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Home My WebLink About0090 VINEYARD ROAD �o y�.;�� d: i Assessor's office(1st Floor): Assessor's map and lot number 04- /51 zj �Pyoi THE>o`+ Conservation ew Board of Health(3rd floor): / O • Sewage Permit number / -f/ _ S�STUL . •o rua Engineering Department(3rd floor): ° i639. House number Definitive Plan Approved by Planning Board 19 1141`�� APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only / TOWN OF BARNSTABLE ' BUILDING INSPECTOR APPLICATION FOR PERMIT TO P(,i,Lv ci TYPE OF CONSTRUCTION 19 = TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: L Location O U ( (.-r,� tl� + Proposed Use ( \ter « C^r�. /(v, d m _ Zoning District Fire District - Name of Owner /r �u/6 u C_ OC I'A I t Address Z_5 3 A S C,'Z (C, 3 i Name of Builder /,t t� (/r t r �i �G� Address G 6 Name of Architect Address Number of Rooms Z- Foundation Exterior r t ?c r V1�Lti.t �- Roofing Floors Cr�L Lv��, _ . l,yn Interior r Heating Plumbing Fireplace /`? Approximate Cost Area 7 X� Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. t Name I I rlA11A .._ + v Construction Supervisor's License oo n y 3 ' CaCHRAN; ' MAR)BELLE' A=016-01 9 0/6 � / No 34687 Permit For REMODEL GARAGE Accessory ,to Dwelling Location 90 Vineyard Road Cotuit + Owner Marybelle Cochran t� - Type of Construction' Frame , aJ r _ t Plot Lot + " r' Permit Granted November 8 , 19 91 r Date of Inspection + ' 19 Date Completed 19 ' r r ' } i s r r ' I � F �Do /ll�a Assessor's map and lot number ... 4.........1_:4.T..........�� 0*TNEto� Q � Sewage Permit number ......................... .1�..�.. ........... /, Z BARNSTABLE, i House number ......ID........................................................... 9 MAB6 � �p 039. 00 IIPy A,� TOWN OF -BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..QC't' .... .... W ................ ........ f�. ............. TYPE OF CONSTRUCTION ....... ..... . .. .. ........ ... ..f.,� t. .. f .14=!>^ S .............'A .................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .../.4 .... ........ .. .P�.p .....'(`?.0 G..o4..............l i c. ............................................................................ Proposed`-Use .. . ... I... . . Zoning District 4 .................................................Fire District ... ... Name of Owner ` . .... C..�?..� � .li ...........Address .s .:3�....�tl�?!h...�.3y..�N .�UCl.OL..O�1 Name of Builder ................Address I, . ...P��S.4....... .' t.. ............ Name of Architect /. 'l.c�ac....� el' �..........................Address .�t�./........ �fl .! ................................. Number of Rooms ...!z b ..............................Foundation .�........... . ......................................................... Exierior .��4r-ter'�st. r... .lr �!'V..................................Roofing ...a,l..r,a..l...................................................... Floors .... .........................................................Interior ....y.L�c t�J Zr-t ........................................................ Heating ..... .................................................Plumbing .....�q. ,�................................................................ Fireplace .......'.....................................................Approximate Cost ........��. ..... ................_/ Definitive Plan Approved by Planning Board -------------------_-----------19________. Area ....�Q............................ Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I v OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I- hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. o �� Name .:.. .7 !................ ..CY' Construction Supervisor's License 02.4.27i. ........... COCHRAN, MARYBELLE A=16-19 No .... Permit for ..,,Addition/Exterior ....I................. Single Family Dwelling ............................................................................... Location ........ 90.....Vine and Road ................................................... ` Cotuit ............................................................................... Owner Marybelle Cochran .................................................................. Type of Construction ,,,.,,Frame ................................................................................ Plot ............................ Lot ................................ i + Permit Granted ...October 21,.....................................19 85 I ' Date of Inspection .....................................19 Date Completed ......................................19 Assessor's map and lot number .... ......:.. ..........1.J. SEPTIC SYSTEM MUST EE �F7ME Ta �Q o Sewage Permit number '.......::................X�.k. ........... INSTALLED IN COMPLIANC ""`' WITH TITLE 5 E-NVIRONMENTAL CODE AN t BafiB9TanLE, House number ........ . r rhea ...................................................:...... TOWN REGULATIONS ° p 039. \00 TOWN OF BARN-STABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .. (%t ...s ...... . ... 012 ........s..................�j. s..... s..., �lr�!c ........... TYPE OF CONSTRUCTION .......�Lrt�Z -Cr�...... e .C�y.Uj................,....... ........o)./).j................. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby`applies for a permit according to the following information: Location .. �... a .....K�'n .aG.............�'c. ........................................................... ProposedUse � 3�......................................... ...................................................................... ZoningDistrict ................. .. ...................................................Fire District ...(i. ....................................................... Name of Owner ...... - ..09.�-� -...........Address 2,33....G ! :. tJi..e. v.lN<C1� .t.L�l.2a . 1�7,3 Name of Builder �y/1Ld ✓.. .. .........................Address .Z(r.. ......4c�.a .. �c�. ............ Name of Architect .-1. c ...IAI ..........................Address .f ... .. � .....................ii,��. ............ Number of Rooms .�M.1...�� ''!f .�,�......... .........Foundation .Iry 1!l.S. ...................... Exterior ... /............................... Roofing ...��s� . ?.C�- ............................................................ -. '[1 Floors .... ..........................................................Interior ..., ,`17-1Z,��-z�......................................................... Heating ......�L L_ r. .................................................Plumbing ..... 4 ................................................................ Fireplace ...........YL-.............................................................Approximate. Cost ........`wy..... .......... ....... Definitive Plan Approved by Planning Board ________________________________19________ . Area ............................ Diagram of Lot and Building with Dimensions Fee 1�,e.-""................... SUBJECT TO APPROVAL OF BOARD OF HEALTH J 1 (� c kt i f c / { 33 ' OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name /.7.k .. ..��-��Y .41.( !................ Construction Supervisor's License 024.29.?5�........... COCHRAN, YAIRYBELLE Permit for ...Addition/Exterior Stairs No .................................. Single Family Dwelling . .................... .......................................................... Location .......9.0...Uneyar.d..XQ.ad...................... ............... ............................. .............. Owner ....Ma .ry b.elle...Co.Qhr.an... .................... Ty pe of Construction .......Fr.ame........................ ................................................................................ Plot .............................. Lot ................................ Permit 'Granted ....October...21, 19 85 Date of Inspection..........tom 9 Date Completed ................ .. ...............19 .Inv 4_1 ;k t f Assessor's office(1st Floor); INSTALLED PTIC SYSTEM MUST T BE �THE� Assessor's map and lot number OIL- rJ/� /'�� S o 0 IN COMPLIANCE ��'`�`•. Conservation Board of Health(3rd floor)- WITH TITLE 5 or): • Sewage Permit number - �,* ENVL4R `..+IEN 'AL ' E AND t+ YInc Engineering Department(3rd floor): V_ TO �;;� oo oe39. House number Definitive Plan Approved by Planning Board APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNS ABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO e TYPE OF CONSTRUCTION . — f 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the followinginformation: Location C(O U f tAk L1a r (�S Proposed Use l0 if C 1A)Qf—lam Zoning District r Fire District Name of Owner_ MW kC Me- KI e-A fALA Address 2.3 OZf q-3 Name of Builder M W �14 6LE Jtil Address G d 62ek Name of Architect Address Number of Rooms Z Foundation efeli1,11el Exterior Cd s,�K �^^��°�-e- Roofing Floors CeL�eti Interior 1 A Y i 1 � S Heating Plumbing Fireplace n Approximate Cost 3 Area Diagram of Lot and Building with Dimensions Fee f OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. /1 n , II Name � /✓V/lA1/. v`""1 4 - Construction Supervisor's Lice��e �� COCHRAN, MARYBELLE r4 , 3'4687 No' Permit For REMODEL GARAGE , Accessory to Dwelling , Location' 90 Vineyard Road tuit f Co Owner 'IKarybelle Cochran 4 Type of'Con`structi6n Framecr Plot 'Lot Per 8 , 19.i 9l mit Granted November- , z t ! Date of Inspection j ` 19` x, Date Completed 19'_ ,-, ra i f 1 r lF ft y i i F = - . e u J x MOXG I)OOie CO UI G�R pGF, ALTERATIOrd i 4X r '53V • Li Li X qE K4 D E R H x 4 1 F .S CND �RR�1IN� 'DIAURATI Ito i�JILQAr+ (-O(- i : , N N L07UIT 67 �:t ' AJEIPPTI0N�. .. - COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY r OF 1010 COMMONWEALTH AVE. ; BOSTON,MASS.02215 ,. ; MASSACHUSETTS _ ENCLOSE CHECK OR MONEY ORDER LICENSE 4`' V EXPIRATION DATE CONSTR. SUPER'V.I'SQR FOR REQUIRED FEE, 06/30/1993 _n + PAYABLE TO j RESTRICTIONS o EFFECTIVE DATE LIC-NO. 1 NONE` Cp a�J .4, qn 06/30/1991 001743 z "CoM1v1>SS ER OF PUBLIC SAFETY" I`• �CI V S-Y N T 2 • p I. WILLIAM .A-' DICKSCN T n (p(p,,NJ4!+,SfNDCASH). 60 WESTLAND-RD . �•` l y WESTON MA •02193 Pt fAS'E .NOTE FEE INCREASE PHOTO(BLASTING OPR ONLY) FEE: DAP,*So �c,;,'„ 100.00 EECTIVE FEB. .. 1 1989 `• +- k ,t>-�j;Y 77; HEIGHT: NOT VALID UNTIL SIGNED 8Y LICENSEE AND OFFICIALLY , ' y I STAMPED-OR SIGNATURE O THE COMMISSIONER. I L tt 'a � 0 NOT. DETACH LICENSE STUB .. , THIS DOCUMENT MUST BEF SIGNATURE OF UC SEE SIGN NAME IN FULL-ABOVE SIGNATURE LINE CARRIED E THE PERSON G- ) • THE HOLDER WHEN ENGAG- '�' OTHERS•RIGHT THUMB PRINT ED IN THIS OCCUPATION. COMMISSIONER y I. 20OM-2-87.81428 -- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION` Map ! Parcel l Permit# '/(0 7 Health Division Date Issued Y& �9! Conservation Division FeePJ d- o� Tax Collector Treasurer `t 9 Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village 06 �� `�fi 1 Owner Address -**Z-21,7�- •�h _Sr vieclvloi Telephone 4F a b + l— 17 sr I — Permit Request (2 CXte,r a r U) fl-LC1S cwr`� Z�tiil�' Q e44Y- e� ate. Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type ( Lot Size Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. v Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) f Age of Existing Structure LAO KOW) ) 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 Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other 'N4 Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No v .Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name1�tJ78'2 f�. �11y Cs Lam/ Telephone Numberg Address l ePc_,0 OS LL License# O (44 7 A-X) 01 1y� Home Improvement Contractor# f yL� � � Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �Go Q , e SIGNATURE l/� DATE _ G 3 9 ~_ l t FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED :` ♦ MAP/PARCEL NO. - ADDRESS VILLAGE OWNER DATE OF INSPECTIQFN: ` .ma's - C • • • FOUNDATION FRAME { , INSULATION "f- FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL , FINAL BUILDING \� DATE CLOSED OUT ASSOCIATION PLAN NO. t� of�y rr yi:. is urdelY 1 { k CON IRUC,i`ON f 0t41g77 ''6/G'1 000 Restricted 10 �(! t' HORO IJ 10i1 d PO 9DX: .;.• • ;. A N 0 W I 1. � z ✓'W;�07JbI)t0%/!��'.0�..//�ll<k7fLC/I,ILJP.Ct, �# � !' HOME IMPROVEMENT CONTRACTOR r « j; Registration 101695 k, l� E pirati0n O6%29l00 _ t I_ EDWARD W. DINGLEY,-CARPENTRY .W Edward W. Ding ley ,r, 'a rowell Rd/PO Boz 665`� `n 'ADMINISTRATOR'. T - a � - •° S-a'ndwich MA 025.63 « f p SNE Tp� The Town of Barnstable • snxtvsrnBM • 9�A '0 � Department of Health Safety and Environmental Services rEGMA�A Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: Ltz idh �o Estimated Cost a 14'259� Address of Work- Owner's Name: (iGL� l/ZeC�X Date of 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: / f /g , Date Contractor Name v Registration No. OR Date Owner's Name q:forms:Affidav = 1 - ice: -_: =- -= ' Department of Industrial Accidents . - �a -_ aflfca offoaast�g ONS r� 600 Washington Street --•`, Boston,Mass 02111 Workers' Compensation Insurance davit name: Cu "►� , / Lam-C�L I location: ' f'-P d4oaJF—u' /� b - S{�N55cyt� �'A —F city phone# ✓S .j .:p,� ❑ I am a homeowner performing all work myself. capacity M I am a sole p rietor and have no one working 'in any I am an employer providing w:::..*.;.,::..*.... or.:....,-..."..:.:...:.I�.ke..�,i:X.�"...I.:...:...:".i:.,�"...:.:...,*.r..:.�:.,:.'s'.:-�::...,'...:.:.:.:....c......:.:..�:..�........:..:::...*..,:..:.::.�...... ompensat::-:.-G-.:�.�.k.:,ion:�...�.,`:.��..�,::...::.....,.,-.:�,....,.�-..1��..I.:..:.�j....:::1 fori::j....'��: .mi�....:.x..:.�i::�...:.:..;.�...:�..::-::.-...,-:.;:��-.*.� y emp.,�...:��:;..'�....,.-,.�:.:-]loy�::.::::....:�...-.-.::.i�."-.:::..�....-.:.:i�.--'.:::-..i..':: eei,..:�-��1....:..�i*..::-�:...:i x�.-:�-s w�.:.,.-1:�-�-...::.�.:.:.-:...:.�-..::..-.'�-..�.*:.orking on:...-...�..::.:..::::1.-,......:.,"...::.:�---.�I...:-:X:..::t..*I...�:..�:-..:-.::...:.,...j his job..:.......-..:.--..:-..:....,.*.-...:.-.---.::.".:.....,....*:..,.:. �i".,)i:Ii..J�.:,:'i,.-..:..�*,�..]�..,-.I;�.:.e.-i:...*.!, .:�...*....::.:��...,.�.,*::-: ......�-..:*.,-X.��...*:.....-,�.-.:'-...,.�..�..:....-�.� S::.*...�:::,::-.]::.'i:.�:...::::�:.:.X..,:� .:..*- �*,..::�::::::.j��::;....":::...-�..n:�...;,�ii-:.::-.�, :..`...I.:......".,:I:::..: : ..:.*.-.--.I w:-..:'.'...,..-...`.*....,:-*..�....!.:.--..'"...-.--.I,: .:..".-.....",.:,-..,:.....'.-.-.:,...,....:,-..,..*.-.." �..'.-..-....:...,-.X,..,,..:. �...,-.i---i..i�.,..�1:. �..i,-�.-.-..-.i..J..-.i.:--..�. �.,........:-,�...�- rnmaanv name c., -.::.:`....'....-.�.'.:---.,..!......-..*,.-*..:.-.:.:....:X*.....,.....:A.-.:�...*...,...'...:...*.;;. ...:.'...,....-...:.-.-.-..-.:..�:*..,..-..!z-.