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HomeMy WebLinkAbout0506 SANTUIT ROAD Efficient Buildings, 'LLC October 31, 2011 , Town of Barnstable Attn: Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 re: 506 Santuit Road, Cotuit, MA 02635 r , Dear Mr. Perry: r +. This affidavit is to certify that all work completed at 506 Santuit Road, Cotuit, MA 02635, has been inspected by a certified Building Performance Institute (BPI) inspector. Work included air sealing, attic hatch insulation, and installation of 160 sq. ft. 8" Class 1 cellulose in attic, 166 sq-ft. R-13 FGB to kneewalls, 384 sq. ft. 11" Class 1 cellulose to attic, and 160 sq. ft. cellulose to slopes. All work performed meets or exceeds Federal and State requirements. Sincerely, , Steve C. White .- ` Owner/Managing Member ` , n Efficient Buildings, LLC A, 8 Jan Sebastian Drive, Unit 10, Sandwich, MA 02563 Tel: 508-888-1110 Fax: 508-888-1109 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health'Oivision Date Issued I 31 ifi Conservation Division ;;.Application Fee Planning Dept'. Permit Fee' Date Definitive Plan Approved by Planning Board p/ Historic - OKH Preservation/Hyannis Project Street Address Village CUfiy/f Owner �i�i^`�P ylUf�e Address Telephone 50 Permit Request Square feet: 1 st floor: existing - proposed 2nd floor: existing proposed Total hew Zoning District Flood Plain Groundwater Overlay Project Valuation � 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 eti, Basement Finished Area(sq.ft.) Basement Unfinished Area (sq:ft) " Number of Baths: Full: existing new Half: existing x o° new »_ a CD Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count— z Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing 0 new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing 0 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) AName S%e Ut ��1 i�� _ F~ -��a- Telephone Number I/ p d AddreT ��U��kW Ave, License # r yeA.4'f Aa- Home Improvement Contractor# 15'YY 39 Worker's Compensation # We- Ny `1�0115 ALL CONSTRUCTION DEBRIO RESULTING FROM THIS PROJECT WILL BE TAKEN TO7, yQt/ylp�i T� SIGNATURE DATE 4 4 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED r MAP/PARCEL NO.;_r. ' ADDRESS - VILLAGE J OWNER t c } DATE OF INSPECTION: FOUNDATION_a',._ ` FRAME f INSULATION., FIREPLACE r� ELECTRICAL: ROUGH FINAL 4 f PLUMBING: ROUGH FINAL GAS ROUGH= .,,, *0 fi� FINAL . ,:FINAL BUILDING: ,DATE CLOSED OUT ASSOCIATION PLAN NO. P 4� The Commonwealth of Massachusetts I Department of Industrial Accidents Id Office of Investigations z ,i P"�a 600 Washington Street Boston, MA 02111' r www.mass.gov/dia Workers' Compensation Insurance Affidavit:, Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organ ization/lndividual): �,_ a Ilk. Address: .all 4Ck5/lip- Aklke jib i/ e� 4 0��-d3 Phone#; �� /J ra City/State/Zip: �1�i1��°ff� � C�� /� Are you a.n employer?Check the appropriate.box: Type of'project(required): 1. I am a er em to with 4. El am a general contractor and I employer ti. ❑-New construction '• employees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. $ ❑ Remodeling ship and have no employees` These sub-contractors have 8. 0 Demolition working for mein any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its officers 10.0 Electrical repairs or additions required.] have exercised their 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4), and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#I must also fill outthe section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors,must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. a Insurance Company Name: CriJ Policy#or Self-ins:Lic: #: WC / VI •57�O.5 Expiration Date:t Mal; A6//. Job Site Address: 7� S x­/&, !Y1' City/State/Zip:C,y G/ Ae Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). . Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in°the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be.advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for_insurance coverage verification. I do hereby certi y under the pains and penalties of perjury that the information provided above is true and correct Si afore: � � ./, . '. Date: _ . . Phone#: � ^ F ial use only. Do not write to,this area,to be completed by city or town official City or Town:. Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 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." 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, §25C(6)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, MGL chapter 152, §25C(7)states"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 out the workers' compensation affidavit completely;by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)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 Town Officials 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. In addition,an applicant that must submit multiple permit/license 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 locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that 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. The 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. