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HomeMy WebLinkAbout0381 MAIN STREET (COTUIT) _ . . . _ __ , �, �� - � �ro, 1 �� �- i r I �/ �} / S i I �. _ �-�---- ,, - .. _,._ ,__.-._,��.._-. �. .Y_ f 4�p . olarCy x j. z 6 December 30, 2015 Town of Barnstable ATTENTION: BUILDING DEPARTMENT wl Lo/NG 200 Main Street ,1�fI FPT Hyannis, MA 02601 J~I o�ZO� TOW 6 RE: 381 Main Street, Cotuit NOFBgRsTq Permit No.: 201406274 eLE Our Job No.: JB-026423 NOTICE OF CANCELLATION r This letter is to certify our proposal to install Solar_ (PV)at the above-referenced property has been moved into a cancellation status. SolarCity Corporation and Lenore M.Thornton will not be'moving forward with the proposed installation at this time. We would greatly appreciate reimbursement for the permitting fees paid, but understand that the town will,not refund any fees. If you have any questions or concerns,please.don't hesitate to contact me. Thank you for your attention to this matter. Sincerely, CheryCGruenstern Cheryl Gruenstern Permit Coordinator SolarCity Corporation cgruenstern@solarcity.com Telephone: (508)640-5397 .. i r, - - - " TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION S Map 02a Parcel 0-R7 Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 3S/ Aea;,n _ %beet- Village Cocci Owner Le vaine 7`rorm-664i �.t7icts Address .381 MQ1N�St� Cjo�ici� MZI Odd 35 Telephone ,�SO�-��D-dOA7 Permit Request _ 5l;w . 5oLAR E*LEejRie.PA#gL_5 om RaoF or',rxj5T1Ai614calE 1✓.17-N .QNL? &64AADES.4XSRCd1A74-0BY P.E. !o he ekeleze:zZ i!usAfx1- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District IMP Flood Plain Groundwater Overlay _ Project Valuation /6000 Construction Type ,AC&rq 0',i SOLMT Lot Size `-- Grandfathered: ❑-YeWAI-do If yes, attach snap orting documentation'. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure .w s Historic House: ❑Yes X No On Old King's H4ighway: .0 YesY No' Basement Type: ❑ Full I— ❑Walkout ❑ Other => Basement Finished Area (sq.ft.) '7" Basement Unfinished Area (sq.ft) o� 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: -0 @M ❑ Oil ❑ Electric ❑ Other Central Air: ❑-rW..9 0-No Fireplaces: Existing—.N&Jew Existing wood/coal stove.' s 0-No Detached garage: ❑ exis**AL-mw size_Pool: ❑ existWSnew size _ Barn: ❑ 271 -71 new size_ Attached garage: ❑ existA0 tJ-new size —Shed: ❑ Tx-b6o Thew size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ;<\lo If yes, site plan review# Current Use s,,.ygCc l�Am,'L�c� Proposed Use .v0 G. #V e, APPLICANT INFORMATION �Lls (BUILDER OR HOMEOWNER) er,q Name Telephone Number 4f*16 74CY Address /../D �oryort FARk & , 7,9-Vo License # CS /B7ft"G 3 &Jro%e. MA 0,935.9 Home Improvement Contractor# /",:r7.Z Email N ew= Worker's Compensation # GVA766 D064 AA: RI/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 6P SIGNATURE C.tZ'�f �i DATE P-)7•o?O/5/ FOR OFFICIAL USE ONLY x APPLICATION# i DATE ISSUED MAPS/PARCEL NO. ADDRESS VILLAGE : OWNER DATE OF INSPECTION: , FOUNDATION FRAME INSULATION = FIREPLACE . • B ELECTRICAL: ROUGH FINAL, PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ? FINAL BUILDING, DATE CLOSED OUT r ASSOCIATION PLAN NO. O Solar "ty. OWNER AUTHORIZATION Job ID: Location: .�g _M a;n • �iy /1A I l eyior2 ,1/ ,V Zorl as Owner of the subject property hereby authorize SolarCity Corn—HIC 168572/ MA Lic 1136 MR to act on my behalf, in all matters relative to work authorized by this building permit application and signed contract.'MtJ nature of Owner: Date: i rvt9 3Et;f.ha .i4 7r-7 f, �� _st ..,Gt{I�`: 1 17 i.-1 '='. {� } SOLARCITY.C'0M; ifkl�t.�.a_�Zi utt4* '�-�.:`V (( �.::p'iF `.�.Y NE1 z� ,,.��t4,�m��'..: �I a.l.�'1.1 f Y'l��'-k7P• /v�:.