.•4,..: ' '.&+�.v-i.P ,k^.'+���J`!R."'p,rK`.''i{'..k.�Y.`•:{Y,..n:: ,ii�a r,,;c.'%t. i {.. N. Z J,r c.r " IA M801111 tH.,Cugonw E§reapenslbta fat meftllowklQUeannrR50 ilmlhscolwa&wMiing.SlalNng,Alumsystem49cO11"Wrecomw ou"Pumalwift eteess 1!q p�anyucarWali>saela0pri avaf Moth; tfc Cry of arlief d&s[d g Fzmett is?ncaMs vL+i:Sv9Ea6ad'. Ptd ,�i�,6r�1o,r�t�talarrr�utar - '.�ustomefaJ�t` � � k� '.:.;<?�,:• 43, (1fr?N ' }�( CuatLaim Ordmrppy$xRoot C �t ?�.,�� y'x"�`` ats�`-gy)•.ply ft.t .t'Sil+t ar.Sct3. 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Oa Commonwealth of Massachusetts Division of Professional Licensure �, Board of Building Regulations and Standards ConstruCtlon'Snpervisor CS-072772 Eisllires: 0410712020 51 ft JEFFC STEELE 24 SHERWOO'Q AVE k' OANVERS MA 01923 Commissioner ' '"f'�r��i,.wr.�Nnraeu//J�jGr:�ir�:�cicJrr<�r(/• , Office of Consumer Affairs&Business Regulation HOME:IMPROVEMENT CONTRACTOR TYPE•LLG Regl on r 'on Tt9 04/1112020 WINDOW WORL'DOFBb$TON LLC. JEFF C.STEELE 15A CUMMINGS WOBURN,MA 01801 Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,AM 02114-2017 www.mass.gov/dia 11 orkers' Compensation insurance Affidavit:Builders,Contractors,Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Letribly Name (Business/Organizafion/Individual): Address: /.5'A C ten,�-..'�� s � K City:/State/Zip: A Phone 3 z - ygo 5-- Are you an employer?Check the appropriate box: Type of project(required): 1.C11 I am a employer with employees(full and/or part-time).' 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers camp.insurance required.] sF�I am a homeowner doing all work myself.[No workers'comp.insurance required.; j 9 ❑Demolition 4.F1 1 am a homeowner and will be hiring contractors to conduct all work on my property.e I will 10 a Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. l2.❑Plumbing repairs or additions 5.17 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.I 1 13. Roof repairs 5.❑We are a corporation and its officers have exercised.heir right of exemption pe-MGL c. I i 14.�ther_yW I n O i 152.§1(4),and we have no employees. [No workers'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 hip: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'camp.policy number. I am an emplover that is providing workers'compensation insurance for my employees. Below is the policy and joh site information.Insurance Company Name: A arl-Co-rr Ere Tn S J RA W C S CQ Policy#or Self-ins.Lic.#: Z Z y1/C- C L J 2 Expiration Date: 1- Z 7— 19 Job Site Address:_ & Z- 'Dr. City/State/Zip: n-I ,,;Ile M4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152:§25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this s tement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verifi lion. I do hereby cer 7under a pal erjury that the.information provided above is true and correct Si ature: Date: 7—1 Z - / Phone#: - .3 2--- '35 a use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ,�►� CERTIFICATE DA-M§W MY-M �...� OF LIABILITY INSURANCE 018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCA7�':IO�ER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAQE AFFORDED 8Y IME POLICIES BELOW. THIS E O TIRADE E INSURAI+iCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRIvENTATNE OR PRODt1C)-CR,AND TIME CERTIFCATE HOLDER SUBROGATION'ANT; If certificate holder is an ADDITIONAL INSURE It SUBRC+GA710N I ;3,the policy(ies)must have ADDITIONAL INSURED preywo�s or be endorsed If S WANED,Subject to the terms and.cMditron9•0f-the this certificate does not confer lights to the certificate holder in lieu 0#sLrcim eDdo�seynerds my require an snrFnrsemenL A statement ar: PRODUCER Marsh&McLennan ee cT Carl VWtdjer,CIC,CISR CBIA 3J525 N,EIM St, J��2nL�LLC PHONIE Greensboro NC 27455 c o 336 544 fi85p F�D10;292 S07-6516 np Al : Carf.V+Atc marslrmma.com PJSURJ3i(-AFFORDING COVERAGE NAIL$ INSURED 1NSURERA:Allmerica Financial Serofit 31534 b:7ND0.2 vtnndoiiv World of Boston,LLC vmuPER B,Hartford Fire LRswmce C a i 196a2 118 Shaver Street JNSURER C.I<Massachuse$s 'Insurance Corn p,3pb North Milkesboro NC 26659 UNSWERD iL'SURERE ' i - COVERAGES INRF: CERTIFICATE NUr'A3ER 1016015772 RI=T/f",,It7N NUl1ABEP THIS IS ED CERTIFY THAT THE POLLCIES OF)NSURANCE'LISym-BELOiN}LAVE BEEN ISSUED TO THE IPISURE()NAMED ABOVE FOR THE POLICY P ER-OD INDICATED_ NQT!