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021 U Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass..gov/dia I Massachusetts- Department of Public Safety Bmtrd of Buildim, Regulations and Standards a Construction Supervisor License License: CS 95M Restricted to: 00 STEVEN WHITE 147 RIDGEWOOD AVENUE 1-116NNIS, MA 02001 Expiration; Z/"292012 F C Immi.�i.mcr Tr~: 19311 t t �.1�os�woowwalQf ,�kaoaaaluaaA2 � Bored ofD�iy MOE rCONTRACTOR .154359 8/2011 TA 280764 _� Y Ce�poroAlon L� •,¢; W RIDQEINDOO i 4YANNIS,MA 02801 Adn"drstor . s a Ilse K Ode ftly , 'e1 Fw!L IiRflr�tl d Teton to: t �. � �aed 3�udards Y.-• ate•.�.-� __-.___-_.-.-�____ [ .. t.����^ for f !' � »�;• R i G `k+7 ddsy 44 f DATE ACORD,M CERTIFICATE OF LIABILITY INSURANCE 09/1S/2010 PRODUCER 508.945.0393 FAX S08.94S.4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eldredge & Lumpki n Ins. Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 697 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chatham, MA 02633 j i INSURERS AFFORDING COVERAGE NAIC# j INSURED Caliber Buildin and Remodeling LLC — --- 9 g tNSURERA National Grange Mutual Ins Co 14788 I INSURER B: Commerce Group CIG001 147 Ridgewood Ave INSURERc: Granite State Ins. Co:-ARWC 13102 Hyannis, MA 02601 j Y r INSURER D: INSURER E: -- — COVERAGES 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. s INSR DD' -----� —_._....-------------------P�LICYEFFECTNE POLICY EX ' LTR N8R TYPE OF INSURANCE POLICY NUMBER DATE M DATE MM/DDMIYY LIMITS GENERAL UAWLITY MP0273601 09/15/2010 109/15/2011 ;EACH OCCURRENCE $ 11000,000 i Xj COMMERCIAL GENERAL LIABILITY I PREMISES(Ea ooarrenoe $ f2,000j0 500,OOCLAIMSMADE Fk]OCCl1R _ y•.,- MED EXP(MY one person) $ 0APERSONAL8 ADV INJURY $ 0GENERAL AGGREGATE S GErfl AGGREGATEMAT AP(P�LI�ES PER: 'PRODUCTSCOMP/OP AGG $ OO POLICY PRO- JECT I I LOC -- AUTOMOBILE LIABILITY BBNVCS 02/16/2010 02/16/2011 1 F1 COMBINED COMBINED SINGLE LIMIT ANY AUTO (EeCO B _ $ 1.000.00 ALL OWNED AUTOS I -- BODILY INJURY B j X SCHEDULED AUTOS (Per person) S HIRED AUTOS BODILY INJURY I NON-OWNED AUTOS !(PeraodCent) $ PROPERTY DAMAGE $ . (Per aomdant) } +GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ 4 ANY AUTO OTHER TFyW EA ACC $ AUTO ONLY: AGG $ j •EXCESS/UMBRELLA LIABILITY - EACH OCCURRENCE $ t OCCUR CLAIMS MADE AGGREGATE •DEDUCTIBLE i RETENTION $ $ I WORKERS COMPENSATION - WC7425405 03/02/2010• 03/02/2011 - i AND EMPLOYERS'LIABILITY Y/N - - ( I TORY LIMITS ER _ ANY PROPRIETOR/PARTNER/EXECUT E.L.EACH ACCIDENT S SOO OO C OFRCERMEMBER EXCLUDED? j r ((NanCrtory in NH) - E:L.DISEASE-EA.EMPLOYEE $ 500,OO Ill yes r]esmbe under ,,_ . ..,:.. _:. _..._._ SPECII PROVISIONS below _ E.L.DISEASE-POLICY LIMIT S 500 OO OTINER 9 OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Ft_ CSZWK-ATE HOLDER CANCELLATION L,.,� ,"^i^+ a •SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION �• t DATE THEREOF,THE ISSUING INSURER YYLLL ENDEAVOR TO MAIL L=_ DAY - •+^' r S WRITTEN N TO.THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Tom of Barnstable h slelwOeE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR / ention: Building Department I rAmlEs ftin Street J�ITIDBI>�D1tEPRE8ENTATrvE : i s, MA 02601 ~� Ala It Presider a 011 ; hACORD CORPO ION. All rights reserved. a r'` The ACORD name and logo ro n>tg>eiared n�rl�,ofACORp: - f as owner(s) of the subject property at: 5-a6 S•a,` Gi /�� CO hereby authorize Brian McCormack of Caliber Building,And Remodeling, LLC (contractor)to act on my behalf in all matters relative to the building permit application. signature of o er date signature of owner date I i I �oFtw�� Town, of Barnstable *Permit# ti� Erpires 6 montlisfrom issue date Regulatory Services - PERMIT g Y Fee hvsrxa�. -+� v pnss.1619. Thomas F. Geiler, Director i, IP C� AR�JS�fAii r�.: Building Division - in Perry, CBO, Building Commissioner 200 Main Sheet, Flyannis, MA 02601 www,town,barnstable.ma.us Offic e: 5 08-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Nol valid without Red X-Press linprint Map/parcel Number e571751Bd,7 . Property Address - �� o-- v,f 9?lCe'sidential Vah16 of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name & Address /7h`11 Contractor's Name 1_- ' (e V. pp�,�s E,ortiS�a�e,�.tri Telephone Number `9 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable)_ 4Q/Y &�orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name ,2,wt z:,., ! �qf�4 Workman's Comp.Policy#•�el G✓ Y'fo Copy of Insurance Compliance Certificate must accompany each permit. Permit Request (check box) 0 Rc-roof(hurricane nailed) (stripping old shingles) All construction debris'.will be taken to ❑ Re-roof(hurricane.nailed) (not