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HomeMy WebLinkAbout1331 MAIN STREET (COTUIT) f33 � ..........lllll;zi� i J1\40F NEW BEDFORD p A WEATHERIZATION CO. www.JMofnb.com T: 508.992.5770 info@jmofnb.com 423 Coggeshall Street F: 508.992.5773 New Bedford,MA 02746 March 21,2013 Thomas Perry, CBO Town of Barnstable Building Division 200 Main Street Hyannis,MA 02601 RE: Insulation permits Dear Mr. Perry: This affidavit is to certify that all work completed for insulation work at 1331 Main St., Cotuit has been inspected by a certified Building Performance (BPI)Inspector. All work performed meets or exceeds Federal and State requirements. Sincerely, Matthew Perry JM of New Bedford �-; :R C;) 'tea - cv tyy _ Existing Home Insulation1Slope ' 1 Roofing Air Sealing Energy Audits i i 4� - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map .o l Parcel _-- pP lication # Health Division Date Issued cam' Conservation Division _ Application Fee Planning Dept. Permit Fee35 Date Definitive Plan Approved by Planning Board Historic- OKH ! Preservation/ Hyannis Project Street Address _J(n Village (�1 Owner Address J3,31 l4Cyr In rJ`T-, ju Telephone Permit Request � �� "� p� s Square feet: 1 st floor: existing proposed 2nd floor: existing proposed _ Total new Zoning District Flood Plain Groundwater Overlay Project ValuatiA2 0,0 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 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 npV CZD Number of Bedrooms: existing —new " `'' c? Total Room Count (not including baths): existing new First Floor Room County n I > CIO Heat Type and Fuel: ❑ Gas ❑ Oil ® Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing_ New Existing wood coal sto e: ❑ O s ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size Barn: ❑existing ak.0 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, Telephone Number Address a OT— - License#- /� U iAORC Home Improvement Contractor# 105RIS Worker's Compensation # �,�� ��✓�.X ALL CONSTRUCTION DE IS RESULTINQ FROM THIS PROJECT WILL BE TAKEN TO ti SIGNATURE DATE_ / FOR OFFICIAL USE ONLY APPLICATION# \ \ A E ( jM\,/PARCEL NO. { ADDRESS ' VILLAGE OWNER DATE OF INSPECTION: . . FOUNDATION TON } . a ( FRAME ' 2INSULATION: \ . } FIREPLACE . . . . . \ ELECTRICAL: ROUGH ° 'FINAL } PLUMBING: ROUGH FINAL- ROUGH , \ . \ FINAL ! aj AS,-1, m. ® x } 3g }NALBUI DI g a « { } . \ \.-D ATE CLOSED OUT . ƒ ASSOCIATION PLAN NO. . ! >r »: . \ . . . ems. I S�,, The Cc,',nmonweahh of Massachr�setts . Deparim.ent of Industrial Accidents Q'l`iee of Investigatioaas 613�J �t.slalfa;t-on :Stre�t n .l� Boston, MA 02111 193'�%YV.YMIS&VOv1dia j W£'i3 ker s' Compensation Insurance AffidPa@ At: Inforlx;atiot Please Print LL-,p T' arne (Business%OrgarizatioiL'lndividua.l): JM Of New Bedford Co. , Inc. Address: 423 Coggeshall Street C.Hy/State/Zi : New Bedford, MA 02746 Phone#: 508-992-5770 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer vrith 4 4. ❑ I am a general contractor and I 6. ❑ New consuurction employees(full and/or part-tbiiie).T have hired the sub-coutzactors I 7 ❑ Remodeling l listed on the arwcbc-d sheet. I 2.❑ 1 am a sore proprietor or partner- ' ship and have no employees These subcontractors have 8. ❑ Demolition. . working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition ' [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electiicalrepairs or additions required.] `.1.El11.I am a homeowner doing all work right of exemption per MGL ❑ PIumbulg repairs or additions myself. vivo workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] i employees. [No workers'insurance Other Insulation conip.insusa i.ce requi�ed.] — *Any applicant that ciiecl,s box P*I,gust also nil out t'pe section tx:Iow showing thcir workers'compensation policy information: T Homeowners who sutnnit this affidavit indicating they are doing all work and then hire outside contractors must subm t a new affidavit indicating sueh. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infoizmation. Z art an e.ni/;lo},er that is providirtg workc,s'cor.itic,ascafioit irssurarice.for my employees. Below is the policy'andjob site infor rnatio➢L _ Insurance Company Name: --Savers Property & Casualty Policy#or Self ins. Lic. WC 0 0 0 0 6 5 5 Expiration Date: 1 0/21 /1 2 � a Job Site Address: Q'tY� City/State/LiI;:� 1 1 A + W Attach a copy of t re workers' compensation policy declaration page(sho,*,ing the policy my.rnber and.expiration date). Failure to secure coverage as required under. Section 25A of MGL c. 1.52 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year ix-tipnsonznent, as well as civil penalties in the form of a STOP MIRK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coveraue 7verificati.on. 7 do hereby ert' 'under t1i2 pat . rid pert;Blties of perjury that the inforrrrriiori provErled a ove is true tie and correct. Signature: _ _ Date: 5 Phone#: 508-992-5770 ofeiEal use only. Do not in this area,to be completed.by city'or town official. City or Town: Permit/Liceuse# Issuing Authority (circle one): t � 1.Board of Health 2_Building Department-3. City/Town,Clerk 4_Electrical Inspector 5.Plumbing Inspector, „ ... .. I 6. Other Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of.hire, express or implied,oral or written." Am 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 dwelling house having not more than three apartments and who resides therein, or t]re 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 au employer." 1vIGL chapter_152, §25C(6)also states tbat"every state or Iocal 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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter intro 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 Pease fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or")!;'own Officials Pease 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. in addition, an applicant that.must submit multiple peri- it/li.cense applications in any given year,need only submit one affidavit indicating current Policy information (if necessary;and under"Job Site Address"the applicant should write"all Iocations ' (city or town)."A copy of the affidavit twat has been officially stamped or marked by the city or town may be provided to the applicant as proof aat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e- a dog license or permit to burn leaves etc_)said person is NOT required to complete this affidavit. Tie Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. at Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents ®face of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE F-Av � 1�17.