HomeMy WebLinkAbout0087 SCHOOL STREET 5?7 _
I
of Barnstable *Permit# -
,y�' Expires 6 months from issue date
egulatory Services Fee
snaxsznsr,E,
JAN 20 2016hard V.Seali,Director /
1639. ` nQ�
plan �a osit cling Division L4 'I S
T®``nnIIN�F�
V" Tom Perry,CBO,Buil ding,Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 635 617
'
Prope Address
Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
f>�J� �/}p�a Telephone Number
Sam 7� 7 ,9
Contractor's Name
Home Improvement Contractor License#(if applicable) /S d s 0 S"' _ Email: /�✓e. 5 S 6 v►i�o/,i q q o /-G o h?
Zorkman's
ion Supervisor's License#(if applicable)
Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I,afn the Homeowner
have Worker's Compensation Insurance
Insurance Company Name S s C> ,1 0AQ_ (�,t�►� rS
Workman's Comp.Policy# 4)C C, — .SU 0 — S0 S 0 9 Z 0 1 �'
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Req t(check box) iJ
Re-roof hurricane nailed (stripping old shingles) All construction debris will be taken to
( )( PP g g )
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans mprked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit-does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy, the Home Improvement Contractors License&Construction Supervisors License is
re
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\E)PRESS.doc
Revised 040215
Tlie Comraroynrealth of Massachusetts
Dep{arrtwewt o,f Indksh ial Accidents
- - f3,Bice of.£nvestigations
600 Washington Street
�. Boston,A! 02111 '
*Grit*-mass�govIdin
Workers' Campensatian Insurance Affidavit B:mldersiC mtractorsAEIectrkians(Plumbers
Applicant Infarmatku J Please Print LegibIy
Name
Address: < t Ir C., l.�
Cityfsta& l G Ah S Ala G z-6clPhoiifi 7 7 )' 79 7 7 .
Are you an employer?Checkthe appropriate box: Type of project(required):
1.❑ I a employer oath 4. ❑I am a general contractor and I
layees(fu11 azldlor part-time).
* have hired.the sub-contractors 6. ❑New constmr-tion
2.tl I am a sole proprietor or partner- listed on the attached sheet. 'I_ ❑Remodeling
ship and have no i gees. These sub-con�frac#ors have
employees b
$_ ❑Demolition
worLing for me in any capacity_ employees aiid have workers'
[No worlmrs' comp.insurance comp_insuranv l 9. ❑Building addition
s-
required-] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a h,ameoumer doing all workofficers have exercised their ILEJ Plumbingrepairs or'additiom'
=�y set€ workers' right of exemption per MGL -
�o - 12.0 Roafrepairs
insurance required.]i c.152,§1(4h andwe have no
employees-[No workers' 13:❑Other
comp.insurance required.]
*Any a"Eicavtthat checks•bas 91 Bros#also fill out the sectionbelow shoa-ing their woskere compeasaticapeR y informsaan.
1 Homeowners who subra t this afiidasit in&cwing they are doing all wa t and.then lie autide coatzactors mast Submit a new affidavit indica31ag sack.
FContractors that rhea this boat mast attached au additional sheet ahoumg the name the sub-coact umis and state whether ernatthose enMieshave,
employees.Iftheaub-caatractershave employers,they mustpmr-ide their workeW comp.policy number.
I am an eumplaFer f7mat is prvtidur, workers'conlpertsativrtlnsurance for m}*enrp£v1 es Se£ory is thepo£icy and job site
information �^ J
Insurance Company Name: - 5.50 G!
Policy,4 or pelf--ins.Lic_ t'V C G $O 0- So l So 9 '7 -Z a IS ocpigatiott Date= 6 I
Job Site Address:- 0 � ✓ G�� J J�� City/State/zip:
Attach a copy of the workers'compensationpoRcy declaration page(showing the policy number and expiration date).
