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Home My WebLink About0171 TROUT BROOK ROAD Xssesso's map and lot 'number ...... .................... . 1 Pd �► 1.. � T . Coll P ��i 11 Sewage Permit number .... ............................................. . .... � yoFT"ET°�� TOWN OF BARNSTABLE S i BARNSTABLE, i 1639. ON BU:>ILDING INSPECTOR � ar a' , APPLICATION FOR PERMIT TO ......Construct New Dwelling............................... . TYPEOF CONSTRUCTION ..................................................................................................................................... ........`??Y...5.............................19.75... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Lflt 28 T utbrook Road - �� r,Tr ��Ja Cot=t..-..B'ax stab]............................................. Location ............................ ........................................................ ProposedUse ...........Dwellinq............................................................................................................................................... RD-.2 ....................................Fire District ...COtAf;................................................... Zoning District .................................... .......... Name of Owner SEA—LAKE C1URP. „ Address P.:Qr... X.2�14 -..S1GW�C�1s..Nk�tSS.................. BQ ............................... Name of Builder .SEA.-I'� COS......................................Address Name of Architect ---a---- ....Address 77% .................................................................. .................................................................................... Number of Rooms ..................................................................Foundation 10.7..W.alls7P.Oured..Cmcrete-2':n4"..PAur Exterior ?i ..Cedar Clear..$.ha c��,(�5.. Roofing 235 Self-Sealing Asphalt..,Shl g��$.......... Floors Kit-Bath-Vinyl sheet/all Sher hardwoodlnterior .....z��...sheetrOcJc ........ ....................................................... Heating ............................................................C�.�...................Plumbing ..... ? X..&.XadS iG.................................. ..... Fireplace ........Yes...................................................................Approximate Cost .....��.20j000..00 �.. Definitive Plan Approved by Planning Board _____1115-----------------19 73____. Area .. 21 �..... .,...:. Diagram of Lot and Building with Dimensions Fee ....... 23.00........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . `" Sea-Lake Corp. N6-- . 1770 , ......... ..... Permit for ...,.,one, story......., gingl.p'—f aldly...dy'PlUng..................... Location Tro.utbr.o.QkAoad..................... ........................X1111W.....Qatuit........................... Owner ............SeanLake-Comp........................ Type of Construction ........frame....................... ................................................................................ #28 Plot ............................ Lot ................................ Mao 21 75 Permit Granted .......... ...........19 Z(Date of Inspection .............(t if 9 Date Completed ........19 PERMIT REFUSED ................................................................ 19 ................................................................................. . ............................................................................... ............................................................................... Approved .................................................. 19 ............................................................................... A 1L c: Yr U 57 i X Z U1 �'+ •- \tl f ' { t I , �o t J l Wit, - ' - ;l, PLOT PLAN OF LAND CERTIFY THAT THE BUILDING SHOWN HEREON IS ACTUALLY LOCATED ON THE FYI y� it b h t- ice— GROUND AND MEETS ALL 1 f�J \~r .� ,p. i � ��'` '"� i SCALE:- = � DATE: N1A1� Q ZONING REQUIREMENTS. f f EWALD & MASCHI INC. ��r;_it.t �'" ;.! ' • ' ENGINEERING CONSULTANTS DATE: . STZC> J� -�- FRAMINGHAM, MASS. C. P. P. .t. Town of Barnstable *Permit# 00 �OFZHE Tp Expir month r0741' date r Regulatory Services Fe PERMIT w BARNSTABLE, * Z00Q Thomas F. Geiler,Director AlF01A & Building Division TOW F BARNSTABLE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Fax: 508-790-6230 Office: 508-862-4038 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number...._:____-- ( s luf i✓?i Property Address ___./ 9 / TIQ6"701466 j/ Residential Value of Work t 1R60~ Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address ],�w►��s s / t�, �L. /�o<<_�� / (Y,() Ivi cl�I'Y1C� 5t 7-5 �'r �� !mac 7t C� !"1�c« �i ?, f Telephone Number �l�p c/9 0 Contractor's Name_ 176R W 1 lome Improvement Contractor License#(if applicable) 7G l (0 Construction Supervisor's License# (if applicable) eS lees ❑Workman's Compensation Insurance Check one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name N -- Workman's Comp. Policy # A,// Copy of Insurance Compliance Certificate must be on tile. t'ermit 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) Ke-side ❑ Replacement Windows/doors/sliders. 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. A copy of the Home Improvement Contractors License is required. SIGNATURE: G' slc.tin r V I'I-ii.I.S\P()RMS\building permit for is\EXPRESS.doc Revised 100608 Tian 'paNi � Board �o�""riw�uu Of Building Regu naaaa� HOME IMP and Standards ROVEMENTCO to Registration;•;, NTRgCTpR 101980 I,. EXP�rat�on_ 6/30/2010 w i t l r,.i Tr# 267616 BARRY W. GAL LIJ r, �Ty ". Individual Barry Gallus 170 Trout Brook Gotuit, MA 0263 ` Administrator 7-1 or Oceftse Sjpev amnstc�ctjo� S �6305 Co LIcevse, GpnIA9A5 5291 Ni e . t S �� inner ,� GP`�Vv nnmss � � — ARR�W OpK FtD C �` y GOTRZ.MP02635 4*'R r r valid for individul use only License or registration `" ' before the expiration date. If found return ds t Board of Building Regulations and Standards One Ashburton Place Rm 1301 x Boston,Ma.02108 nature IE; Not v id without signature _ mo e �- `idgns : Sit tiuotion 16305 s S C 1 _ cot, � en e. 9 4 t. S 10f1119�5 'Ct# 52 1 •� B,�haate 10n12p09 o <•..� , A l�gstn tea GP`lvKR� f Conmss E Ala-TV,H F 02635 ". y-_ THE ro Town of Barnstable Regulatory Services BAIF iA"Ms9 $ Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508'-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder V as Owner of the subject property hereby authorize l3 A/R / 6V . 