stripping. Going over existing layers of roo fl Re-side # of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .35) #of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations, i.e. Historic,Conservation,ctc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors License is required. ' SIGNATURE: �AWPFILESTORMSIbuilding permit forinslEXPRCSS.doc ACORDTM CERTIFICATE OF LIABILITY INSURANCE °A09/07/2o 0 Y' PRODUCER (508)428-0440 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mark Sylvia Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 771 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Osterville MA 02655 INSURERS AFFORDING COVERAGE. NAIC# INSURED Doyle& Thomas Construction,Inc: INSURER A: Farm Family CasualtyInsurance PO BOX 168 INSURER B: Centerville,MA 02632-0168 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS L R PE F INSURANCE DATE MM/DDlYY DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X . 2001 X0485 7/21/2010 7/21/2011 DAMAGE TO RENTED 50,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ CLAIMS MADE Fx�OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-CO P/OP AGG $ 2,000,000 X POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT. ANY AUTO (Ea accident) $ ALL OWNED AUTOS g BODILY INJURY $ SCHEDULED AUTOS (Per person). HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTYDAMAGE $ (Per accident). GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WC STATU- `X OTH - WORKERSCOMPENSATIONAND 2001W6390 7/1/2010 7/1/2011 A EMPLOYERS'LIABILITY 500,000 _ EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE SOO,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under Yes E.L.DISEASE-POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER " r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CarDentry CERTIFICATE HOLDER CANCELLATION (508)790-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable Building Department DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE f ACORD 25(2001/08) ©ACORD CORPORATION 1988 �T a�r�ma�zeue Board o f Building Regulatioffs anStandards L` License or registration valid for indrvidul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ' {° Board of Building Regulations and Standards, Registration 145954 4 One Ashburton Place Rm 1361 •"� Expiration _._3/15/2011 Tr#. 282668 Boston Ma.02108 ` r s �..' Type Private Corporation DOYLE+T}IOMAS CONST INC t TROY THOMAS 499 NOTTINGHAM DR .,« ,"`Gb° '` '' -- nat _ CENTERVILLE,MA 02632r Administrator Not valid wit out siggnature f( # Y A=' IVlussachusetts- Dcliartment of Public Safety r t n Board of Building Re4,.%ulgioris,and Standards -.1, u Constructio.n,SppervisorSpecialtyLicense Y +° F: License: CSSL 9994.3 = Restricted to: RF WS 4 g . TROY THOMASre tA U41 . 499 NOTTINGHAM,DRIVE CENT,ERYILE MA02632 kX. Is, }' Expiration: 4/13/2012Conunissioner ' Tr#: 99913 1 0d 3+•M � a The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations !' 600 Washington Street Boston, MA 02111 c S' www.mass.g o v/dia Workers' Compensation Insurance'Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: elo. &x City/State/Zip: elaL4"., 116 Phone #: �3S' Arl an employer? Check the appropriate.box: Type of project(required): 1. m a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction 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 8. ❑ Demolition working for in any capacity: workers comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required] officers have exercised their 10.❑ Electrical repairs.or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c' 152, §1(4), and we have no 121�-Iibof repairs insurance required.] t employees.[No workers' 13.❑Other comp. insurance required *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / / Insurance Company Name: `��4/� Lv✓I rt�t C�f•c r Policy #or Self-ins. Lic. #: :GW/ 661ya Expiration Date:' Job Site Address: T /Cdc `City/State/Zips,11,f4l Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as.required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. .Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains,n penalties of perjury that the information provided above is true and correct Signature: -Date: /�'L. ;02� AJ� Phone#: Official use only. Do not write in this area, to be-completed by city or town official City or Town: Permit/License# Issuing Authority(circle one); 1. Board of Health 2.-Building Department 3.'City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector, _ 6.Other. Contact Person: Phone#: 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." 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, §25C(6) 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, MGL chapter 152, §25C(7)states "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 r-- Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)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 Town Officials 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. In addition,an applicant that must submit multiple permit/license 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 locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that 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. The 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. 