Failure to secures coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,50D OD andfor one-year imprisonment,as well as civil penalties.im the form of a STOP WORK ORDER and a fine
of up to$.250_D0 a day against the-violator. Be ad%ised that a copy of this statement may be Enwarded to the Office of
Investigations of the DIA for' ce-coverage verification_
Ida Irerediy csrtrf t and 'is rmatties efpet jury thatf7me informati u ptmided abm is and carrect
Sitmahire: / Date:'
Phone;k 7-7 1- -7
Official use only. Do itot saute in t£ris area,fa be camp£etesd by city ortown oIfreiaL
City or Tana: PermitUcense if
Issuing Authority(dude one):
1.Board of$eaItii 2.Building Department 3.Cit
y1rown Qerk d,Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions -
Massachusetts C=neral Laws chapter 152 regthes all emmployers'to provide workers'compensation for their employees.
Pm suantto
this statute,an.mrpIayee is defined as."_.every person in the service of another under any contract ofbae,
express or implied,oral or writinu_"
An employer is defined as"an individnA partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged ina 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 -
d-WeIling house of another who employs persons to do mah tcamm,construction or repair work on such dwelling house
or on the grounds or building appurtenanf:thamto shallnotbecause of such employmentbe deemedto be,an employer."
MGL chapter 152,§25C(t7 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 army
applicant who has not prod-acedacceptable evidence of compliance with the insurance.coverage required."
Additionally,MaL chapter 152, §25CM states"Neither the commonwealth nor any ofits political subdivisions shall
enter into any contract for the performance ofpublic work u tl acceptable evidence of compliance with the insuranc, 6..
r ents of this chapter have been presented to the confr��a amthodty_"
egtm�em ,
Applicants
Please fill oimt the workers'compensation affidavit completely,by checking the boxes that apply to your sitnafion and,if
necessary,supply su:-contractor(s)name(s), addresses)and phone nunber(s)along with their certfficate(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 instance. If an LLC or LLP does have
employees, a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial
Accidents for conffimnation of msar mce coverage. Also be sure to sign and date-the affidavit. The affidavit should
be retmmmed to the city or town that the application for the permit or license is being requested,not the DeParhneat of
L ,strial.Accidents. Should you have any questions regardmg the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below, self-insm-ed companies should enter their
self-n,�ce license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and primed legibly. The Department has provided a space at the bottom
of the.affidavit for you to fll out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to Ell in the permit/license number which wM be used as a reference number. In addition, sn applicant
that must subunit multiple peraut(license applications is any given year,need only submit one affidavit indicating current
p olicy infbrmation(if necessary)and under"Job Site Address"the applicant sho,�Id write"all to cations in (city or
town)_"A copy of the-affidavit that has been officially stamped.or mandrel by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fntore permits or licenses Anew affidavit midst be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial vmttrc
(i.e. a dog license or permit to bum leaves etc.)said person is NOT regtazed to complete this affidavit
The Office of Investigations would Imke 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
Tht f GMMW tar of Massaclzusz-tbs
Department of 1adustdal Ar ent%
��e�f�I.ve�fzgatio�
��4-� tQu 5fr�t
Boston,MA 02111
T(,-L 617 727-49W Qxt M6 or 1-a IAS&kFF,
Fax#617-727 7749
Revised 4-24-07 masg-gavfdia.
IMMNSTABM
MASS f
9 Town of Barnstable 4
Regulatory Services
Richard V.Scali,Director.
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property /Be
Complete and ction
If Usingasect property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this ding permit application for:
(Address o Job)
Signature of Owner ` Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the ,
reverse side.
Q:\WPHLESTORMS\building permit formsUTRESS.doc
Revised 040215
Town of Barnstable
Regulatory Services
�oFTHE rOiy,� Richard V. Scali,Director
Building Division
* snar�szasr.E Tom Perry;Building Commissioner
MASS.
1e39. 200 Main Street, Hyannis,MA 02601
ArFD" www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone# .
