HomeMy WebLinkAbout0068 FULLERS MARSH ROAD � �� _ .�
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Cape Save Inc. r J,
7-D Huntington Avenue
South Yarmouth, MA 02664 �
Tel: 508-398-0398 Fax: 508-398-0399
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1/9/20
Brian Florence CBO
Town of Barnstable
Building Division
200 Main St.
Hyannis, MA 02601
RE: Insulation Permit 19-3964
Dear Mr. Florence:
This affidavit is to certify that all work completed for 68 Fullers Marsh Road. Cotuit has been
inspected by a third party Certified Building Performance Institute (BPI)Inspector.
All work performed meets or exceeds Federal and State Requirements.
Sincerely,
William McCluskey
�e
PHONE CALL
A.M.
FOR DATE TIME P.M.
M
P}iDNED
OF
RETURNED':
PHONE YOUR CALL''
AREA CODE NUMBER EXTENSION PLEASE{MALL,
MESSAGE
WILL CALL
AGA1N
CAME:T0:,
SEE YOU,
WANTS TO `
1� SEE YOU:'
SIGNED Inive al 48003
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NOTES
Town of BarnstableBuilding
` m the Street=,ate roved PlansMust=be.Retained oiiJob andthis Card Must>be Ke t
Post This Card So That it is Visible Fro
sARxSCABLE, ;� fc,. ,,Y s „ � ;:,,. Epp. s .. `"� _:; y:,• P. . k�'::
M Posted Until Fyinallnspection Has.Been Mader fi �' y Permit
�Z'.s,.,,`:. '$ sE ;f �'nst€ aZ J
° Wherea Certificate of Occupancy is Requlred,fsuch Buildmgshall Not be Ociupie�until a Final Ihectionhas been made yY
Permit NO. B-19-3964 Applicant Name: William,McCluskey Approvals
Date Issued: 11/22/2019 Current Use: Structure
Permit Type: Building-Insulation-.Residential Expiration Date: 05/22/2020 Foundation:
Location: 68 FULLERS MARSH ROAD,COTUIT Map/Lot: 006-068 p. Zoning District: RF Sheathing:
Owner on Record: NOAH MANACAS Contractor Name: William J McCluskley Framing: 1
Address: 68 FULLERS MARSH ROAD Contractor License 102776 2
COTUIT, MA 02635 Est Protect Cost: $3,800.00 Chimney:
Description: Add R-10 rigid insulation to the attic.Add R 19 fiberglass,and R-10 s Permit Fee: $85.00
Insulation:
rigid insulation to the basement.Air seal the attic plane and
Fee Paid
basement with expanding foam. General weatherization
$85.00
51,
Date 11/22/2019 Final: ®Ky
Project Review Req:
Plumbing/Gas
Rough Plumbing:
Building Official - y
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work author�iz"ed°bytthis permit is commenced within six monthsafte issuance.
All work authorized by this permit shall conform to the approved appl tw and the approved construction documents forwhichhis permit has been granted. Rough Gas:
All construction,alterations and changes of use of any building and structures shall be in with the local zoning, law •and codes.
This permit shall be displayed in a location clearly visible from access street or road nd shall be maintained open for pubIi6Jnspection for the entire duration of the Final Gas:
work until the completion of the same.
- Electrical
The Certificate of Occupancy will not be issued until all applicable signaturesiby theaBuildmg and Fire�Officials are provided onzthisspermit.
� -` Service:
Minimum of Five Call Inspections Required for All Construction Work it
1.Foundation or Footing ,
2.Sheathing Inspection : .
Rough:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final:
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy
Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction.
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
Building plans are to be available on site .Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
of Town of Barnstable *Permit#
Expires 6 months from issue date
• sAxsr►sE Regulatory Services FeeY ,q Z 2-o
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s639. Thomas F.Geiler,Director
Building Division
Elbert C Ulshoeffer,Jr. Building Commissioner
367 Main Street, Hyannis,MA 02601w 'PRESS PCR T
Office: 508-862-4038
Fax: 508-790-6230 ,)U N 2 5 2 0 O 1
EXPRESS PERMIT APPLICATION
Not Valid without Red X-Press Imprint ,TOWN OF BARNSTABLE
Map/parcel Number 6QW—d6 ce
Property Address /4/9-Si-I 2_04-cl
Residential OR Commercial Value of Work 6O0
Owner's Name&Address {Z _2Q
Contractor's Name Telephone Numbert,60`'6,)"Y,�,l) —3/dot
Home Improvement Contractor License#(if applicable) J2bL/y�/
Construction Supervisor's License#(if applicable) Uy7 9
orkman's Compensation Insurance
Check one:
I am a sole proprietor
I am the Homeowner
I have Worker's Compensation Insurance G
Insurance Company Name L Y1: L)��/�
Workman's Comp.Policy# - j y 19 02
Permit Request(check box)
Nj'*`Re-roof(stripping old shingles)
Re-roof(not stripping. Going over existing layers of roof)
dRe-side
'Replacement Windows. U-Value (maximum.44) �UE.`t)
Other(specify)
Where required: issuance of this permit does not exempt compliance with other town.department regulations,i.e.Historic,Conservation,etc.