-7o- '7'7Aa � --� JMOFN-1 OP ID: PC A�OR� DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 02/17/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER 508-997-3321 NAME: Humphrey,Covill&Coleman PHONE FAX Insurance Agency,Inc. A/C No Ext: A/C,No): 195 Kempton St. P.O.Box 1901 E-MAIL New Bedford,MA 02741 ADDRESS` Raymond A.Covill INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Savers Property 8:Casualty INSURED J.M.of New Bedford Co.,Inc. INSURER B:Atlantic Casualty Ins.Co 423 Coggeshall Street New Bedford, MA 02746 INSURER c:Torus Specialty lrlsuRER D:Norfolk$c Dedham 23965 INSURER E, INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS: EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR iADDL UBR: - ' POLICY EFF J POLICY EXP LTR TYPE OF INSURANCE ! POLICY NUMBER MM/DD !MM/DD/YYYY i LIMITS I GENERAL LIABILITY ! EACH OCCURRENCE S 1,000,00 B X COMMERCIAL GENERAL LIABILITY 'LO81000893 11/15/11 11/15/12 DAMAGE RENTED 50,00 ^� ! PREMISES Ea occurrence) S CLAIMS-MADE X ! OCCUR MED EXP(Any one person) 5 5,00 PERSONAL&ADV INJURY S 1,000,00 _ GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG ! S 2,000,000 r— POLICY 1 • PRO- ; LOC S AUTOMOBILE LIABILITY : COMBINED SINGLE LIMIT I 1,000,00 Ea accident S D ANY AUTO i91253253A 01/05/12 01/05/13 BODILY INJURY(Per person) j S ALL OWNED SCHEDULED BODILY INJURY Per accident S AUTOS X AUTOS ( )' X !HIRED AUTOS X NON-OWNED PROPERTY DAMAGE S _ AUTOS Per accident X DOC X ; UMBRELLA LIAB IX 1 OCCUR EACH OCCURRENCE $ 1,000,00 C ^—~ EXCESS LIAB CLAIMS-MADE! 1'81775C110AL1 12/27/11 12/27/12 ;AGGREGATE !S j DED X j RETENTION$ S WORKERS COMPENSATION X WC STATU- BOTH- ;AND EMPLOYERS'LIABILITY 'TORY LIMITS ER A :ANY PROPRIETORIPARTNERIEXECUTIVEYrN �WC0000655 '•. 10/21/11 10/21/12 E.L.EACH ACCIDENT ;S 1,000,00 OFFICER/MEMBER EXCLUDED? iN f A (Mandatory in NH) ; E.L.DISEASE-EA EMPLOYEE'S 1,000,00 If yes,describe under ' DESCRIPTION OF OPERATIONS below j i E.L.DISEASE-POLICY LIMIT i$ 1,000,00 ' � I i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insulation & Roofing Contractor f , CERTIFICATE HOLDER CANCELLATION MECHANI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN JM of New Bedford Co Inc ACCORDANCE WITH THE POLICY PROVISIONS. 423 Coggeshall Street - AUTHORIZED REPRESENTATIVE New Bedford, `MA 02746 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �la,sachuuits - Department raf Public.oafcl% Board ollltlildin- Rt yiilations anad �(;Illdai'tls - Construction SuperAsor License License: CS 104088 Restricted to: 00 Il ELWELL PERRY a 75 MYRICKS ST � ! BERKLEY, MA 02779 �; Expiation: 5/20/2013 ,numi.•i„m•r Tr`: 104088 ;eu�ts;not j !jUA;o.,�-- •_ 13.'A il_ - _ ,Cas;a.taas.aapun _ 9ti42:0 VW 'Ob0.Ja38 M3N 1S IlVHS30S03 cZb --// d S ll3Ml3 9IIZO vw`uo;sog 0NI '00 M10A438 M3N 3Q Wf r . OLIS upnS-uzuld)iaud OI uolle.tod-io0 alenud uoyulnag ssaulsng puu stle ZIOZ/9/L :uol;ejldx3 JJV aatunsuoj Jo aa!j30 :ad/!1 96I£OI :uol;e�;sll3a :01 u.m;aa punoJ JI 'a;up uol;u.tldxa a► a.to a 1J la J q 8010"IN001N3W3AONdWI 3WOH Cltw asn lnpinlpul aoJ pgen uol;u.t;s120.1.to asua3l� uoliVIRI)II ssau1l�s la 7 stteJ/(Vwzt�suoDso 339J0 v,�aam.�cry�l,-d9 �J� OWNER AUTHORIZATION i (Owner's Name) owner of the property located at � ! 04 V1S - (Property Address) L:i 1 ` (Property Address) hereby authorize (Subcontractor) an authorized.subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. CW ' k ' Owner'. Signature' Date MA I,P7 Jai . s a` .:a-h:. ,.yy.,.:._ : w n ..,. 4 _.. _ .�.. s:.: - - _ e..•.,.a..y,,.n--.w.,w: --.?td^`. ••w +,r7.•. 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','�,�c� ���. r�'.�r�wi.s b �'.' x�.', �r�►,i'�°•�"�'� .>� �4'"�` �.^� M:,� �:y� p�,rtacle�,;, �i .rz „�.� ✓ r . ���� +.,,+.a+ �,Mi --sa-�-�-..�•,•—.:.� a,�; ;r: z..+ra:�Y�'. rAr x to m 0 N N 0 �• J S � U � 0 i m O \ . m U co I I I m �r 250.86 I � m t � � F � 1 � W S Y Ngq,3q SO,e 9 � 20. m r � to m ; 7c D CD w 'cn `�, v m — O O s qi e rr S w.m.,. w sxa• w ... .. Vol rn ro 10 i N o . lT .a O cn - 0 W i N ' �O im—J rn m ' T 162.35 _ 93.00 s ' v 419:74 MAIN, STREET `. ." 