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 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE. Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia 506-326-1635. SPECIALIZING IN ALL FORMS OF ROOFING & SIDING doyleandthomasconstruction.com , P.O. BOX 168 BBB. CENTERVILLE, MA 02632 Fully Licensed & Insured Construction Supervisor Lic# 99913 Doyle and Thomas Inc. Proposes to perform the following work: Location of proposed work: Mr. Phil Burke 506 Santuit Road Cotuit, MA 02635 Date on which construction shoul&begin: Fall 2010 The homeowner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that cannot be avoided by the contractor shall not be considered as a violation of this contract. The contractor agrees that when such delays become known to the contractor,the contractor will advise the homeowner as soon as possible. The homeowner hereby acknowledges that in certain remodeling work,the demolition process may reveal defects in the existing structure which must be repaired, creating additional work which.may need to be carried out in order to complete the work described in this contract. In such case the homeowner agrees that the duration of the work and the schedule date of completion may differ, and that such variation is not to be considered a violation.of this contract. The total cost for labor and materials under this contract: $5,569.78 30 yr.GAF/Elk Timberline Architectural shingle To replace the Sidi on the thr eek wall nd ound th bu head f�%ram �iiould be'a ditional :00 'I To replace some trim rot on a few different areas would be an additional $145.00 cdlal in the event that while stripping,the roof we find rot that needs to be replaced,the homeowner then has to agree and authorize any replacement or restoration. Then in addition to the above contract price,the homeowner agrees to compensate the contractor for any repairs or restoration at the hourly rate of$45.00 for carpenter and$30.00 for a carpenters laborer, plus the cost'of materials. - -Roof to be stripped and cleaned of all old shingles and debris -Roof to be papered with weather watch leak barrier, synthetic roof underlayment and installed with Timberline architectural shingles using galvanized nails. (Storm nailed) -All new 8 inch drip edge and pipe flanges to be installed -Cobra ridge vent to be installed on all ridges Timberetex premium ridge cap to be installed -Proposal includes contractor to install wire mesh over the gable vents @no charge -10 yard container will be needed on site; and will be removed-at completion of the job- -Contractor will be responsible for all building permits needed at the property NOTICE REQUIRED BY LAW With the agreement of the contract$500.00 of estimate is due. Further payments under this contract are as follows: 1/2 of the estimate due at the start; and remainder due at completion of,the job. Balance of all materials and labor shall be payable in full upon completion of work described in this contract. Payment as agreed upon shall be made when due. Any payments which are delayed shall be subject to a finance charge of 1.5%per month. The contractor warranties the work completed under this contract for a period of ten year from the date of completion. During the stated warranty period the contractor shall be responsible for the service of the repair or adjustment, but the contractor shall not be responsible for the normal maintenance, repair due to abuse, misuse,and or normal wear and tear,which shall be the responsibility of the homeowner. All warranties for the materials supplied by the contractor shall be passed directly to the homeowner. The homeowner maybe required-to register or.mail in such warranty card or evidence of. , ownership in order to activate such warranties. Homeowner failure shall not create any responsibility for the contractor under the warranty provisions;the choice of repair of replacement shall be at the discretion of the contractor. The homeowner acknowledges that the form, content, and notices contained in this. contract are intended to comply with the applicable portions of the Mass. General Law Chapter 142A, . and regulations promulgated there under. In the event of any instance of non-com pliance,'only such portion shall be invalid and the remainder of this contract shall be in full force effect. In addition,any such portion not in complianceshall be read and interpreted so as to have its intended meaning to the, maximum extent allowed under such law and regulation. Signed as a sealed instrument on this dater Date: Homeowner Contractor ��L .