Signature
exprntrg
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90
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Fullers /,Act
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-TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map t)D Parcel Permit# ' 7 �
Health Division '�..e Date Issued '7lei 6 m ;
, d
Conservation Division 7 &a 1 �1'`h'�-- e _ Fee
Tax Collector 1�(a2/p j Ck Y i
Treasurer U � ggptII SYSTEM MUST BE
2 �
Planning Dept. VJITk TITLE 5' '
Date Definitive Plan•Approved by Planning Board t ENVIRONMENTAL COOS AI"D
TOWN REGULATIONS
Historic-OKH Preservation/Hyannis
,Project Street Address 6u l ( RS ma25t+
Village C6i7 ,;+ '
4 +
owner Sc)kn ?)a2bQ?=Ck M Ff h4 1 ., Address 35�'a C 01t,M(l*_�9i- 14,"f—
,Telephone '
Permit Request A-W p_ PzLory r- F
Square feet: 1 st floor: existing 9/mil proposed_;.( 2nd floor: existing proposed Total new
Estimated Project Cost Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: ❑Yes- ❑No If yes,attach supporting documentation.
Dwelling Type: Single Family ) Two Family ❑ ' Multi-Family(#units)
,age of Existing Structure 19&Q Historic House: ❑`Yes ;WNo On Old King's Highway: ❑Yes Iallo
Basement Type: ❑Full N Crawl M❑Walkout W Other -,,1"g A,�, 1. tAv%�\IZ.,
Basement Finished Area(sq.ft,) Basement Unfinished Area(sq.ft) 36
Number of Baths: Full: existing / new Half:existing new '
Number of Bedrooms: existing__ new _tea,,
Total Room Count(not including baths):existing S new First Floor Room Count
Heat Type and Fuel: ❑Gas •❑Oil ' )6.Electric ❑Other
Central Air: ❑Yes- g No- Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing .❑new size Pool:l7 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 r Proposed Use
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BUILDER INFORMATION
,L Name � ��y,r,-�T- Po ho ptt ;e lc. Telephone Number C� � 2C1 — 316
Address ///a nw --. License# 0,9717aSf
OS7F_a-v J L,—P . An 4. aZ6e_ss— Home Improvement Contractor# /0(ofL//
Worker's Compensation# `
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE - DATE
a
_ FOR OFFICIAL USE ONLY
2 PERMIT NO.
DATE ISSUED. , . � .. � ' y 4•T -•'y .Y .. _'-• - _ t. � ' ; _A ,, � ,
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
11 t
DATE OF INSPECTIONS
FOUNDATION � -
FRAME IA '
INSULATION. ' • - � , . . .y _, ,�- ;{"�-` a.^ ,:.
FIREPLACE _
tELECTRICAL: ROUGH, FINAL;
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ir
PLUMBING: ROUGH FINAL - ;
GAS: ROUGHI FINAL
FINAL BUILDING
DATE CLOSED OUT-
- ASSOCIATION PLAN NO. c
Baardp°BuiidingRegulations and Standards
I License or registration valid for individ
lu(use only
'10ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
�. Registratlon: 106147 Board of Building Regulations and Standards
Expiraaon._07/2212002 One Ashburton Place Rrn 1301
TYp®-- PRIV,''rE(;0--0RA1:7N Boston,Ma.02!08
STEVEN J.SISMOpRIC INC_:
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Stt=ven Sisttopric
00� PO BOX 687!1112 MAIN$7 t11d1'�- ! L`mow^
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N OSTERVILLE,MA 02655 4 "--
t: tldministrator Not val withoat s' nature
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The Commonwealth of Massachusetts
Department of Industrial Accidents
-- — Orrice of/nsestigations
600 Washington Street
Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
name: 1 USN �r S�
location: P�
hone#
city
❑ I am a homeowner performing all work myself.
❑ I am a sole propnietor and have no one workin m' acity
rovidin workers' co ensation for my employees working on this job. .:.:::::::::.::.::::::
❑ I am an employer p ..... .:...g.. mp ...; '::... .