}1ViIHSTAIfD1NGM,'Y P.EQUIP.EMENT,TERM OR CONDITION OF ANY COArWCT OR OTHER.DOCUMEN;.tM7H P.ESPECTTO 11IB11CH THIS CERTIFICATE MAY O ISSUED OR SUCH PELICIE,THE INSURANCE AFFORDEL• PY THE POLICIES DESCRIBED HEREH'E IS SUBJECT TO ALL THE TERM, D:CLUSIONS AND CQPID1TtOMS OF SUCH POLICIES.LIMITS SWYM, MAY HAVE BEEN REDUCED BY PAID CLANS, LLTRR1 TYPEOPLUSORANCE ADDLiStteR 1 POOLEFF VroOLICyxp � C 1 x CO4=r-RCfALGENE ! 'PDLiCY NUMBER I" RALLSABRnY UUs-�g2x7 yr7r�18 gpE {o L I CLAWS b14]G OCCUR j I GEACHOCS� S I,C�IO DOD EFJI sm n pmm rn 5590d00 ME[)ESP(Arty OM p=pn) S 5.000 f f GCDPLAGGPCGATELIdA1TAPPLIESPER ( PERSONAL8ADVJPUU�Y S-,OSEg00D f j— '' i PC:LICY CIPRO- LOC = i II G'cNF3iALAflG�CATE $20D40DC 1 7 OTHE1t } j ( l PROCiJCTS-CONP;OPA6G i r2.0WGW A AUT*MOBiLE UABJLVy , ! g ._��ANY AUTO I (A6V6B757G15 6.ry@P,�OT7 Eirye Q C-`Jh£i9VED 3i�YGi.E Li ?$d J OVMIED 5^[VDU EC j ! i BODILY7�I�Y(perpeQ%, c J1!! L- -AUTOS ONLY F_ AU7as SOL-Y MUL RY;PE?—WCerq (--I ED AHJTO ONLY Lr OS DACJAGE C ix UTABRELLALIA$ ! S OCCUR ° EXCES9llAB CLAIMS-DAA 3 DE7.A2y17 41PdM7 4111109E "cACHOCCURgE'ki OCCURRENCE bZdoo,LW OEO DNS ! AGGREGATE S2 aW.00D fl TTaORiQRSCONIPENSATlON t I S ti '•��5 77 :PER opi- tAMDEMPLOYERS'iU1BIUTV YtN( i � I SlZ7720Fb � 7J27J2D'19 j�- � - UTE OFFICEOPEOP.M 1EpDBERIXCLU �1� I,'-�, p11 A ' Wandata Lam; ELEAC}iAOC10F�Tr Ss00{!DD YY in NH} LfyyBs,describeunder i E•1.-MEASE-EAFAFLO'IE S60D.00D ,ESC1tIPTr(X+I OF S>pERAMONSbd&a, j ELIILSEASE-POLICYliw SFXWO - i 1 DESCRD'TIDJ}OFOP`RATLONSfLOCATI=JyE13r M(ACGM18J_AthWu dlrternarl SelgsWrgm�beattathedefmorespac+isregd{red) CERTIFICATE 14OLDI_R CANCELLATION SHOULD ANY OF THEABOVE-AESCMMV POLICIES BE CANCELED BEFORE THE UMA110M DATE THEREOF, NOTICE WILL BE UE3,}VEM-D IN ACCORDANCEIFJITH 7HEPOLICYPRMS10NS. AORRMD REPRF,SENI•AT1VE Ilip, - j ( 191SM201SACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACOJZD name and logo are registered rnarks of ACORD L e I Cape Save Inc:OF vuis: nLl- 04 y 7-D Huntington RAvenue� 06 South Yarmouth,!lV1A 02664 Tel: 508-398-0398 Fax: 508-398-0399 9/29/14 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits - Dear Mr. Perry, This affidavit is to certify that all work completed for 62 Thistle Dr., Centerville has been inspected by a certified Building Performance Institute(BPI)Inspector. Ceiling: R-42 cellulose; R-28 cellulose Basement: R-19 fiberglass blanket on bog sill All work performed meets or exceeds Federal and State Requirements. y Sincerely, William McCluskey_ • t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 6Map /T Parcel Application �V / Health Division Date Issued 2�l Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address 6 c� /`\ J�a Villages _ �/a Owner // C(X P 6 411V Address rhl e au eL Lo tllf Telephone l S 01 J 11 Permit Request 14r f^ sea/ CL J-C m 4`2 ie--,JrReq/— 'l d k e Me 1,4 ",f 4 At�-oi YL 0 c _J /1 r C( Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1-1600 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup 0 ing dodiiiinen ion. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) " -- Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Hig way: ❑Yes to Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) 0- 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 I 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 APPLICANT INFORMATION ►� (BUILDER OR HOMEOWNER) Name !