CURRENT MAILING ADDRESS: -
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures.'A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such homeowner' shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be reMonsible for all such work performed under the building pemlit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case;our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doe
Revised 040215
f t1aschu��istat~me�it pF dab' Safeye '
BBaQ S�'tjding QulattoFls -t�trtc(atytl
}ery sor..j w
• , ��, � "''Lt�e�3s� CS-058S87 �- � � ,�
-
�'`STEPHEN E BOBOLA
j 24 cis SIR
%f HYANNIS MA 02601 I
t
2
1 #f 1-
'. Expiration
�F Commissioner 02/04/20tE
I t ��e�porrr�rr�antuea�C� ��/�i..taacluae�
Officeyof Consumer Affairs&Busia dess Regulation
/ ME IMPROVEMENT CONTRACTOR
/ egistration: 1`58588 Type:
xpiration: _,211112Q16_, Partnership
MASS UILDING SYSTEMS
ij it
STEPHEN BOBOLA",-"
24 ST. FARNCIS CIRCLE
HYANNIS,MA 02601 =-r" Undersecretary
'r
•
r
FROM:
Mass Building Systems PAGE NO. I OF 1 PAGES
24 Saint Francis Circle
Hyannis. Ma. 02601 DATE:3I15114
PROPOSAL SUBMITTED TO:
Vernon Crabel
57 School St JOB NAME:Same
C'otuit. Ma. ADDRESS:Samc
PHONE:508-776-2038 CITY/STATE/ZIP:Same
I We hereby submit specifications and estimate for: i
1)Remove all rooline and dispose of debris.
'_)Apply new dripedge, install ice and wooer shield to baselines,hips and protrusions.
3)Install new pipe boot tlashings,cover rest of roof with waterproof paper, low pitched areas are I00'rat ice and water..
4)Apply 30 year architectural roof shingles in owners choice of color.
5)Cut open ridge install ridge vent and apply caps. ---
* Contractor to obtain permit and remove.debris
*Replace rotted root deck boars s mostly at P—Orc , r heplace other rotted roof edge moldfnzs. __
* Add 1 1/2 thick facia to front porch area.
i
We hereby propose to furnish labor and m iterials—complete in accordance with the above specifications.. for the sum of Eight Thousand j
Seven Hunched twenty Five Dollars with Payments to be made as follows:
4,400 at start, 4,325upon completion
All material is guaruuceil it)be as specified.All work to be completed in:t workmanlike manner according to Standard praiiices,Any alteration or deviation from above S
Specifications involving extra Costs will he eXccuted tndy upon written orders.and will hccomc:m extra charge Veer and nbt the estim.itc_All aerecnnnts cuntinvent upon
strikes,accident or delays beyond our control.This proposal subi ct to acccpt:u7ie++ithin I5 Clays.rod it is void thcreaf etl.rioi unilinit nc 1.
Authorized Sitamatrre
ACCEPTANCE OF PROPOSAL
The abort:prices,specifications and conditions arc hereby accepted.YOU are authorized to do die work as specified.ltaymcm will be made as unlined above:
ACCEPTED:
�7Q Signature _.
DATE P-C� ! 47 Signature
t•Y CCNTRACfGE26 FOt2I:95 FL7F?I1.1 NO-Plif)P 3' 17
7 ,
V
w
Vernon Grabel <vgrabel@gmail.com>
bp�,<?tF�yls:
roof
massbuilding@aol.com <massbuilding@aol.com> Mon, Dec 28, 2015 at 7:23 PM
To: vgrabel@gmail.com
Hi,
The additional facia will be 800 material and labor to install. Painting the finish coat may
not be able to be done until spring because of temperature.
The first payment would be 5,200 which includes the additional facia and the completion
payment would remain the same.