COIIIQanY Hanle f �U ,� "
BildCes$ . :.> (.�.
cltw
shone
� r ` ea`'
iasurance:co. z %/
❑ I r(circle one)and have hired the contractors listed below who
am a sole proprietor,general contractor,or homeowne
have
nsatio n o lices:
following workers comp _....P.._........::::.:::::::::,::::::::::.;::.::::::::::::.::::.:::::.::::::::::::::::.::::.;".:: .;;;;::::::::::.::::::;;.;:.. : .
the g...................:.::::::::::::.:: .. ,:::::.: ::.:::.....-:::.::::.:::::::...::::..::::::::::: :. :.::::.::......:::.::.:...:...:_.:::: : :::::: :_......:..:::::::::::::.:::::::.:.:: :..
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COWS name:
........ .......:.::;:................................
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sure: ... ..
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address,
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in�arance ca:: :
Bafiure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of cr minal penalties of a Sue up to 51,500.110 and/or
out years'imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification
I do hereby certify under the pains and penalties of ped ury that the information provided above is true and coned
Signature Date M 6 -6/
Print name 11�-� .�y�: w< S� `�a j`Z Phone#
official use only do not write in this area to be completed by city or town official
permit/license# ❑Building Department
city or town: ❑Licensing Board
is cored ❑Selectmen's Office
[Icheckii'immediate response required ❑Health Department
contact person:
.phone#; ❑Other
(tmud 9/95 P1Ia
Information and Instructions '
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract
of hire, express or implied, oral or written.
r ,
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or
trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal
of a license or permit to operate a busyness or tg
o construct buildings in the commonwealth for any applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additio""natlq,neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
co
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the
authority.
I
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the perayit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you
are required to obtain a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be rein m to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
please do not hesitate to give us a call.
The Department's address,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#: (617) 727-4900 ext. 406, 409 or 375
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Jul 06 01 09: 27a Steven J. Bishopric 508-428-4841 p. 4
g CMMO? � ,M
OF ASSACH JSFe T •S
�^ e� Da.4ju m3NT OF aw U$7RL&I..�bCCID.ErM
600 WASIUNGTON STU-
ran+es_ (,ar woeo BOMN. MASSACHUSE'a•TS 02111
oc—.rmssione• 'woR ERS'C01vTINSATION INSURANCE AFFIDAVIT
Steven J. Bishopric Inc. / HR Logic
1.
¢iecitaeeljaermiacc)
with a principal place of businesslresidcna ac
P 0 Box 687 Osterville, MA 02655
(Ctylstatclzip)
do hereby ecr%ifj; under the pains and penaJties of perjury;that:
(ill am an employer providing the following workers' eompcnsation coverage for my crnployees w'o6 ing on this
job.
Liberty Mutual WA2-63D-004155-017
Dnsurancc Compiny Policy Number
() 1 am a sole proprietor and have no one working for roc.
�) I am a sole proprietor,gcncraJ concraaor or homcowrncr (eirde once and have hired zhe eontraacrs lisccd below
%Ao have the followingworker'compuuaoon iasur7ncx.policier
1,4mc of Conm=r Insuruscc Corapany[poliq Numbs
Name ofConrnaor. Insurance CornpanyfPoliey Number
A'sanc o(Conm aor Insurance Compa.nylPolicy Numbcr
Q 1 am a homeowner performing all the work mysdL
DOTE Pleue be aware%bat wbila bowcowaen wbo eCmploypersoa:to eio rosiatt:Dasre,eoorereetiou or repair v.vrlc oa a
4wd(int of not soorc thaa twee waits io wbU�the homeowner alav ruidcu or oB the grouadr appuruaaac llcteto arc Dot gcccrau).
considered to be croploycrs ua&r the "orLen eompeaastioa Act(GL O.152,ceet- 1(5)).a?P'iutioa by a boroco roes fora tic SC
or permit may evidcoee the legal sutut orta cr.ployer under tbC Workeri Coropcosatloa Act,
i understand that a copy of ties statement will be.for-ended to t'rtt Depa:tr:ent of Industrial Acddcnti 0M of hnsara"t f0t.rave124c
-.4604anand that failure tosceure coveracc a re$usrcd usades Sccdoa 25Acf,MCi.152 can kid w the impo:iaoa orlyrniaal penalties
impr1,oaracatt eats tip to one Tar grad cavil pcns! in the form of a Stop votk Order and a
eonsuon=of s one of a,p to S1So0A0 anfJot
fine of S100.00 a day against roc.