�a�'43��i� r DocuSign Envelope ID:64C48AOE-1A85.49DO-A4DO-EDF1A1E26389 ' 4olarCity. Power Purchase Agreement Amendment c� Congratulations! { Your system design is complete and you are on your way to clean,more affordable energy.Based on the information in your System design,there are some amendments we need to make to your Power Purchase Agreement(the"PPA"),The amendments are as follows: • We estimate that your System's first year annual production will be 5,226 kWh and we estimate that your average first year monthly payments will be$77.08.Over the next 20 years we estimate that your System will produce 99,694 kWh.We also confirm that your electricity rate will be$0.1770 per kWh,fixed fo the next 20'years(i.e.electricity rate$0.1770 and tax rate$0.0000). Your Details ' Exactly as it appears on your utility bill a Customer Name&Address Customer Name vService Address Lenore M.Thornton .381 Main St 381 Main St ' . Cotuit;MA 02635 Cotuit,MA 02635 r By signing below,you are agreeing to amend your PPA and you are agreeing to all of the new terms above. If you have any questions_ or concerns please contact your Sales Representative. a Customer's Name:Lenore M.Thornton SolarCity D�erd�: SOLARCITY APPROVED. 1t1a4Yt 11A �tAVufbu 9/14/2014 Signature" Date Signature: UNDON:RIVE.CEO'' .a .. Customer's Name: (PPA)Power Purchase agreement,. • r :JAI.Soiarciv Date:. 8/2112014 Signature Date ' f • - 1. .. ., .- �. . _ .... 3055 CLEARVIEW WAY, SAN MATEO, CA 94402 888:S.OL.CITY I1888365.2489 I SOLARCITY.COM- -MA HIC 168572/MA LIC.MR-1136 Eggineering Dept. (3rd floor) Map c Parcel Oa7 Permit# -7 / (o House# Date Issued Board of Health(3rd floor)(8:15-9:30/1:00-4:30) 4:�-�6 CFee Conservation Office(4th floor)(8:30-9:30/1:00-2:00) ! CiLl OIL, SEPMC A in Board 19 ANGS it CS INS MALLE TOWN OF BARNSTABL07 v��saSOB' Building Permit Application ` TProjeceetress Village Owner I/�S' �.� :� • .�, Y-0 A-J Address Telephone G5�(7 �� .d 2,--7 'Permit Request d-0f First Floor square feet Second Floor 6 square feet Construction Typed Estimated Project Cost $ /'�y ' Zoning District Flood Plain Water Protection Lot Size 36,e S 2d Grandfathered ❑Yes ❑No Dwelling Type: Single Family 1 Two Family ❑ Multi-Family(#units) Age of Existing Structure /S Z.o (Ff Historic House ❑Yes XNo On Old King's Highway ❑Yes ONo Basement Type: X Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Q Basement Unfinished Area(sq.ft) fed r' " 4*6 r 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: V Gas ❑Oil ❑Electric ❑Other lc�4c"� t Central Air ❑Yes ANo Fireplaces:Existing e/ New A�y 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 Telephone Number ��Q�) TZu �3j Address License# /,�01Wf IV.r 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 D,FBRI1$RESULTING FROM THIS PROJECT WILL BE TAKEN TO r SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) I FOR OFFICIAL USE ONLY PERMIT NO. f DATE ISSUED MAP/PARCEL NO. 1 4 ADDRESS VILLAGE ' .OWNER t 1 q DATE OF INSPECTION: FOUNDATION Loa 1 FRAME ' INSULATION �-707 FIREPLACE, ELECTRICAL: ROUGH FINAL - PLUMBING: ;ROUGH FINAL GAS: _}ROUGH FINAL FINAL BUILDING�� DATE CLOSED OUT-.} ASSOCIATION PLAN NO. f 1 i I - - - - - -44 +__ , �_ _ 4-. 1 ve1-4 w - j I I tD //S' �Jr� -- _ 1- 1 T +• Tf 1 1 i i I I I 1 V.2N I � TE i �i i 4 i. 1 I ( � I ' i L-. I 1� i i -f- L- r- � — - f I 1 tt I I �•Z - - -- - --+ IT T- 4-- ;. i , } I - - i f I f Ise 1� TIF i I ( � I 1 T , i i I PHONE CALL A.M. FOR DATE TIME P.M. M O F r PHONEo s F#E7UANE0 PHONE Y17ltR CALL AREA E UMB EXTENSION MESSAGE PLEASE CALL Wi 1.CALL :AGAW C�SME To SfE YOU WANTS,To _ j SEE YOU SIGNED AIVersal- 4B003 ,NOTES i , HOME. IMPROVEMENT CONTRACTOR Registration 118952 Type - INDIVIDUAL Expiration 05/08/97 THOMAS P DAMELIO THOMAS P. OAMELIO G�toh, 7�, &8-=6$'DORY CIRCLE o ADMINISTRATOR ,. MARSTON$ MILLS'MA 02648 s DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE t< Naxber ; Expires: s. Restricted ion: :,1G y vr THONAS P OAHELIO DORY CIRCLE. a HARSTONS MILLS, HA 02648 r The Commonwealth of Massachusetts •+ i� _ `-._-_-=j;_.�- Departinent of Industrial Accidents t i Office 81111 rOSM2110M 13 -4 W �61 7 a' 6II(/ {{'ashi►r;;ton Street ': Boston,A1uss. 02111 Workers' Compensation Insurance Affidavit 0 _ ._........ _.,._._..._... ,- .......... _....._. ... ._.._ _.._._._..__..._......... .......-- .._...__ .__..._....- - m • �lJ /7z'S /(� l Iorntion• city nh()!1S lE0�) 542, --SJ/f- I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ' -.f`.;..;.-.awa�•;d-ra±•--•^su• :.p-,§'•_-...t'tA"�.itia�nxw.<r.y'3Aylq£,17.'^42T.RSn' ga��°^:'.,�2..°!'���`;o. "itP�w.+""u��;•i°.A�A �^ ••-M-"•^T*^ .rr • -�" ::..a..,w.r�,.a'1..•�.m:..:x,sn..,..,�_.9'.aL:s.u�.