----Original Message---
From Vernon Grabel <vorabei0_)gmail.corn>
To: massbuilding <rr+assbuildinq@aol.co;r>
[Quoted text hidden]
1 of 1 12/30/2015 01:40 PM
f
I
V
i
I
li
1
i
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5015097-2015A
PRIOR NO. NEW
ITEM
1. The Insured: Mass Building Systems LLC
DBA:
Mailing address: 24 St Francis Circle FEIN:**-***4170
C/O Carolyn &Steve Bobola
Hyannis, MA 02601
Legal Entity Type: Limited Liability Corporation
Other workplaces not shown above:
2. The policy period is from 09/16/2015 to 09/16/2016 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTEA 9990
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $550 Total Estimated Annual Premium $3,964
GOV GOV Deposit Premium $4,169
STATE CLASS
MA 5645 State Assessments/Surcharges
$3,562.00 x 5.7500% $205
This policy, including all endorsements, is hereby countersigned by 09/25/2015 -I
P Y� 9 Y
Authorized Signature Date
Service Office: Bryden&Sullivan Insurance Agency Inc
54 Third Avenue 88 Falmouth Road
Burlington MA 01803 Hyannis, MA 02601
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
i
,,I�ngineering Dept. (3rd,floor) Map 3,�p -` /Parcel Permit#
House# ` V1 ��'i , tom" ✓�.. Date Issue
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee: �J
Conservation Office(4th floor)(8:30-9:30/1:00--2:00)•
Planning Dept.(1st floor/School Admin. Bldg.)
Definitive Plan Approved by Planning Board i 19 ;
i - BARNSTABLE. `
TOWN OF BARNSTABLE
Building Permit Application
Project Street Address �� 6c!� off.Village ( ,OTU( f t
Owner Vu NoN C 2A5EL- ' Address P D. 7DD
Telephone
-Permit Request 51DC LJ kOLs W l T1 ' Q C,EDD<2__ M N9 116 W I(P 0P�C{�-'PDO,L
{
S
First Floor D0 - square feet Second Floor 10D square feet
Construction Type kl 14 kN Q6 Val DUB
i
Estimated Project Cost $ 600
Zoning District /fieSi pm'(I Flood Plain U Water Protection
Lot Size •30 QCOS I Grandfathered Oyes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure'(P5 Historic House ❑Yes �No On Old King's Highway ❑Yes *No
Basement Type: tKull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) — D — Basement Unfinished Area(sq.ft) 70D
Number of Baths: Full: Existing I 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: dGas ❑Oil ❑Electric ❑Other
Central Air ❑Yes \dNo Fireplaces: Existing New Existing wood/coal stove IYes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
None b/shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# VX Recorded_ ❑
Commercial ❑Yes l�iNo If yes, site plan review# .
Current Use �Qyi CQa/1 U�/ Proposed Use
Builder Information
Name Telephone Number
Address 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
SIGNATURE DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
i - FOR OFFICIAL USE ONLY _
PERMIT NO. -
,
DATE ISSUED
_ r
MAP/PARCEL NO.
ADDRESS ► VILLAGE
,
OWNER `
DATE OF INSPECTION: ; k
FOUNDATION-
FRAME ,
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS:,- ROUGH FINAL'.
FINAL BUILDING 'T I Q 'ai�
DATE CLOSED OUT _
ASSOCIATION PLAN NO. ,
_ Amer
®f Barnstable ,the Town ..
• .ter •
e$1 Department of geaIth Safety and Environmental ervt
6 BuiIding Division
367 Main Street,Hyannis MA U601
Rahn Crasser-
Office: 508-790-6=7 Building Conn
Fax: 508►90-6Z30
For office use only
Permit no.
Date << 0 q7 AFMAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization.
conversion, improvement, removal, dem I Least one buton, or not�moreon f an than fourn to dwelIi�ng units pre-existing to
owner occupied building containing at
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements
Type of Work: C'S�hNC Est. Cost �6oco-
Address of Work: nj 5(��DoL
Owner's Name
Date of Permit Application:
I hereby certify that:
Registration is not required for the fotIowiag re:sson(s):
Work excluded by law
_Job under S1,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEM OWN PERMIT OR DEALING WITH UNREGISTERED
.CONTRACTORS FOR APPLIG Pg Go RAM OR GUARANTY FUND UNDER MGL HOME MOROVEMENT WORK Do a. I4Z.� �
ACCESS TO THE ARBITRATION
SIG,IED UNDER PENALTIES OF PERJMY
I hereby apply fora permit as the ng nt of the owner.
l �� �-7
Contractor N e Registrad No.
Dare
T/1L• Ca1111 umil-culth UY-AtassachusellY
Depur111rC111 of lud11S1r1al.Accidents
J .3 �, ;'�( - � Oflfc�a/layestlgatlans
jjji. ' hfit] Mushi»"turn Street
Work ' Compensation insurance AMd. it
-
ic nr infnrntattnn Plc•tse f RINT Iedii_tiv�'�!