-.:'...-...:...... .:-.:.....,..-..�......::*.....:..W-.:..:.....,.-....::-.:X'....-..:�*..-.��....:.'-..:.'...-.W;.......::-.::�......':...:.,...:.:-...-.:........:.�-�........":.' ,.:....-. .*,-..i.....i�.:..'...�.*`--.i..�.:..-.i..-.:�:i�...i�i..iXX.: -�....i�.,..�..-.Ii:1..�-.,-.i�.-..i.---..i...: ......:.�......i-...1..-:�.l......i-........:......Ii--..I......�.....i I.........�....:........�...H,.....,�.....�........i.....�........,-.......��......I.....�........�*.......�..'......i*.....�..-*......i.......�......IIi.......i......:-......�.".......�..I---....�.i�.........--.-........�.......i....-........�...'....:-.--.......�...........:...-�....�.*-..:.....-.--........*..........:..-.........,......i..I.'.".--'.......*-.-..:...,.....-I......,..........i-.............�.�........--....-.... �'f J...-..�-..1-.17....II....-.............I*......—....&.................,.-..-.,...,...............��::�.��.:..�--�:�:.i:�:-.:�ei::�:i.;:�.�:.�]:i-.::s::�:�i::.i.:::.::..::si�.::.:�.::i:�:�..i::.:.-:�:*.i:....:::.�::,::.i::::�;.�..��:..:::.:;]::.��.;:�..�..� :::�.��i':��i:i��:.:.:.:]::i..i]��.��:�..�,i,�.:��::,i.�:.::�i�:...:��:i�..4��::.-i.��,-�..�: �:i::-i�:��,.,i^�]ii:-..:---&�::�.*-:�:i,ii::�ii i�:i:*:��;.:i.�i::�:�;I:'.��i..��:..i*.-i:..i`�i::.i :::.:.:..-:..I,..:-�....]w,,.';:�..�:::..:i.::.:..,..i::.:.:.�::...,.i*�.:.:.i,...::..�,..[..:.-.i..::..�,.j1*:".:..."..i-...:..:...:..:...--.:i..-:.....:.i......:i..:..:..�'...-,:�..-.i.:.:.:-.,:"-�....:.i-.:..:..i-:....:.�:.:...:.i....:..::i:.....-i...".i-,::....:-�......i-":..-:.:-,...�...-'.]":,.....:.....-:-.".:-..-:.�..�.-��.-.,�..1-.-:.......�:.i.'-i.......-:......-.1.&-:�..:.....F...'-i'.....,�-:...'....-'-�.....".:...:.....*' '-:....:*...1."...:.-..j-.g."�....:...i-.."..-..:.,-Y..:..".�..;...-j",.-..".-..:."*.&......-j**.....-...:-............j�.......-......-....f.;.'.�....-....�...,'..-..:..*'...i.."*...1-......-.....`.:I......1..:-.................... .-:..:.2.....::-.*..:.:.'..,C.*:-*:"......I....:I..:.:-:..:..-.. ;..:.:..:*...:.:..:..�,:.-i.:�,.*'.-:.:..-:.�....: .:�-1,.::-:,.**...�:...:.:.:......:,I.:::.....- .�...:�:M -:i........:��"......::.�..":....�; :�:.:,...��.,:*,:...:::-::.,..:��,..::.-,.:. .�.:.....�-..i.:::.:..:.i:�.:. .:..:.:.-,:.*...I....,:...�:;...:........-*.....,.,....*".....�:::,1..:.i:.�...,...-. :i..-..��.:.....]....-'i*:.�:.:::.:-.. 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VA llafinre to secure coverage as required under Section 25A of MGL 152 can had 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 3100.00 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 eomd Signature Date �� i —�E _ . Print name�Ja CV A 12 Q I.0 ID /el(.4,'Q� Phone# official use only do not write in this area to be completed by city or town official city or town: permitJlicense# . ❑Building Department ❑Licensing Board ❑checkif immediate response is required ❑Selectme n's Office _ ❑Health Department contact person: phone#; ❑Other uevised 9/95 PIA) Information and Inst.ructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law",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 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. 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 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 and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Departm=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. 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 peimit/licease number which will be used as a reference number. The affidavits may be retumed 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 Imlesugatlons 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375