�»- c . .:... . .... ...ts.'�". :. ,_ --e... ......_....�...� _ t I am an employer providing workers' compensation for my employees working on this job. r , company name- address: city: Rhone#• insurance co. _ policy# �" '•' �.... .. ? ..3;. ,t-...�.::�.. w.+, .�w,w,m-r++..+rw swon .r.,s..eR+`7•sP!, �„�'4!'�.�',P^�!E'yY..:� «.!^t.,.r I am a sole proprietor ra contracto , r homeowner(circle one)and have hired the contractors listed below who have the following workers compensadon po ices: con anv name: Q / J 1 So le address city: rzh n insurance co policy# a .�. �y`_....:.y-.. ��.. "..�.._'�rC�yny7'^�. �7"rT"vwwrg R "r - �'. x y„ _ '6 .Mc'+•'..'^^--zr �-_,-_._•.x_...__...._..,,a..wc.a.tim_._.__ ....�s�i��• a.i.�`:....5]'...ia`i:.ia�.';ii ►M..'��t� •L..z'157�F11^ � �.a�saidtars-.mzis�tia� s�a:�:c.a...iL•t�w .a.ia:y:us. company name: address: city: phone#• insurance co policy# .Attach additional sheet if necess'Kif . c. __._.._..._� Failure to secure cove. ......rage as required under Section 25A of 111GL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that.a copy of this statement may bc• var cd to the (Tice of Investigations of the DIA for coverage verification. 1 do hereby certijt'r nd tlr sins r pe ties ojperjun t t the information provided above is true ar d correct. Si_nature Date Print name ef�1f-j ✓ '��a'�n' �` Phone# y ✓ / official use oniv do not write in this area to be completed by city or town official r city or town: permit/license# r'IBuilding Department oLicensing Board check if immediate response is required ❑Selectmen's Office t Dllcalth Department contact person: phone#; I"(Other r.: Ue.,sed 3/9;PJAI Information and Instructions N Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for their employees. As quoted from the "law", an e►nph vee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An emp/over is defined as an individual, partnership, association. corporation. or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. t, y 7777 City or Towns Please be sure that the affidavit is complete and printed legibly. Tile Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. ,?.rn►w+c..x..^s-vor.?nsaicr.—rr.?n- -�+aq•«.r-a•,.,,rn.w. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations n 600 Washington Street Boston,Ma. 02111fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 of Barnstable Town The T ental Services • = d Environm • NAM Department of Health Safety and Building Division 367 Main Street,Hyannis MA 02601 Ralph CrOssen Building Commissioner office: 508-790-6227 Fax. 508-790-6230 For office use only Permit Date O AFFIDAVIT OONTRALTO SUpPLEMFSIT R LAW HOME SUPPLEMENT To PERMIT APPLICATION onstraction, alterations, renovation, repair, modernization, that the "rec re-ezisting MGL c. 14 improvement, requiresoremoval, demolition, or construction of an addition to any units or to conversion, impreVe1IIeat' at least one but not more than four dwelling owner occupied building containing tered contractors, with structures which are adjacent to such residence or building be done by regis with other quirements* certain exceptions,along S B Zf � Est.Cost Type of Work: Address of Work: Owner's Narne-2�:�� Date of Permit Application: I hereby certify that: Registration is not required for the following reasoa(s): Work excluded by taw Job under S1,000. Building not Owner-occupied Owner pulling own Permit given that: OR DEALING WrM UNREGISTERED Notice is hereby, THEM OWN PERMIT VEMENT WORK DO NOT HAVE OWNERS PU �F�R APPLICABLE RO ME GU UNDER MGL c.142A CONTRA TION PROGRAM ACCESS TO THE ARBITRA ` SIGNED UNDER PENALTIES OF PEWMY I hereby apply for a permit as the agent of the owner. Registration No. Contractor Name Date OR. k owner's Name narP Map cDcD- Parcel a7 Permit# ao 0 � Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:45)_ �'' ���� ,Fee Engineering Dept.(3rd floor) House# 38 EJS °ems SSP M MUST BE 9Na1' UPLIANC 19 SNVIIR LE/7�5jF'n TOWN OF BARNSTABLE ® • f fJ r ' Building Permit Application Project treet Address Village Owner t(T wo E r— /Pl, /G(D,eAl Alw Address 3 S/ A A-j5�j S%. (2�,) Telephone Permit Request � 17c 8 cs� t First Floor square feet Second Floor square feet Estimated Project Cost $ 02 d717j� Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure �,3 (lLrs, Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths o2 �A� No.of Bedrooms Total Room Count(not including baths) First Floor �{ Heat Type and Fuel;?