1922 RELOC. 33'WIDE c p y a� �z S 47°54'20"W -_ L I 24.40. / r w I I., ' 0 0 M co p z rj co 3 19cj '\6 i :" v y Z _ N sIP, ro o 60SgE�� N620I8'17"W HELEN $r PG 36 � 2.50 PC-CB --- BK 65a I JAMES M. DUNNING LC. 15600A CB(FND) CB(FND) PLAN OF LAND IN BARNSTABLE COTUIT) "MASS. FOR ANNA M. MURRA SEPTEMBER 26, 1973 SCALE I"= 40' EDWARD E. KELLEY REG. LAND SURVEYOR ' CUMMAQUID,MASS. - APPROVAL UNDER THE SUBDIVISIO - - - CONTROL LAW NOT REQUIRED. OCT DATE .. - _ - BARNSTABLE PLANNING BOARD / ,� /yam r• Engineering Dept.(3rd floor) Map y 6 ; Parcel .:d 76 Permit# House#. j 33 Q Date Issued . ,o o y Board of Health(3rd floor)(8:15 9:30/,1:00=4 39j "` Conservation Office(4th floor)(8:30- 9:30/1:00=r 2:00) 7 Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC SY. STSE Definitive Plan Approved by Planning Board 19 INSTALLED CE WIT TOWN OYBARNSTABL'' `� ' �° MiD ' Building,Permit Application + Project Street Address 13,3 t Village!S:�"1�' A -Owner Vny c a 6T LA t Address l .Telephone 0 4 ol 9 Permit Request , I First Floor C�A0 square feet Second Floor k(A6 square feet Construction Type \AL�on Estimated Project Cost $ —1, Zoning District Flood Plain Water Protection Lot Size 1 kk O Cy-2 S Grandfathered ❑Yes ❑No Dwelling Type: Single Family hud Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No 'On Old King's Highway ❑Yes ❑No Basement Type: V Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 21.%R c\ Number of Baths: Full: Existing�_ New Half: Existing New .9 No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: b(Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes )(No Fireplaces: Existing iNew 'ems-- 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 f)dNo If yes, site plan review# Current Use i Proposed Use S rvv(E�! Builder Information Name e 5 i Telephone Number Address --:3 )4CtV\AU License# eS 0,�3,34(� G a .S Home Improvement Contractor# /62�5 7 O Worker's Compensation# W4�3 0 L4 0,V G8! NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING,EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL LL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO J aw,e,k`n c. C3Y' 7k3 r_l: SIGNATURE DATE BUILDING PERMIT DENIED FOR TIDE FOLLOWING REASON(S) V j - FOR OFFICIAL USE,ONLY �' A o PERMIT NO.. DATE ISSUED MAP/PARCEL NO. 3 r +i• � . i r � t _ - w vc- i '" .`i. E P ,rt mm1 t v ADDRESS t 't VILLAGES OWNER } F "„ n .. •r � 1 ` � i #: t tx t _ ',,, 4 , a ... 't � � ' � a � r d a+ } DATE OF•INSPECTION: - r F [ ��. � / ,•Q e t , ; f .. .` p � � ` a 4 A• f i• ,t ' 4 . � t t a FOUNDATION FRAME INSULATION-«- t �• i �. + � :c Y _ � � - - FIREPLACE s y ELECTRICAL: ROUGH FINAL .' Y a. i. PLUMBING: GROUGH FINAL Fv GAS: !ROiJGH; 4 FINAL M i�: l x - FINAL BUILDING��- C7 �"' *: o: DATE CLOSED Ol t 19 : s ASSOCIATION P O. cu . .� The Town of Barnstable • L►xivsrnBi.E. • 9ebp ` ,0�' Department of Health Safety and Environmental Services rF1659. � 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. Type of Work. `y�E/A�C'C `�- k� G1 Pc� Est. Cost (300 Address of Work: t GA)A S- • Owner's Name \ 4 V 'A\(\ J C—k c, T-e �:h 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 fora permit7asthe a ent of t owner: z/ ' S "J o" F GU tomtlw Date fontract r a Registration No. OR Date Owner's Name ne Commanli•culllt of.1 fassaclrusctlr ' t �'j' ►_ 1�• Deparinrent of ludrwrial Accidents • � (nwo 'lr - •: 61111 1f asithi rtaa Street Bat-won. fa= 92111 Wori:ers' Compensation insurance ARdavit „�.._.� ------ Aintorm•+titiri • Ptc•tsr pR1NT`1tN•i�il_•,y��,�,�_ eh%.