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HomeMy WebLinkAbout0193 SCHOOL STREET 93 sc:2o01 l own of Barnstable Perrrut ' Expires 6 months from issue date ERM� Regulatory Services Fee X.PFtE Thomas F.Geller,Director 4 t7 JUL 1 INS Thomas Division Tom Perry,CBO, Building Commissioner �� w 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 Property Address J SC/) aC- Residential Value of Work b®<DO Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address i1 EJbR1__1+ Contractor's Name r�_� c Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) J�;Jorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 7951X 6 1 1 Copy.of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *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. Improve ent Contractors License is required. SIGNATURE: . Q:Forms:expmtrg Revise071405 TrTaero Construction Roofing & Siding Specialists P.O. Box 1845, Cotuit, MA 02635 Phone: 1-508-428-2292 8y Fax 1-508-42870123 RE-ROOFING PROPOSAL. 647 June 21, 2006 L ye Mr. & Mrs. Robert C ( r y' o, 0 193 School Street Cotuit, MA 02635 Phone: (508) 420-3920 FRASER CONSTRUCTION herby proposes to perform the following services in a neat and professional like manner and in accordance with the manufacturer's specifications and local building code. -Remove and Haul away,all of the old Asphalt Shingles -Re-nail all plywood sheathing as needed. Supply and Install - CERTAINTEED XT AR-25: 25-Year Warranty, 5 year Sure Start Protection, CLASS A FIRE RATED,ALGAE Resistant, Extra Heavy Weight, Self- Sealing, Multi-Layered 3-Tab, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with a Full 10 Year Warranty against ALGAE Containment. Color: Supply and Install - CERTAINTEED XT AR-30: 30-Year Warranty, 5 year Sure Start Protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self- Sealing, Multi-Layered 3-Tab, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with a Full 10 Year Warranty against ALGAE Containment. Color: Supply and Install - CERTAINTEED LANDMARK: 30 -Year Warranty, 5 year Sure Start Protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self Sealing, Multi- Layered, Architectural Style, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with a Full 10 Year Warranty against ALGAE Containment. Color: Fraser Construction Roofing & Siding Specialists Supply and Install - CERTAINTEED LANDMARK PREIUM: Lifetime Year Warranty, 10 year sure start protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self Sealing, Multi-Layered, Laminated Architectural Style, Fiberglass Based Asphalt Shingle with-New England's Exclusive COPPER/CERAMIC Stones with a Full 10-year Warranty against ALGAE Containment. Color: Supply and Install - CERTAINTEED LANDMARK ULTIMATE: Lifetime Warranty, 10 year sure start protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self Sealing, Multi-Layered, Laminated Architectural Style, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with a Full 15-year Warranty against ALGAE Containment. Color: Supply and Install— CERTAINTEED WINTER—GUARD: (ice &water shield) Waterproof Underlayment System (3ft. on eves and valleys, 18" on rakes, walls and skylights) Supply & Install - Roofer's Select Underlayment Paper (recommended by CeiTainteed) Supply & Install - Hick's Ventilated Drip Edge. Supply & Install- Aluminum & Neoprene Soil Pipe Flashing Supply 8s Install-AIR Vent Ridge Vent. (recommended by CerTainteed) Clean $s Remove - Debris from work area daily. TOTAL INVESTMENT: XT AR 25 - $69,435.00 XT AR 30 - $6,575.00 LANDMARK - 6 645.00 LANDMARK PREMIUM - $7,345.00 LANDMARK ULTIMATE - $8,045.00 RUBBER - /�C.1GLC�/>�1� `J l?T4 *4 Star Warranty Applied if proposal is signed and returned within 10 days of receipt (see enclosed brochure) Payable immediately upon completion NO MONEY DOWN - NO Payment at the start or part way thru Payments accepted are: CASH - CHECK - MASTERCARD - VISA- AMERICAN EXPRESS e Fraser Construction Roofing & Siding Specialists Possible Extra-After the shingles are removed from the roof, we will lift one sheet of plywood to.make sure that the insulation be not up against the plywood sheathing, preventing ventilation from the eaves to the ridge. If it is, ventilation panels will be installed by; removing the plywood sheathing, installing the panels, turning the plywood over and then re-installing the plywood. If needed, this would be charged for as an extra at the rate of$4.00 per panel including Materials & Labor. There are 6 panels per sheet of plywood. Possible Extra-Any rotted or otherwise deteriorated trim boards, plywood sheathing, lead flashing, or other carpentry needing replacement will be done and charged for as an extra at the rate of$45.00 per hour, plus materials, plus 20%overhead mark-up on total extras. FRASER CONSTRUCTION Warranties the labor for 10 years FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years. CERTAINTEED Warranties the shingles and labor 100%for the first 10 years, and then on a pro rated basis for the Lifetime if the shingles become defective. CERTAINTEED Warranties the shingles to be ALGAE resistant for a full 10 years. Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our controL Owner should carry fire, tornado and other necessary insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION:Carries Workman's Compensation and Public Liability Insurance on the above work. DATE OF ACCEPTANCE: 12-6 2- 00 SUBMITTED BY: Homeowner r� ras Lction e commonweazitz of massachusetts Department of Industrial Accidents Office of Investigations `(_ a 600 Washington Street a Boston, MA 02111 " www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Il�..c.�.�.•�n �Rn,�J� Address: 06x City/State/Zip: - Phone#: Are you an employer? Check the appropriate box: 'Type of project(required): 1,ET4 am a employer with��- 4. ❑ I am a general contractor and I 6 employees(full and/or part-time). have hired the sub-contractors ❑ New construction 2.El am a sole proprietor or partner- listed on the attached sheet $ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me 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 doiWa all wnrlc right of exemption per MGL l l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'cornp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and,pob site information. Insurance Company Name: Policy#or Self-ins'.Lic. #: Expiration Date: Job Site Address: d City/State/Zip: 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 ha_y under e p n malt'' s of perjury that the information provided above is a and correct. Si a Date: o4 Phone#: 1� �- 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 Inspeesor 6. Other !