�&&Ib 46r Ate^ Central Air Fireplaces l Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds 1 Other Builder Information Name Telephone Number 171,�d —( 0 oZ� Address 3 �1 �v/l License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �IGNATURP�- / DATE a 3 P BUILDING MIT DENIED FOR THE FOLLOWING REASON(S) -fOR OFFICIAL USE ONLY PE MITT NO. t D ISSUED M P/PARCEL NO. . , ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' t FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ` GAS: R. FINAL FINAL BUILDING.C. DATE CLOSED OBIT t.' • jai J � i ( s • r ASSOCIATION PLAWNO�Er ; F , r • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. -:: DATE % JOB, LOCATION Number Street address Section of town "HOMEOWNER V,-, P_ Q Name Home phone Work phone PRESENT MAILING ADDRESS City town State Zip c: The current exemption for "homeowners" was extended to include owner-occ: dwellings of six units or less and to allow such homeowners to engage an dividual for hire who does not possess a license, provided that the owner acts as supervisor'. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends tc side, on which there is, or is intended to be, a one to six family dwell: attached or detached structures accessory to such use and/or farm structi A person who constructs more than one home in a two-year period shall not considered a homeowner. Such "homeowner"• shall submit to the Building Of on a form acceptable to the Building Official, that he/she shall be resnc for all such work performed under the building permit. . (Section 109.1.1) The undersigned "homeowner" assumes ,responsibility for compliance with th Building Code 'and other applicable codes, by-laws, rules and regulationsJ. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and re iremc' and that he/she will comp with sal roc es and requirements. . HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL .Note: Three family dwellings 35, 000 cubic feet, or larger, will be requir' to comply with State Building Code Section 127. 01 Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which - bur: permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided tl Home Owner engages a persons) for hire to do such work, that such HOE shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assc the responsibilities of a supervisor (see Appendix Q, Rules and Regula for . licensing Construction' Supervisors, Section 2.15) . This lack of a often results in serious problems, particularly when the Home Owner hi unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home Owne as supervisor is ultimately responsible. .:�. ... To ensure that the Home Owner is fully aware of his/her responsi.biliti communities require, as part of the permit application, that the Home certify that he/she understands the responsibilities of a supervisor. last page of this issue is a form currently used by several towns. Yo; care to amend and adopt such a form/certification for use in your comet. The Town of Barnstable . es ' ;g Department of Health Safety and Environmental 5ernc Building Division 367 Main Strut,Hyamtis MA 02601 Ralph Crosser Off= 508 790-6n7 Building COmmisstc Faye 508-775-3344 For office use only Permit no. Date AFFIDAVIT HOME WROVEMENT CO TRACrO IAW SUPPLEMENT TO PERMIT ION that the-=p�rucuon,alterations,renovation,repair.��tion,conv Eon, MGL c. 142A requires ed improvement,.remo%ml, demolition, or conmcdon of an addition to any pre-caste ow= �� waits or to s �' building containing at least one but not more than four darcuing��certain moutionss . alongsare with Other to such residence or building be done by registered contractors. requirements Type of Workz ��� Address of Work: 2W-/ l�/Il�t ST �-h i Gt-� / 0%_ner.Name: "/d Date of permit Application:, I herzb♦certify that: Registration is not required for the following rcason(s): Work excluded by law Job wades SI.000 Building not owner-o=upiedOivrscr pulling own permit Notice is hereby gi%= CONTRACTORS OWNERS PULLING TIMR OWN PERMIT OR DEALING WITH FOR LESS TO ME APPLICABLE HOME IMPROVEMENT WORK DO, ARBTrRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PER MY I hereby,apply for a'permit as the agent of the owner•. 