<plr,)O-a*S,!�ei Q I am a homeowner performing all wort:myself. I am a sole proprietor and have no one working, in am•atpaciry Or'I am an emplaver providing workers' compensation for my empiovees working on this job. t. � eff m r n e n W y o,CX-��,a it t• � G C� ° ¢ ` p "7 incannre rn q eg 1(%V� .T\j C \ CS nniir�•1! ('r - i O n�g �S •[1 I am a sole proprietor. gencrai contractor,or homeowner(circle one)and have hired the contractors listed beiow who i:a: the following workers' compensation polices m env natnr• eir v nhnne+t• in��ir•rncr rn Wolin•a -,— �__�_ mm��m•n�rnc� itlrc��• tin nhnne a• suran r ffflffer a Attach additionai sheer if necessary . i.�•.._.., ..�i^:._._. ... ._..-•..ram. •rw::�... ..i_•...w��.�t•� �.���.�.rr.��n ruiiu toecur se cut cracc as required under aectton 3A of A1GL 152 can lead to toe rmpostuon of cnouaal penalties of a line up to 51300.uU andrur re une%•ears•impnsonment as well as civil penalties in the form of a STOP«•OItX ORDER and s fine of SI00.00 a dar apinst tree. I understand that a cope 41f this statement ma% be forwarded to the OMce of invntit:ations of the DIA for coverage verification. 1 rla herehr cerr'••unrler the.pains nd penalties o rrrr that the informarian prmided above is true and correct t Sian= _ • a,� r one!!C5 C3�` b Prim name amcial use univ do not write in this area to be completed b�citr or town ofllcial city or town- permitilicense 0 r'Uaddint:Department • O1.1resunn Owrd check irimmediate response is required QSdeetmea's Ounce . Otleatth Department contact person• phone p: ^Vther�� information and Instructions MaSsaChUNCUN General Laws chapter I52 section 25 requires all employers to provide workers' cc�►u,Pcnsaticm for employcrs. As quoted 1rom the "law-.an enzpluree is defined as every person in the service of :ur ncer under any contract of hire. express or implied. oral or wrinea. , All cnrph rcr is defined as an individual. partnership, association. corporation or other legal entity. or an.• two or :-, : the foregoing end-aged in a joint enterprise.and including the legal representatives of a deceased employer. or tic receiver or trustee of art individual . partnership. association or other legal entity, employing employees. Howe:cr owner of dwelling- house haying not more than three apartments and who resides therein.or the occupant of the dwcllim_house of another wim employs persons to do maintenance, construction or repair wort: on such dwc1ling or on tie_-rounds or building appurtenant thereto shall not because of such employment be deemed to be an ernpic% 25 also states that every state or local licensing!agenc,% shall withhold the MGL chapter 15'_ section issuance or rencival of a license or permit to operate a business or to construct buildings in the commonwealth Car am• applicant ti�ho has not produced acceptable evidence of compliance iAth the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perforance of public work until acceptable evidence of compliance with the insurance requirements oftiris cltap::r m been presented to the contracting authority. Ah1►iic�:.ts � affidavit completely, b •clreckin�!the box that applies to your situation arc Please fill in the workers' compensation affida p ) checking, the compam• names, address and phone numbers as all affidavits ma'_v be submitted to the Department of Industrial Accidents for con tirmation of insurance coverage. Also be sure to sign and date the af'Tidavit. Tice a " =..'it should be returned to the city or town that the application for the permit or license