�0 �� I I gfyl 11 � C1"1<1eY1CV1C '-l('aloe Telephone Numbe 02 71i Address t%PJ ` "� License # qt/ Home Improvement Contractor# J �- A 'V� Worker's Compensation # r x/r ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO &KA1 0� SIGNATURE 0Z DATE & ��, FOR'OFFICIAL USE ONLY APPLICATION# -rya DATE ISSUED MAP/PARCELNO. 'e ADDRESS VILLAGE .,> OWNER ` DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL. z FINAL BUILDING DATE CLOSED OUT , f ASSOCIATION PLAN NO. 1 . . 5 Building Permit Authorization I, Dax Fountain F, as owner hereby give my permission to Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office:508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 62 Thistle Dr . Centerville, MA 02632 Signed Date The Commonwealth of Massachusetts Pant Forms Department of Industrial Accidents Office of Investigations _ t s I Congress Street, Suite 100 , l Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pltceibly bers A licant Information Please Print Name (Business/Organization/In Cape Save,Inc. dividual): — Address: 7D Huntington Avenue Cltyp/State/Zi : South Yarmouth, MA 02664 Phone#: 508-398-0398 Are you an employer? Check the appropriate box: Type of project(requ ): 1.❑✓ I am a employer with 17 4. ❑ 1 am a general contractor and 1 6 ❑New constructi employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building additi [No workers' comp. insurance comp. insurance.± required.] 5. ❑ We are a corporation and its 10.❑ Electrical repai r additions 3.❑ 1 am a homeowner doing all.work officers have exercised their 11.❑ Plumbing repai r additions myself. [No workers right of exemption per MGL comp. I2.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no insulati employees. [No workers' 13.❑✓ Other i 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 indf• g such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those en_ s 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 job site information. Insurance Company Name: Technology Insurance Company p Policy#or Self-ins.Lic. TWC 3353968 Expiration Date: 04/09/2014 #: Job Site Address: �>°C � \4'� � � r � City/State/Zip: &4 'fps Attach a copy of the workers' compensation policy declaration page(showing the policy number and exp' tion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead`to the imposition of criminal alties 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 ORIP R 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 O t e of Investigations of the DIA for insurance coverage verification. I do hereby cELV&under the pains and penalties o perjury tl at the information provided above is true and c ec� Si ature: _ -- --- -- — -- -_ — --- -- -'Date —__ -.__ —_ _- Phone#: 508-398-0398 O rcial use onl . Do not write in this area,to be completed by city or town officiaL ff y 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 I Apector 6. Other Contact Person: Phone#: 1 CERTIFICATE OF LIABILITY INSURANCE DA MMIDDJYYYI7 � • ' 4 2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE DER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES.NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS THORIZED 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 WAIV subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not con f ghts to the certificate holder in lieu of such endorsement(s)- PRODUCER CONTACT Colleen Crowley NAMrRisk Strategies Company PHONE E : (781)986-4400 C. No:<76193-4420 15 Pacella Park Drive E-MAIL .Suite 240 INSURER(S)AFFORDING COVERAGE NAIC Randolph MA 02368 INSURER Selective Insurance INSURED INSUPER13:SafetV Insurance Company 3618 Cape Save, Inc INSURER C.Technology Insurance Company 7 