2 '9 Regisuation No. ate Contractor name OR The Cummun»•callit of Afassachusetts "' ,j �1----=_ '' ' Department of Industrial Accidents, ,� OfllceallaoesD9alloas `?; .;l•. �_a� `� 60( vhitr910n Street Bovan.Auras. 02111 Workers, Compensation Insurance ARJav it AR�s. nt �.,.....�.:,,..__. Please PRINT,c,�ilv / J name, location. &A;;z2z 5 6---2 7 I am a homeowner performing all work myself. rl I am a sole proprietor and have no one working in any capacity •- 1 am an emplover providing workers' compensation for my employees working on this job. c+omnnm nnmc 10 adduce Sit) phone#. ' atr•�nc �� policy a I am a sole proprietor,general contracto ,or homeowner( rtle one)and have hired the contractors listed below who i the following workers' compensa`tiioon/post_ •. comnnn♦ nnmc address! ci \/ NBC l/Ylnlni-h� "Vdl phone mcurnncc o :3- 0n—e, We4 e 0 peiicv# _ m •tm•na e- itv phoned• - polio# SUMtIC Pf• ��ww,pq,l7,�••�•••�.' $22i�"�5-�-- ;Attach additioQai'sheei if ii,ccuar Faiiurc to secure coverage as required under Station:SA of AIGL 152 can lead to the imposition of criminal penalties of a Gae Up to SISOOAO aaL one tears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against ma I understand tbt copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage veritieatioiL 1 do herchr crrrij• adcr t/�c pains and pen tier ojpcdurr that the injornmtion ptmdded above is true and correct Signature . Phone# Print name ofticiat use onh• do not write in this area to be completed by city or town oiQeial city or town: permitNeetsse# Mguilding Department (3Uceasiag Huard • OSeieetmen's Office cheek if immediate response is required . (311eaith Department contact person: phone#t 110ther. i _ nw•..,.:roc oia�'- information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for employees. As quoted from the"law", an emplQa•ee is defined as every person in the service ofanather under am contract of hire, express or implied. oral or«Titter. An empinrer is defined as an individual. partnership, association. corporation or other legal entity, or any two or n 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 owner of a dweiIing 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 or on the ;,,rounds or building appurtenant thereto shall not because of such employment be deemed to be an empic MGL chapter 152 .-cction 25 also states that every state or local licensing agency shall withhoid 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 chaptf- been presented to the contracting authority. ` .�.�..��• +...'�, " .. 'fk.:!•i• .\Ts a.:� =y...•�ti:g♦r('.•s.:,��' .••• `i.�' ::aL:.Y�'r,�a`:'.r"�f•.=:7 j 's.•ay ..u.-,_ Applicants Please `;II in the workers' compensation affidavit completel%, by checking the box that applies to your situation ar, 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 requi. to obtain a workers' compensation policy, please call the Department at the number listed below. Cin- or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottorr the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. f be sure to fill in the permit/iicense number which will be used as a reference number. The affidavits may be returnE the Department by mail or FAX unless other arrangements have been made. 17ie Office of Investigations would like to thank you in advance for you cooperation and should you have any quest please do not hesitate to ;,Live us a call. f�•M �.w.•••.wr.......r.��rwr....• ..... — .. ..... .. _ . •,wv�. iriJ..w ..wr�.��,:ia .i.a .�-:..�;�+..r...'_• :�l.:r. .w•!.. .T'he Department's address. telephone and fax number. The Commonwealth Of Massachusetts t. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 nhone #: (617) 727-4900 ext. 406, 409 or 375 a — — — 77. - , 7 : Of tH MOLD 4 I} N �'7i'E MADE = I CERTIFY T�T THIS SURVEY �. C� o : . 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