Signed this day of 1
Licensec/hrrnincc Licensor/Pcrmirror
Jul 06 01 09: 26a Steven J. Bishopric 5l08-428-4841 p. 3
�h,. 7:�%oortoxc•.a�ae z�ll off:. <�a:iJl.[crzu4e(.1
BOARD OF BUILDING REGULATIONS
!License: CONSTRUCTION SUPERVISOR
Number: CS O47928
Expires:09/29/2001 Tr,no: 5792
Restricted To: 00
STEVEN i BISHOPRIC _
1018 RACE LANE
MARSTONS MILLS, MA 02648 �!
Administrator
, -�Xe trnnr-rrtrdiurullh. o`", lLaliucaraelGi
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 106141
� l Expiration. 07/22/2002
Type: PRIVATE CORPORATION
STEVEN J.BISHOPRIC INC. i
Steven Bishopric I
PO BOX 667/1112 MAIN ST UNIT y
OSTERVILLE,MA 02655 Administrator
. The Town of Barnstante
Regulatory Services
10'�' `® Thomas F. Geiler, Director
CEO MA'S�
Building Division
Elbert Ulshoeffer, Building Commissioner
367 Main Street,Hyannis MA 02601
Fax: 508-790-6230
Office: 508-862-4038
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
alterations,renovation.repair,modernization,conversion,
MGL c. 142A requires that the 'reconstruction, �g owner-occupied
improvement,removal,demolition,or construction of an addition to any pre-
exis- 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. �a
Type of Work• �oP� co
, �ajia&, Estimated Cost l ��
Address of Work:
Owner's Name:
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
[]Work excluded by law
[]Job Under$1,000
[]Building not owner-occupied
[]Owner pulling own permit
Notice is hereby given that: UNREGISTERED
OWNERS PULLING THEIR OWN pERMIT OR DEALING WITHOE DO NOT HAVE
CONTRACTORS FOR APPLICABLE HGRA GUARANTY FUND UNDER MGL c.142A.
ACCESS TO THE ARBITRATION PRO
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Registration No.
Date Contractor Name
OR
Date Owner's Name
q:forms:Affidav
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Map D Parcel z ermit
✓ Conservation Office(4th floor)(8:30-9:30/1:00-2:00) $ ,� Date Issued
�oard of Health(3rd floor)(8:15 -9:30/1:00-4:45) Fee
✓Engineering Dept.'(3rd,floor) House# m ,t ,; �
Bid IN@STALL�fED, 1ANCE
�T
Board 19 ENVIRON ME , E AND
TOM RE ODDS
TOWN OF BARNSTABLE '
uilding Perriit Application
Project Address
Village '� r
'Owner D Address
,Telephone _-
Permit Request X 020
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,First Floor c� �� M1 square feet
Second Floor square feet
Estimated Project Cost $ �� , -?ov .
Zoning District Flood Plain Water Protection
Lot Size Graridfathered ?
Zoning Board of Appeals Authorization Recorded
Current Use �.6Y j� T Proposed Use geed
Construction Type
Commercial Residential
Dwelling Type: Single Family Two Family Multi-Family
Age of Existing Structure Basement Type: Finished
Historic House Unfinished
Old King's Highway
Number of Baths No. of Bedrooms
Total Room Count(not including baths) First Floor
Heat Type and Fuel Central Air Fireplaces
Garage: Detached Other Detached Structures: Pool
Attached Barn
None Sheds
Other
Builder Information
r
+//Name Telephone Number
Address License#
Home Improvement Contractor# 4,00
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
2
SIGNATURE DATE
BUILDING P RMIT DENIED FOR THE FOLLOWING REASON(S)
T, FOR OFFICIAL USE ONLY -
PeRMIT NO. -
DATE ISSUED - +
MAP/•PARCEL NO.
ADDRESS VILLAGE p '
OWNER _ t
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
t
FIREPLACE p
ELECTRICAL: ROUGH FINAL Y
{ ='! _
PLUMBING: , !DOUGH FINAL
GAS: t 0'u6,?i:"_ 'FINAL -
FINAL BUILDING. �x S
Y of C) E ,
DATE CLOSED OUT SW 0
ASSOCIATION PLAti NQ-r f%)
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IMPROVEMENT; NTRACTOR '
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The Town of Barnstable
� NAM g Department of�Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Office: 508 790-6227 Ralph Cro=
F= 508-775-3344 Building Commissio:
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-adsting owner espied
building containing at least one but not more than four dwelling units or to structures which are Aacmtt
to such residence or building be done by registered contractors,with certain exceptions, along with other
requirements.
Est Cost
,,-"Type of Work: �n
-.,'�Address of Work:
,11- Ow•ner.Name: z
ate of Permit Application: /,z r G 9
I herein 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 WrUNREGISh�ED CONTRACTORS
IB
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE
ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
Date Contractor nardY Registration No.