is being requested. nog a Department of Industrial Accidents. Should you have any questions regarding the "law"or if.you are reeu:r_ to c' -ain a workers* compensation polio}•. please call the Department at the number listed below. Citl• ar rowns Ple:se be sure that the affrda%,it is complete and printed legibly. The Department has provided a space at:he bottom. the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding :lie applicant. P'. be sure to f:i in the permit/license number which will be used as a reference number. The affidavits may be returnee tite Department by mail or FAX unless other arrangements have been made' Tile Office of Investi_ations would like to thank you in advance for you cooperation and should you have arty questic :ease do not hesitate to rive us a =11. rThe Department's address. telephone and fax number- The Commonwealth Of Massachusetts :Department of Industrial Accidents Office cf Investigations 600 Washington Street Boston,Ma. 02111 fax (6I7) 727-7749 1 q Y. ➢ � � Sy1�4��/� `p1 i 1 'yr �.�� � �}nSz�Y �� '3_' �t < s� < , yl;r°"S�K��C.�Y�•An �.�`J� . t gr4�.'d�1Y'§�' �'a,d4 J �� �� «�� '� r•:•`R�'i i�. Yk w t t J ,1.. ` ��tY��{f'v1 `�.r� �` c �1 @i✓ 1 � t 4 R 'TT '� '�''!• i —I 1 ` a Ott`' • `t� � �4 5—. Y..`�' _ ,y .ter°,#,•ti F:'. F 1 1 t� son e TO A`�h A ovr oAo, Qir�" 3a �a a �G 114 Oleo U 14 Taft, % r o o ' eCIG e C i Ulf 3a" A I d � O � I C~.1 I K p` Z co I O ^N C, I N=> O Rf Li clj W C H !n S cy- dcn i W Y d I i I cc I � O I Z I I r � I 1 _ _ _ _ _ -Tom.-�� a�✓t�°° ' I DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Nuiber LL Ezpires� Restrict Q;Io � �'U0 KENNIrTH STUAR�:' C POCASSET, MA 02559 i ,I WORiJERS( 010.k.'En SX110N AND EIYIPLOYEWSLI,t 131 1-1TYINSUIUNCE POLICY INFOIIIVIATION PA(ali" NM Co. No Policy No. I- WC2-0120298 L INSUREI.)- KENNF-11-1 I S1UAPNTJ Renewal of Policy No. C P4,QI 0 11— Tbc Insuin2d/Mailiuk i,tldrcss- 63 HANDY ROAD INSUMNCE COMPANY FX.J Individual Partnership POCASSET, IMA 102559 Corporation or Otbt,,r workplaces not shown above: Insured's I.D.No(s). (if applicable" See WC 00 00 01 F.E.I.N.4 027342602 Ri sk'k ID if2., POLICY PERIOD: 1"be policy period is from 03/26/1997 to 03/26/1998 12:01 A.M.Standard Time, at the Insured's mailing address. 3. A. Workers CompensMion Insurance: Part One of the policy applies to tile Workers Compensation Law of the states listed here: Massachusetts 11. F-niployers Ins'."-Ance: Pa"tTwO of die policy applies to work in each state listed in iteni 3.A. The firruts of our Uabililv wider 'Bodily Injury by Accident 100000 each accident Bodily Injury by Disease$ 500000 policy Ilinit Bodily In,tii-N by Disease$ 100000 each employee C. Other States Insurance: fart Three offlie policy applies to the states, if any, listed here: D. TIiis policy includes 11-wse e;icici-senients an(] schedules: WC,000000A,WC:000001,WC000414,WC000311 A,WC200301,WC200302, VvIC20003,WC200306,WC200601, .1, —NE—T-1)1-prell)illill for this policy will be detennined by out-Manuals of Ituies,Classifications,Rates and Rating Plans. All information required below is subject to verification and cliage by audit. Code Premium Basis I Rate.Per Estimated Annua Classifications No. Total Estimated " Premium Annualikenluneration Remuneration SeeSee WC 00 00 01 ------------ .1 f indicated below,interii-o a4justinents of'premium Premium for Increased Limits Part Two,if applicable $ ;iall bc,imadt,-- Total Prei3iiiiiii Subject io the Experience Modification $ L-]QU-arterly; 44011tiliv Preinivini klodified to Reflect