D Huntington Ave INSURERD: I NSURER E: South Yarmouth M& 02644 ,NSURERF: COVERAGES CERTIFICATE NUMBER:CL134960509 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P PEE PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT (CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AL TERMS, . EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE ADDLSU13 POLICYEFF POLICY EXP LTR POLICY NUMBER MMIDD MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11,000,000 •X COMMERCAL GENERAL LIABILITY DAMAGE TO RENTED (Ea occurrence) $ 100,000 A CLAIMS44ADE a OCCUR S199448001 0/16/2012 0/16/2013 MED E7tP(Any one person) $ I 10,000 PERSONAL&ADV INJURY $ 11 11,000,000 GENERAL AGGREGATE $ 11 12,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-CORIPIOP AGG $ 12,000,000 7X POLICY SE LOC $ AUTOMOBILE LIABILITY - Ea BINED�ISINGLE LIMIT - S 11,000,000 B ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6208200 1/6/2012 1/6/2013 BODILY INJURY Per accident) $ NON-OMAUTOS AUTOS 1 ) X HIRED AUTOS N AUTOS ED PROP ER�DAMAGE $ X Undennsured motonit BI sphl S I 100,000 A X UMBRELLA UA8 X OCCUR 199448001 0/16/2012 0/16/2013 EACH-OCCURRENCE $ 11,000,000 ' EXCESS LIAB CLAIMSMADE AGGREGATE g 11,000,000 DED RETENTION$ $ C WORKERS CONIPENSATION Officers Excluded from X b`.0 STATU- OTH- AND EMPLOYERS'LIABILITY YIN T RY LIMITS ER ANY PROPRIETORPARTNERIE>ECUTIVF_ overage OFFICERIMEMBER EXCLUDED? NIA NIA EL EACH ACCIDENT $ - 5OO OOO (Mandatory In NH) 3353968 /9/2013 /9/2014 If yes.describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES(Attaeh ACORD IOI,Additional Remarks Schedulo,if more spaee is required) Issued as evidence of insurance: Issued as evidence of insurance. National Grid Corporate Se r es LLC d/b/a/ National Grid, Action Inc., Colonial Gas Company and NStar Electric are listed as additiaial insureds as respects General Liability as required by written contract- CERTIFICATE HOLDER CANCELLATION, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE 10 VERED IN Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 427/SCH 3195 Main Street AUTHORIZED REPRESENTATIVE Barnstable, MA 02630 Michael Christian/CLC z ACORD 25(2010105) O 1988-2010 ACORD CORPORATION. All ri s reserved. INS025(2010o5pi The ACORD name and logo are`registered marks of ACORD r , _ Massachusetts- Department of Public Safety ' Bo:u d of Building,Regulations and Standards Construction Supervisor Specialty License License: CS SL 102776 Restricted to: IC 4 WIL-LIAM MC CLUSKY 37 NAUSET ROAD :. WEST YARMOUTH, MA 02673 -- -- -d i Expiration: 6/28/2013 ( numi.xionrr Tr#: 102776 iVI Imo'` r Office of Consumer Affairs and 13usiness Regulation r i 0 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration` Registration:"171380 Type: Corporation Expiration: 3/14/2014 Tr& 222184 CAPE SAVE INC. WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE - + SOUTH YARMOUTH, MA 02664 update Address and return card.Mark reason for change. - Address —? Renewal j Employment _ Lost Card PS-CAI a 50764104/04-C:101216 • ✓/ze vanz�uoncceald c``::lla:emu ret License or registration valid for individul use only Office of Consumer affairs&B1 uess Regulation . b Y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:. t Registration: -171380 Type: Office of Consumer Affairs and Business Regulation `i Expiration: 3/14/2014 Corporation 10 Park Plaza-Suite 5170 Boston,ILA 02116 CAPE SAVE INC WILLIAM McCLUSKEY -= <?' Y 7-D HUNTINGTON AVENUE SOUTH YARMOUTH.MA,02664 Underseeretary Nut valid o signs Engineering Dept.