6 Af L v s to act on my behalf, in all matters relative to work authorized by this building permit application for. 17/ Cev u) f Ma 62ro3S .(Address of rob) g®Lcl-a CI G.c � r L � 2- Signature of Owner nate Print Name If Propedy Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. O:FO RMS:O WNERPERMISSION THE r�y� Town. of Barnstable Regulatory Services R•RNCr'I Rr� Thomas F. Geiler1 Director � Building Division PrED Tom Perry,Building Commissioner .200 Main-Strect,—Hyannis,MA 02fifl 1 - _.._. . . _._..._.... . www.town.barnstable-ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: ciWtown state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellints 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. DEFBiMON OF HOMEOWN'ER 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 responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assizes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned-"homeownee'certifies that.he/she understands the Tpwn of Barnstable,Building Deperrtment minimum inspection procedures and requirements and that he/she will comply with said procedures and .requirements. Signahim 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 bomeowocr perfonnmg work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -liccnsmg of construction Supervisors);provided that if the homeowner engages a peson(s)for hire to do such work,that such Homeowner sball ad as supervisor." Many homeowners who use this exemption am unaware that they are assuring the responsibilities of a supervisor(see Appendix Q. Rules&Regulations foi Licensing Construction Supervisor:,Section 2.15) This lack of awareness often results in serious problerns,particularly when the homeowner huts unlicensed persons In this case,our Board cannot proceed against the unlicer;scd personas 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 hdshe understands the rnponsrbilities of a Supervisor. On the last page of this issue is a farm currently used by several towns. You may care t amend and adopt such a forrn/eertifieation for use in your community. Q:f6rTm:homccxcmpt �\ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations- ' 600 Washington Street Boston,MA 02111 a www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information . ' Please Print Le 'bl Name(Business/Organization/Individual): ,4 4 /wlit•u, Address: t10 12,,0116 Jeb ° Z Phone.#: S 2 City/State/Zip: � � `rLJ t U 0 y(!l�//¢- � t'o.�S� 0 C,--,� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am 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 ..2:4I am'a sole proprietor or partner-' listed on the attached sheet 7. .❑Remodeling ship and have no employees These sub-contractors have g.'❑Demolition workingfor me in an capacity. employees and have workers' y p tY• $ 9. ❑Building addition [No workers'.-comp.-insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 1.52,§1(4),and we have no employees. [No workers' 13. ,Other S< 11U 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 subnrit a new affidavit indicating such. ?Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have amployecs,they must provide their workers'comp.policy number. I am an employer that is providing workers compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: /V — Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure fo secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of erimirial 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify/der /. the and alties of perjury that the information provided above is true and correct. Si tore: � pains Date: Phone#• ✓F0 Official use only. Do not write in this.area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees. Pursuant to this statute,an employee is defined as":..every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoingg-engag in a join -eiiEipnse,--and inel0mg the legal represeniattie3-Uf"ec-ease$-employery.ar-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 inSUra_T1,ce 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-contiactor(s)name(s),address(es)andphone 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the appiicaiit 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 maybe provided to the applicant as proof that a valid affidavit is on,file for future perufits 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 bum 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 TO. #617-727-4900 ext-406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 1 i-22-06 www.mass.gov/dia V/�&k�7 Assessor's map and lot number of. 0�6 Sewage Permit number ......... ............ ......................... THE TOWN OF BARNSTABLE BAR—N-STAII-LE, 1639- MAAIL ley MAY Ar. BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ............................................................................................................................. TYPEOF CONSTRUCTION ..................................................................................................................................... ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....................................................................................................................................................................................... ProposedUse ................................................................................................................................................................................... ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner ...................... ...............................................Address .......................................... .....2�-, �, -�,L,,? ... ..... .............................. Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exterior ....................................................................................Roofing .................................................................................... Floors ......................................................................................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board -----------------------------19-------- - Area ..................................... Diagram of Lot and Building with Dimensions Fee ........................