experience Mod.of $ Semiannually; E Total Estimated Standard Premium M/11 - DIA AssessineiiI. $13, Premium Discount,if-applicable $ 1:'xpellse Coll's-tala Total Estinlat�d Annual Preni;urn $ Nlitiilnul n Mmium 300.00TN-1, li Tre.iniurn$ 5 ] T(tal.h- __J2 ;n-tin)ted Annual Premiurn $ 500.0 NameofPioducer: AR'1'1-1(J!t.J)CAL,I-'EI-1114';tjR,ANCEAGENC"I," INC. Sel-vicillgoffice: NIASBU Program Countersigned 04/07/97 2517 IIWY-35, MANA,1.',QU/%K N.J. 08*736 742nuthueizcd Representative Date INFORMATION PAGE Willi THE WORK'7HS CONIFENSA'TiON t, D 101PLOVERS LIABILITY INSURANCE POLICY AND L-- ENDol'.SFNIENTS. IF ANY, ISSUED TO FORM A PART 'rnP,.1Li,,0F, COMPLFTES THE ABOVE NUMBERED POLICY. -AN.4 7-9:901 COI'VIMAIT 198", ('01INCH, ON CONH'T"NSATION INSURANCE WC 00 00 01 PREFERRED COMMERCIAL LINES POLICY AL NSu INSURANCE COMMON POLICY DECLARATIONS RENEWAL BUSINESS COMPANY DIRECT BILL Policy Number: CPP 011053 44 42 Named Insured and Mailing Address(No.,Street,Town or City,County,State,Zip Code) KENNETH I STUART JR 63 HANDY ROAD POCASSET MA 02559 Replacement or Renewal Number of CPP 0100534442 Policy Period: From 03/26/1998 to 03/26/1999 12:01 A.M. standard time at the mailing address of the named insured as stated herein. IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Property Coverage Part $ Commercial General Liability Coverage Part $ 428.00 Commercial Crime Coverage Part $ Commercial Inland Marine Coverage Part $ Owners & Contractors Protective Liability Coverage Part $ Commercial Auto Coverage Part $ TOTAL $ 428.00 Countersigned: 02/05/1998 By Authorized Representative 20-00800 ARTHUR D CALFEE INSURANCE 121 COUNTY ROAD NORTH FALMOUTH MA 02556 (508)563-2266 THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVER- AGE F MS(S)AND FORMS AND ENDORSEMENTS,IF ANY, ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY. CD-1 ( -97) Includes copyrighted material of Insurance Services Office, Inc.,with permission.Copyright, Insurance Services Office, Inc., 1983, 1984. INSURED COPY SBU Insurance Agency, Inc. THE MASSACHUSETTS SMALL BUSINESS UNDERWRITERS PROGRAM Two Paragon Way,PO Box 6519 (732)683-1700 F Fax(732)683 4900 Freehold,NJ 07728 STATEMENT OF RENEWAL Massachusetts Workers Compensation Policy Renewal February 5, 1998 TUART JRAmount Due: $512 KENNETH I S CV oil 6 63 HANDY ROAD '�( Due Date: 03/26/1998 POCASSET, MA 02559 .3 Policy Number:WC3-0120298 Policy Period: 03/26/1998 to 03/26/1999 CURRENT POLICY EXPIRES AT 12:01 AM 03/26/1998 CALCULATION OF THE ESTIMATED COST TO RENEW THE SUBJECT POLICY IS: Code Premium Basis-Total Estimated Rate Per$100 of Estimated Annual Classifications No. Annual Remuneration Remuneration Premium CARPENTRY-DWELLINGS-THREE STORIES 5651 $1,144 15.25 $174 TOTAL ESTIMATED ANNUAL PREMIUM $174 UNMODIFIED PREMIUM $174 MERIT RATE OR EXP MOD CREDIT AMOUNT 9885 (0.9500) ($9) MODIFIED PREMIUM $165 LOSS CONSTANT $50 0032 $50 PREMIUM TO BALANCE TO MINIMUM PREMIUM 0990 $95 TOTAL ESTIMATED STANDARD PREMIUM $310 EXPENSE CONSTANT 0900 $190 TOTAL ESTIMATED PREMIUM $500 DEPT.OF INDUSTRIAL ACCIDENTS ASSESSMENT 0089 4.0000% $12 Your Estimated Total Cost to Renew is $512 If you are interested in financing your renewal and your premium is more than$750, please contact your agent immediately. All changes to this offer must be received in-writing no later than two weeks prior to policy expiration date. Otherwise, your written request will be executed as an endorsement. ARTHUR D CALFEE INSURANCE AGENCY INC. 121 County Rd N FALMOUTH, MA 02558 Phone: (508)5645188 Fax: (508) 5637304