(3rd'floor) Map 17/ Parcel J 6 6 a Permit# 0 � g �� House# L� Date Issued Z `Zvi Board of Health(3rd�loor)(8:15 -9:30/1:00- L" ' Fee. 0/1:00 2:00) 4 (� dmin. Bldg.) 114E BE � nning Board '', 19 SEPTIC SY , : A. INSTALLWED 7L�7TOWN OF BARNSTABTT �uF� OD AND ' f4VIRONMENT Building Permit Application TOWN Project Street Address Village , Owner Address :9-- Telephone ®s j r ~Permit Request kpvw LO v - 17 'First Floor 's 61 square feet Second Floor square feet Construction Type Estimated Project Cost $ /®, ®eo®, ®® Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes kNo On Old King's Highway ❑Yes ❑No Basement Type: AFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) ,�• •Q�0 0 Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing_1 New Total Room Count(not including baths): Existing� New �_First Floor Room Count Heat Type and Fuel: P.Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes No Fireplaces: Existing New Existing wood/coal stove ❑Yes No Garage: ❑Detached(size) L Other Detached Structures: ❑Pool(size) ❑Attached(size) /7 A ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number Address License# 0 5 3 (e� _2 G 0/ l AL / Home Improvement Contractor# 0 Z � 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 SIGNATURE � ( � ? �� DATE a' / BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) co) - FOR OFFICIAL USE ONLY PERMIT NO.. DATE ISSUEDi MAP%PARCEL NO. `. , -' �S - . ' h ♦* 5. „'�_ `, - 1 "ski.w. ADDRESS ' .� _ .,j . VILLAGE OWNER -. , j . . L, - Y ' • � •'aryl � •f -' .4.-• �� ' ± ' ? • , .. .- •r .• ke '.5 } � i ` DATE Ol jNSPECTION: FOUNDATION FRAME r , 2, •, /emu' i t i INSULATION FIREPLACE - c t ELECTRICAL: ROUGH FINAL ; r t PLUMBING: R O_u_djlvi FINAL• GAS:.. ROP A ] FINAL FINAL BUILDING , 4 ) i a i DATE CLOSED OUTS ny ; ASSOCIATION PLANS R �r .- E7 y i The Cont»ton lrca111t of Afassac h uscas Department of Industrial Accidents „ oficeo/lnyestlgallans 600lVdAini;tonSlrcet ; ` •�� - �.� Burton.Alas. 02111 Workers' CompcnS2tion,Insur2ncc Affidavit �l�•- -- .--•----' •---- - " -.—.. Plc•tse PRINTIebi�21"��"_..,.-..._....,._-.____— ------ -•- - iltc•tnt information• name: pe e�_ o f Q U ler) Incation- citw• nhnnc 0 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity _,ar- _,....—�.+....»..,r�.�.a;r-•+--'�-,fir..-.�+� -----••,...---•�,...—.,.-_—••�-•S•---------•.•.,...,._—.___•... I am an employer providing workers'' compensation for my employees working on this jab. ✓ cmIII Dan It,name,•i �addresr. 1 f t citA ' I h ne#• . � • ' 1 f [I I am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: comnanv nntne* addresv- cir.•� nhnnc#• insurnncc co. nnliev# i - t —..f tiw^.._..._.._ —r.-t....... .__.._—..��r�.:�'1 ie`•v;�ww• ^.rq•e._:.....—•......w.-......�....—... _ conlnanw natnt^. addresc• r rite nhnnc#* insurance co noiicy# Attach additional sheet if necessary- � r�rr..�.i�r "�• ' y - �r -"ter"•• �.. ..� Faiiurc to secure cover-nuc as required under Section 2SA of 111GL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 andiur unc scars'imprisonment ass swell as civil penalties in the form of a STOP WORK ORDER and it fine of S100.00 a day against me. 1 understand that a cope of this statement mai be forwarded to the Office of investigations of the DIA for coverage verification. l rlo herchv crni t•tinder the pains and penalties of perjun•that the information provided above is true and Corr ct. Si=nature Date Print name �Q✓I Phone# - g�' 13 ' official use oNy do not write in this area to be cumpicted by city or town oRciai ` city or town: permit/license# r'itluiiding Department ❑Licensing Board [ ❑check if immediate response is required ❑ Selcetmen's Office t- ❑Ilcaith Department contact person: phone#: r,Uthcr Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for employecs. As quoted Isom the "la%%`. an empinree is defined as every person in the wryicc of another under any contract of hire, express or implied. oral or written. ' An ennplarer is defined as an individual. partnership. association. corporation or other legal entity, or