� Contact Person: Phone#: i 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-contractors)name(s),address(es) and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(L—T Q or L imited 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 I (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 lie to thank yc.0 in advance for your cooperation and should you have any questions, please do not hesitate to give w 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-o77-M-A_SSAFE Fax ,— 617-727-7749 Revised 5-2645 i w-ww.mass.gov/cia 7 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMfWOVEMENT CONTRACTOR befoi i the expiration date. If found return to: <� `� Bea► 'of Building Regulations and Standards Reg istrafi'6M: 112536 One Ashburton Place Rm 1301 .Ek0►ratP n—�/23/2007 Boston,Ma.02108 p FRASER CONSTI � co DEAN FRASER F 71 TARRAGON CIR COTUIT,MA 02635 Administrator Not valid without signature I ACORIZ CERTIFICATE OF LIABILITY INSURANCE o9%Z2/20 5) PRODUCER (508)588-1260 FAX (508)588-7236 THIS CEF 1FICATE IS ISSUED AS A MATTER OF INFORMATION Wise ,& Qu rm Insurance Agency Inc. ONLY AN'`CONFERS NO RIGHTS UPON THE CERTIFICATE 449 Pleasant St. �. HOLDPR, '1IS CERTIFICATE DOES NOT AMEND,EXTEND OR 1 ALTER TFIE COVERAGE AFFORDED BY THE POLICIES BELOW. Brockton, MA 02301 CISR, Paul Crowley INSURERS AFFORDING COVERAGE NAIC# INSURED Dean Fraser 1 iNSURERA: Hartford Insurance Company DBA: Fraser Construction Co. . �INSUR-RB: 71 Tarragon Circle )INSURER C:� Cotuit, MA 0263E-2443 INSURER 0. )NSURE'R E: T COVE A E THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO T HE INSURED NAMED APOV_FOR THE POLICY PERIOD INDICA T ED,NOTWITHSTANDIN( ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT ESF'ECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN iS S J IJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS 5HOVdN MAY HAVE BEEN REDUCED BY PAID CLAINIS. INSR A001INSRE TYPE Of INSURANCE POLICY NUMBER PCLIr i EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL L"11.ir1 { DAMAGE TO RENTED S tram.) CLAIMS MADE OCCJA MED EXP(Any one person) 5 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGG S POLICY PRO- ECT LOC J AUTOMOBILE LIABILITY COMBINED SINGLE UfArr $ ANY AUTO (Ea accident) ALL OWNED AUTOS ) BODILY INJURY SCHEDULED AUTOS f (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ I (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ a EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 1I CLAIMS MADE AGGREGATE g S DEDUCTIBLE ( $ RETENTION 5 I $ WORKERS COMPENSATIONAND 6S60UB-794X619-1-05 09/26/2005 09/26/2006 X WCSTATU• OTH- EMPLOYERS'LIABILITY A ANY PROPRIETOMPARTNERIEXECUTIVE E.L.EACH ACCIDENT_ S BOO,00O OFFICEWMEMBER EXCLUDEDT E.L.DISEASE-EA EMPLOYEE S 500,000 It SPECIAL PROVISIONS elow /describe under E.L.DISEASE-POLICY UMTr •S S00.000 OTHER f DESCRIPTION OF OPERATIONS I LOCATIONS I VEN'CLES I€XCLUSI yNS ADDED BY ENDORSEMENT I SPECIAL PRO'>ISIONS J n the operations usual to carpentry. a CERTIFICATE R CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TP.EREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 m s WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Fraser Construction Co. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 71 Tarragon Circle OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Cotuit, MA 02635 AUTHORIZED . Nf vE I f ACORD 25(2004108) FAX: (508)428-0123 ©ACORD CORPORATION 1988 of Town of Barnstable *Permit# 3 s�9 �.e XVtr 6 months from Issue date MAM Regulatory Services Fee , : 6,C) ,0� Thomas F.Gallen Director Building Division Tom Perry, Building Commissioner a �� . jF 200 Main Street, Hyannis,MA 02601 Office: 508462-4038 APR, i 2QQ5• Fax: 508-790-6230 EXPRESS PERMIT APPLICATION 4- RESIDENTIAL OWR BARNSTABL Not Valid without Red X-Press Imprint. ap/parcel Number pc2 00 q / operty Address l 1 (Residential. Value of Work 9 l0 00t Da Minimum fee of•$25.00 for work under$6000.00 wner's Name&Address rl o 13P A+ CL P�A) e Ile de-1 a J� Dntractor's Namp_—P )7� - Telephone Number_ ome Improvement Contractor License#(if applicable) onstruction Supervisor's License#(if applicable) ]Workman's Compensation Insurance Check one: _ Oil I am a sole proprietor ®:I am the Homeowner ❑ I have Worker's Compensation Insurance surance Company Name • _ _ _. __. 