�CONOKI Cent=
/�� 92s•g5es �)
city• W TU!T•� ��1�-- �Z�0 �J�7 nt,ttnc� 53q• q 50o CoJ
I am a homeowner performing all work myself.
I am a sole proprietor and have no one Nvorkin= in anv capacity
am an empiover proviaing Nvorkcrs' compensation for my employees working on this job.
emmwrm• nnmt•-
nftonc�•
in-�nr-•nrr rn �o�ier>Y
.:m a sole propriemr. mencral contractor. 0 homeowner circic anc� and have hired the contractors listed be:ow
the .•Oilowin—^ worKM) COmDUSat.On police_:
cnmr:71`11 narnr
-7tirlrr—
ctt• nhnne a•
incur-1irr rn nniicr _ —
cnn.....'IN -lithe
lticlrrcc•
rill• � _ nitnnc r3�
Holley
inKnrncc rn _
AMCh Uiditianli sheet if R EM3.1 r1• --^•.'�•_•-•-•�' .�aa.r .�•• •u•��e+r••••Ir. 'I..._ -.. ....�-.�M�..�.�.Y• -••.�••_-si�a�e•- :--..r�a...t.
Fa,iurc to�ecurc cup crat:c as regwred tin cr�ectton `A of NIGL 1S:can lead to the imposition of criminal penalties of a tine up to S1z00.U0 anurt::
unc cars imprt son inent :t.% weil as Civil penalties in the form of a STOP WORK ORDER and a fine ufSl00.00 a dad•against rue. I understand t1_t
copy �f thi.� .taicmcnt may De furs ardcti to the Once of Ihycstic:tions of the INA for coverage verification.
l do hercOt' CL'n�tt'urrncr r/rc Frurrs a •Fella•ics perjure•thar the irr(ormariort provided above is true mid carters.
�icr�twe Oatc
P:,:,::::�•ac v����' (.�J/G/�/•��� Phone>r % Z� /S��
t
.),jciai se univ du not write in this rrca to be compicted by city or town oinciai '
t Cits• or this n• permitilicense i# ritluiidin_Dcparitnent
K C:uccnsinc Huard
t..
— ;Heel: if imtnt diatc rrsvunse is required [ISeieetmen's UfGcc '-
�- _ Cltleaith Department
phone ti• r'Uthcr�—
-onra;: ncrvrrn:
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' conip6isation for thci
employees. As quoted from the "law". an empinree is defined as every person in the service of anotherunder any
contract of hire, express or implied. oral or written.
An enrplurer is dcfned as an individual. partnership, association. corporation or other legal entity, or any two or more
the foregoing, enuaged in a joint enterprise, and including the lei-al 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
d\k-ellin�,, house of another who employs persons to do maintenance , construction or repair work on such dwelling_ hog
or rni the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer
MGL chajpter 152 section 25 also states that even- state or local licensing agency shall withhold the issuance or
renewal ofa license or permit to operate a business or to construct buildings in the commonwealth for an•
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 h.
been presented to the contracting authority.
...-...�-...�.............r-. ...._�..-.-.w-.w-�... .�T.. ���.. �w.NP►^7
•�rMMr�',+-+11'A1�n'.!^.'.w-.-...•...._.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supilying 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 require-
to obtain a v,,orkers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sire 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 tite applicant. Plea
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned t`
the Department by mail or FAX unless other arrangements have been made.
.Tile Office of Investi=atioils would like to thank you in advance for you cooperation and should you have any question
please do not liesitate to Live us a call.
r....y,.r..-+r.-... ....-..�.-v:-.... ..-..•+..4'.-r..•...�.�•.-..vr>.�T•...-.,�-.T-rTA.+--,-'+�arw.+.wN�+•,7T�++�e�w�•w.wr......�w.•.w..r'+TMVL'J►_T"'T'.• ".�
.. _ ., 77
...
The 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
phone #: (617) 727-4900 ext. 406, 409 ror 375