any two or me the foregoing cnzaaed in a joint enterprise. and including the le-al representatives of a deceased employer. or the receiver or trustee of an individual , partnership. association or other legal entity, employing employees. However owner of a dwellin�a, house having not more than three apartments and who resides therein. or the occupant of the dwcllin�-,house of another who employs persons to do maintenance, construction or repair work on such dwelling, ii( or o» the arounds or building appurtenant thereto shall not because of such employment be deemed to be an empio\ MGL chapter 152 section 25 also states that even-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 leas 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 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 tine Department of Industrial Accidents. Should you have anv questions regarding the "law'or if you are require to obtain a workers- cornpettsation policy. please call the Department at the number listed below. Citv or towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pi be sure to fill in tite permit/license number which will be used as a reference number. The affidavits may be returnee 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 questic please do not hesitate to _give us a cz-11. " The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone T: (617) 727-4900 ext. 406, 409 or 375 Cf THE t The Town of Barnstable e�uuvsrasi.E. 9� MAE& Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only 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 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. e ' 11_�Type of Work: "4" PoIrst/.Cost 0&0 Address of Work: � ..(� � 'L 0wner's'Name ,j7 Date of Permit 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 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: I .,,,,�)/ 9. Date Contractor Name Registration No. OR Date Owner's Name J A U u h V� C� 4 ►�l/� G P� ��t / e Ir" e t1`�c�cr-'t!f� �P �O i 50 g' g gt— 50g � i i pow r ay n �� �: � t,r :j r i, 1 S-,� to ,i:;j -� •!' �r jl;-.`,t�;� ,� a t, •' ?.t � �� r •.` P � �>L .T(l'?i:� Y •r1= ��wer::..Zt.x..e:11laS f t f - "•r. � anvnzaiuuea.�,h� a��ivGaooac�ivae%Za � a ': DEPARTMENT OF PUBLIC SAFETY 1 CONSIRUCTIH SUPERVISOR LICENSE Nuttier- ; Expires: Resrtre T— 16 PE`i�RE� �A9IN� ik 117'OAK�ST Id4 ' ASHLAND, MA 01721 7.7 n- Engineering Dept.(3rd floor) Map l Parcel. 0(ofv f Permit# 11116 House# fDoZ Date Issued Board of Health(3rd floor)(8:15:-9:30/1:00-4:30) Fees . Conservation Office (4th floor)(8:30- 9:30/1:00=2:00) Planning Dept.(1st floor/School Admin. Bldg.) THE D 1-iti Plan Approved by Planning Board 19 ; RNSTABLE. - MAS6. �tEO MAr s`eg' TOWN OF BARNSTABLE Building Permit Application Project Street Address 6 C� Village C��Ji �ke n Owner Address Telephone Permit Request ks First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ yt � Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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 No. 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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name J 1Q.1! -Q 1C✓t.6,Q," Telephone Number Address 7 / TlaaC,-son C 0 License# 06+Lkt /4 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 BETAKEN TO jlq�_;41no2Z6 SIGNATURE DATE a 7 c BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. } ADDRESS VILLAGE OWNER , i DATE OF INSPECTION: FOUNDATION FRAME , { INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT t • t ASSOCIATION PLAN NO. ` me The Town of Barnstable • L►exsrnaie, • 94, 10� Department of Health Safety and Environmental Services ATE p " Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only R Permit no. Date �t AFFIDAVIT ROME 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 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. Type of Work: Est.Cost Address of Work: 6 01%71S,1e, on • t/// Owner's Name ` C) Date of Permit Application:_/3�56 1 hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. 