'orkman's Comp.Policy# opy of Insurance Compliance Certificate must be on file. :rmit Request(check box) ❑ Re-roof(stripping,old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over, existing layers of roof) ❑ Re-side Replacement Windows. U-Value (maxi mm.44) *Where required: Issuance of this permit does not exempt eonquance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improveme nt Contractors License is required. Form mquntrg :visc063004 --- The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnuesdoodens _ 600 Washington Street, e Floor Boston;Mass. 02111 Workers' Compensation Insurance Affidavit: Buildin /Plumbin /Electrical Contractors e name: a e}� 2-42 &P, address: 9 -PAI " " p why CA�M,i� -, state: z zip• O01 b.35 phone# i�✓12 o �2- 03 �� work site location full address): ��t3Z� 1' ~�� ✓ �Z 6 I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel I'am a sole ro rietor and have no one Working in any capacity. Buildina Addition ❑ I am an employer providin workers'compensation for my,employees working on this job. ;;t: ;:y R: .t6 o-.'r•,j, y.a o'x y. .,4 a- r 9L' .o--fi f. ^f �;. .. ,> i 1-i •'y.F•v ;:k ri, ''•.3•''p'. 5'r'n"`.ti�.-�'#? e}�`! +L'i.ti:•, 'ro!x:�• '� t C�� an �ameV� -LY'J"' >XP"•hx"� C-�t.<'iK[ ,�.>wY,��'t 1 Y .�P :t'i�J. �. '� - ..,;�syy34}'a:J -� Z vy>4,�1 z�!'4''a�T,�•�i�., d:>��4i .��'� to-=,J d c•• ��'c<.�• r7 w«,. Ott t._ 4 ! J y y � o { } ' 1 i +a+ r yy...r .5 � ,�p: .(..!t?t�, �-hk'a. a�.'✓t 'r� N,pP �„ ''`tkt : 3 d t N y.s, <c r�: r �(�{t.r�� 51a��.xCr�.'�"S'itF� i� ������j y,,� ,�d+'G'�-'#F•tE��,1��. `F't3 �iC>� 'fir F 4•"+r+ � ''Cl r i c-s�`c>• f.yt t`Zs• �� �l'� ,5�,!>^Y"'sM'' }y �,a it3+t,. �a� 'i.,4 7lCa L a.a+• 'f •. a a i y �. t' ,Fg :t N3. n .:'fi.�r.Y){ r.:y M y K < ,t .�s ..r�»:J�S'"�'ati?`+ -k ti 6 '$rf�y r , r� 4SF. i:F tiv kn 3 f y :St s� yY fit?, t ,Vd It 4. 9y� C;r; ! J �r x c3au£ '. 1� �ag«tea 'ys ka f� s •h^'y 0"i,r.54 � �f Mist►raliee:ob F , w. tthla�s ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have 1 ti ohces:rkers core ensa on the follow2n wo p _ _ _ ... ......r,:'^,Af•.- r....-ta.....,:..r,. ,-.;. .:r-�.,.�.. _+:.. V.�.H:..W-.••a�..} •L.la^r ,'Y>Y :!i�S:.: ::i;;' 7- K- y . . r-•:a.''8t3' ttAIDE.t ii:ii.J „v:C_3 T.A.j „..-;;;:.,,set*; ;�i4x'x ;�a + ' 41 .:rJf... .�: q,.: ".+at .V.:..6:! :.. c•":1.�.,..c1C. 4 j: td'$�dreSS:,:.;,.�r.. -M.,.�4 3r:^'']: `brys;::".•: .+>°a.. t +- t ,4. •r.� ,r-Rr'y, d,?�. wt: , 1 < •Vlt�,fi i i- J y i• d' %f✓' r i I map,WORM { •: t c i� f!�. �,tr .; x.r,��'•,•:#;a M. o ,o.: �r.'��..+.�� 0� .1ff'�"..Y }X f� .'.•. t o: ...:: r :...�:�..o....e`4.,..m: .,..}'S..r,.2-,,..r..,.,a... ._..r�,r. .;. ., a .LIStE[8'n'e�,�AF � •y , Y 1 r, iiwTut try!.r g a•r`:ii a' Y3 is%:tN _.t.. t. 1- w: f '.yV. ..F; 'ad'aftsS':'.a` >'Ri �5j�" ,.)'vi .:� 1•T i ,fir >t � phoney#. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and.correct. Signature �p RI Date Print naive T)0 be ke N/e � Phone# } Fcheck nly do not write in this area to be completed by city or town official : permit/license# ❑Building Department' . - []Licensing Board immediate response is required ❑Selectmen's Office ❑Health Department on: phone#; ❑Other 03) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their �° person in the service of another under an "law",an employee ee is defined as eve Y employees. As quoted from the 1 p y every P q 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 r: 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. o f its political subdivisions shall enter into any contract for the neither the commonwealth nor an o Additionally, Y 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. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance.coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed 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. i mom IN City or Towns . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit%cense 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. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents - Office of Investigations 600 Washington Street,71h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone.#: (617)727-4900 ext.406 C•A ^ r/ d NE l Town of Barnstab BARN� FI Regulatory Services saxxsreac Thomas F.Geiler,Directo� 5 4PR 26 M" 0396 �' Building Division 8: $3 �0 Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 PERNHT#_ g 5'?O FEE: $ l✓' SHED REGISTRATION 120 square feet or less ,2 C D A 12 )-1a L t /V ie - bZ 1� . R S T o d.S m � �( 5 Location of shed(address) Village —FfieMAS J . 3uArRocvs a ;F- Cj2 ?- alb 6- Property owner's name Telephone number ® 76 Size of Shed Map/Parcel# 7ri 2c1 a, GI— 7 — o Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) Z PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN . Q-forms-shedreg REV:121901 Package Details Page 2 of 2 hoose a different car vendor r / 0)to i Details i \ am _ CO Cm 0 4-9Q � t� � o \ A i �9 \ Pt' o x VON. a� � OrQ o n Af 4p. o OD0. ., .� • Cq : v o ) Ip 3 i sue_ ` A. 4?� N 40 y "j oao IL cV 10 If I �" , •�- �r� fps Q i / � /ft , A 40 c' a p aZ"8 f // i0 _l CD If' ;' ryyh Gg� o G bi %� ci, \IN ! / li Town of Barnstable 1,4 ,Vj"E'°'�ti° Regulatory Services, � . Thomas F.Geiler,Director L sARMNSTnBLE MASS. Building Division 1639 ♦� . Tom Perry,Building Comnussionehr7i71 - 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 �0104 lap- PERMIT# rl Ss�rl FEE: $ SHED REGISTRATION" 120 square feet or less e Location of shed(address) Village Property owner's name Telephone number 09 1,7 Size of Shed Map/Parcel#, Signature -Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? . - Conservation Commission(signature required).w' PLEASE NOTE:,IF YOUARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS;THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. .. -' :r a .t i $ - THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN : f Q-forms-shedreg REV:121901 g m A Y `' 37. 0 I93 �O 5.5' e LOT-19 .BLOT`15 1�ipof-LOT']7' SHED • i �S x r r , ' -OQ 33 r a x t t �1S/LOT 93—2 5 ' 4 € _ . ZON RES. E.' 'RF" �`. This; Plan is For; MQRTG'AGE: INSPECTION -FLOOD' ZONE TOWN: _ _— REGISTRY OWNER:'_CHERYL_y WILLIAMS_ $w DEED REF: _6744,/300— — --BUYER: : 90HE1zT NY_p IF w— — A DATE::'—9,1-17197----=--- -- —i— PLAN REF: _15_S_7_' r► - -SCALE I„ 40 ,AFT I HEREBY CERTIFY kT0 ®N_0ffL _CQQPERVITIVE_BA1VIf ���ti _THAT THE BUILDING''. ` ti YANKEESURVEY s_ SHOWN ON THIS PLAN-,IS'LOCATED ON "THE GROUND AS . 4 �'. A •-"CONSU: ANXS :SHOWN AND THAT. ITS POSITION DOES, '_k_ CONFORM � MFRITHCW . N t.' TO' THE .ZONING LAW'SETBACK_ REQUIREMENTS OF THE , 4M,`, SUITE 1 No. 32098 �� j ,TOWN,OF "_13 1?NSTABLE___ _`_._____=_AND THAT $' 'I'fGIStEa� " : INDUSTRY.ROAD }" IT DOES_ NOT LIE WITHIN THE SPECIAL FLOOD HAZAR15 MARSTONS ;M1LL5,�MA. 02648 D VAI'1A1� f4 rt :AREA AS SHOWN ON THE H.U.D. MAP_ llA'I ED_ 02 92 _.r ' TEL 428 0055', t a~' + gC0 u Panel a250001 0021 D _ FAX 420-5553 a . THIS PLAN NOT MADE FROM AN INSTRUMENT ''.P L A. ME 1TlIEW PLS ------- SURVEY, NOT TO BE USED FOR FENCES "ETC. _. µ 21570 DC E