OR
r, Owner's name
F � �
The Commonwealth of Massachusetts
-- •h: _... ��-.�y: Department of Industrial Accidents
-tilt' 6011 {1 asltiir11ton Street
Boston,Afars. 02111
Workers' Compensation Insurance.AMdavit
�ARnlienn nformatio'n, Please PRINT 1-"grl. x '"~ '
4
- 3�
1 am a homeo per perfo ins all work myself.
1 am a sole proprietor and have no one working in any capacity
....ear.••-:f....�, .-r.rr.T-.... : .. .:•. -. .. <
(] I am an employer providing workers' compensation for my employees working on this job.
company name• __
address•
cih•• phone#•
insurance cam. nlL cy'#
1 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,
SjL}•: phone#:
hcu Me Co. noHcv#
17C:..; .r...:T.�.. _... y,Cn!7,-r.S;.•9't�0a"3T'�"'•":'TIR".+Ft•'hl�^'�rrp�• _ __ 'T74F _ •'`R`•�•�:l�fRDN'se-�lv;^Ri!_'_'� �.'�S
�� any game•
address:
city: phone#:
int!lrwnwn.... policy#
:Attach additional'aheet if aeF��� :• ��..- y%s- .;_+' �"up'Y :"`•;^.=" .•• '.'. •'X
It a
Failure to secure coverage as required under Section 25A of 1►IGL 152 an lead to the imposition of criminal penalties of a fine up to$1.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement ma}•be forwarded to the Once of investigations of the DIA for coverage verification.
I do hereht•cerdfj•under the pains and penalties of perjury that the infomutdon prorided above• true and correct
StgnDate
Print name e-5 ��� ��°'�� one it
ofrcial use only do not write in this area to be completed by city or town official
city or town: permit/license# r'iBuilding Department
(3trceusing Board `
O check if immediate response is required CSeleetmen's OMcc
(311allh Department
contact person: phone#; nOther
Vftned3,195 PJA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an emplgvee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An enrplitrer is defined as an individual. partnership, association. corporation or other ;z-gal entity, or an%,two or more of
the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 1'52 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 in 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.
.•�...�r.�-1—.�---;�','^ "^^...'„"' :v: s�f —a+..a. ,;.;_ .y:.. t};: .IN.r' 'f:,*il •. J�•ft'.`1.ii:tY:^�Kt�:..+'.,.�;::1*:��' '•��--
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 affidai it. 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 for
regarding the "law"or if you are required
to obtain a workers' compensation policy, please call the Department at the number listed below.
TTrT'Tt•if+�//af7A/' .. -..:.' ._ ..: i ,k,• •.;1"•` +.�;':.,�1�,M11►S•`s.�Rwi�, YwuF�'�'^:�:'. `:y'• .. ...
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of lnvestivations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
t� ine.+rw.ryw+f►'�•Tr!D'�+• 7:.. •= 'a:�•.... ..-ria•�.w<•.i.•.«1::)f, r : ::. ^.•:.c�-.'.i��:.:••.�.��." :.47:t :e::I';•:.....i.
The Department's address, telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
y, 600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749 •.
phone#: (617) 7274900 ext. 406, 409 or 375
t ... ..
COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY
OF ONE ASHBORTON PLACE rlcrsfopoasiaasc�r!lsr�g
MASSACHUSETTS GV)STON,MA 02106 r siacbvietisSdat®tBm�/da�;
-- d6liciYa6fp!l4YpcitlOi9
LICENSE tAlallceasa.
EXPIRATION DATE C 0 N S.T'R. : SUPERVISOR CAUTION
t.
08/11/1 995 n FOR PROTECTION AGAINST
RESTRICTIONS,r� j EFFECTIVE DATE LIC-N0. THEFT, PUT RIGHT THUMB
NONE 06/30/1993 014702 PRINT IN APPROPRIATE
BOX ON LICENSE.
JAMES P FITZGERALD
8 PUNKUORN POINT "'" BLASTING OPERATORS
IMA.SHPEE i�A " 02b49 �t. MUST INCLUDE PHOTO.
PHOTO(BLASTING OPR ONLY) FE r
foo.00
NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY
HEIGHT: g STAMPED-OR-SIGNATURE OF THE COMMISSIONER
/
THIS DOCUMENT MUST BEAl
{ _ SIGN NAME.IN FULL ABOVE SIGNATURELIN
CARRIEDON THE PERSON OF IGNATURE OF LICENSEE.- ff
THE HOLDER WHEN EN-
OTHERS-RIGHT THUMB PRINT GAGED IN THISOCCUPATION.
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