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 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: Datfi Contractor Name Registration No. OR Date Owner's Name The Commonwealth of Afassachusettv Departmew of Industrial Accidents 1 Office ofinve 02110ns 600 11 aAinrton Street Boston, A1uss. 02111 Workers' Compensation Insurance Affidavit Annlicant information• Please PRINT lebtbly_4J , name• Q-P!An F✓lG -y� locition• -1 1 Td4n c o-\ [�l city hone At I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity '.. f..,.t`«. .^vsa.+y�'_I+^',.sue ;sue..s ss '7rvlmrr�r�rgs�R7^,.,7•^ t ir:i3�'.rmi��'+t ..r °ta.L�N�'��-imFi _ -sr..s�-�'�p-w.-�r ��i.....�-��t..e.".'-..::..��:�-�•ll am an employer providing workers' compensation for my/employees working on this job. company name: �✓1G�.4 r/1 CJ�'`ST/I�IJGT�0+�1 address: city: phone#• insurance co. polio•# AA1 vsa 36 01Y ,. ... ,,-... ... ..,, ::; .«.•.-..�t^r.r" ,.. ..;,:..ra--i....r.+a�.r:cw.';u.7',ay.�;�R. 5/!� •,;n. - I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address city: phone#: insurance co policy# a r:rt:,•s�- .:• <�1w,-�`-r 7....�-�T+y�' t yc.. ^„r" ``r'<'.,""'�Y� "'�"� µr �T��''^ _...�_�..._..o._. ....___._..�srai.:era,.�.`u.:...:...:i...s.�:. J.sr u-r.r.a��- "':�►.r. ��:wc"r. rdsr,.s- u..i.i:,ivm.r company name: address: city: phone#• insurance co policy# Attach additional sheet if tiecessary� _i'h dish' y i .i�'�ti. A�i `•`� Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP N1.ORK ORDER and a fine of S100.00 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. 1 do hereht cc t under ain�and p nities perjun'that the information provided above is true and correct. Si_nature Date Print name A4-'X �'� � Phone#_ � ' aC) 'official use only do not write in this area to be completed by city or town official city or town: permit/license# riBuilding Department C]Licensing Board C]check if immediate response is required OSclectmcn's Office c �11calth Department ' contact person: phone#: nOther (revised I%PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all P employers to provide workers' compensation for their P employces. As quoted from the "law", an empinvee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An enzpinver is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the forcC, -- eng t, 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 Nvho 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. 77 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. :- Cite 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 -ive us a call. y..,,,.v.sr... .,...._....,..._•r,:rr... ;.—� ,.,..,a..r �..,c..• :,--+u�...�s},.yn.nfe—,au.r,•,a„r!Rp:�.nee..��,.—n... ..,.x•^s-,xsra�..7.C'r'.---r-,v.t!..,,+M.tn.s:...n+q.,• _ The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 «'ashington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 Cn(M11- r p ,m /p^ r P Y E*fir `k1. �• V /'R, :Y'`•.��{ IVY/ I � � I -Ir✓If-REIV `1w1Nf `Gc�1� fFAL1C��2 ,ft'REGIS7RAT t. m 5'7//�{/� m• "IY,P 4t�k V V.V� ', . Bui �di.ng Redulata..©ns `and .5tandaxc! 3 b,s One Ash r;ton . . Place ,,:,Room 113 ia ,.-. B3Ostc� , r i"�assachusetts 4U21a8 - qRS ,�/ x„�, "'wu.�. '�'� ..��. e k,� t y a� 44 HOME' MPROUE F1EiNT `'COh�'JRACTOR l 3 , ' 7 �t,• itx xon iU4/06/9Rega�ta .a Type HOME IMPROVEMERIT CONTRACTOR Registration 112536 Type DBA i I r Y _DCAN C ; FRASER x n s f, �� Expirations Od a �f kf - Al TARRAGON sCll; 1 j I s \h �z C(�fiUI7r MA 02639:, u z A' DEAN C ERASER c X`° DEAN C FRASER f z 4?rsD> 1 TARRAGON CIR 1 , r s ; ` nDM�N�s'fRAToa COTUIT MA 02635