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH plea P,05 r,- csq I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .................................................................................. Davis, Mr. & Mrs. Joseph A=22-83 18729 one story, No ................. Permit for ............................. single family dwelling ............................................................................... Location T.r.ou.t.b.rook..one......... .. . .... . . ........ ......... .............. Cotuit ............................................................................... Owner ...........Mr....&...Mrs..................................Joseph D a vis............ ......... Type of Construction .......... frame ................................ . ........................................ ...... 000" Plot ............................ Lot 10.. Octo r 12 76 Permit Granted ........... 0. ..................19 Date of Inspection ............ ......................19 Date Completed ........ ............................19 PERMIT REFUSED ........................... .................................. 19 ......................................... .................................... e................................. .......................................... .................................... ..................................... ......................................... Approved .................. .........--'A............... 19 • . ............... .............. ............... ............ ............ .......................... r Engineering Dept. (3rd floor) Map ParcelOIL Permit# House# Z Date Issued - Fee 07l' Planning Dept.(1st floor/School Admin. Bldg.) �� THE e i 'f e Plan Approved by Planning Board 19 ` MASS 161q. TOWN OF I Building Permit Applicatio Project Street Address ( '�' l f l� !, Y Village C,0-a) 1 7- .4. Owner -rO 0 C Address CO b Telephone (P f`7 (0 q - 0 0'� / .e-�� S >3,) Permit Request 9- G First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ /02 Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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 New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name /�.�-'� Telephone Number c3 (/� ' y- Address 5 et�t � /Zt�. License# lO �o `/ Home Improvement Contractor# r 4�9&: Worker's Compen �n 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 FO LOWING REASON(S) 1 r n z FOR OFFICIAL USE ONLY 1 fti PERMIT 46. DATE ISSUED MAP/:PARCEL NO. e ADDRESS L VILLAGE , OWNER {, ' DATE;OF INSPECTION: s FOUNDATION FRAME INSULATION s s FIREPLACE y d ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL " GAS: ROUGH FINAL { FINAL BUILDING s DATE CLOSED OUT s ASSOCIATION PLAN NO. s CF THE Tp� yo The Town of Barnstable 9�. HAS& �•� Department of Health Safety and Environmental Services ATE16,19.�is Building Division _ 367 Main Street,Hyan is-1V1"A 02601 _ Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 U 0 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW i 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: a �` AZ2D Est. Cost Address of Work: Owner's Name T Z? GC 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 for a permit as the agent of the owner: ) Date Contractor Name Registration No. OR Date Owner's Name The Common"fealth of!Ifassachusals Department ojludustrial.4ccidents Office o1/J7vestigat/ons �~ 6O0 11'a0inrton Street �^ Boston, Alas. 02111 Workers' Compensation Insurance Affidavit �p�nitcant Information - d :,� m • .on: / ( F)C v L) 7 6 ,e 00 15- 410 . city 'U l tT I am a homeowner performing all work myself. 011 am a sole proprietor and have no one working; in any capacity -_rl.:. ��e.�...r....s y.,.�y�.y-.T;�wr,r�,� :s�•�'Td`•tfFF?�r�A"w�www�!"�='Y'��+f�.•YIt'_r_,'rw....._J�.��.a..__�.._._.._.� I am an employer providing workers compensation for my employees working on this job. om att narn •tddres cit% phone#• insurance co nolicv# TT 777— am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers compensation polices: cornliany name- address: cn phone#- insurance co _- ... .. ._ _... .. .... ,�..,.;;�. _ ,.,..ram-- .-•T•:�••, _ ___ .��-�-�•-�` _ - - ..._��:.�d .y�� com anv name: address: city phone#• insurance oiic # .Attach additional sheet if neces_sary..• � _.�' �1 i 1r` '�` �` = ,=��d�' f a ram` •r -�.5" ` —Ytrtr'sC�r"r." .z:w Failure to secure coverage as required under Section 25A of n1GL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one years'imprisonment as.yell as civil penalties in the form 0172 STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the Office of investigations of the DIA for coverage verification. l do herebe certify under the pains and penalties of perjury that the information provided above is true and correct. Si 7 _=nature Date Print name 6 I_q/VJ /lt,L' Phone# official use unly do not write in this area to be completed by city or town official city or town: permit/license# riBuilding Department Licensing Board check if immediate response is required [3Scicctmcn's Office C3I1calth Department contact person: phone#• nUthcr ire used 3M5 P1A) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law". an empinree 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 o 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 `rounds 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 rene"'al of a license or permit to operate a business or to construct buiidin's in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionaliv. 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 ha been presented to the contracting authority. -,::7. ------------------- Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation police, please call the Department at the number listed below. 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. Pleas be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned tc the Department by mail or FAX unless other arrangements have been made. Tile 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. .,w,..n,v„:,.,gn.�..,^.....�w..-.. .�..-+►s.v.-.wv-.arwrvgT.. The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents T Office of investigations F 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 --�-' r t ..� ►., .,� '�' r� x .r_r; L Yj�fix ,• �{�• "` F � � " �i a�aommeosw.ieal�e o�.�oaacdu.,�la HOME IMPROVEMENT CONTRACTOR Registration 116064 _ b` DBA Type _ ;Ezpiration 4 05/15/98 TYNDALL ROOFING ROBERT..F TYNDALL IAR PATCH RD ADMINISTRATOR" x, ASTERVIIIE MA 02655 y