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Home My WebLink About0147 GLENEAGLE DRIVE tPly"yop go wgj gf tau M"Imsemm �c is -AWARR opus v ORO to 0'13�!"I Is IV, "Of ???? fi-51�At Va , wq it PUTTY""_ I)N9I 40 Q_wy— -0- lit; V-4 z ju if I ARM 44 11, ,;7111 owl M i US, VE Aw U1 AQ 0 Sum MEMN twAywh M, Al MANOTM 'Y70" f,1�', ym pan Y� 5W It' lit, AMMMIR ICA— Aw" f- -Vona, 4 rig,nq I H; HN Ir"I 51V ligg-UR Ism 44- lit MR 41" 1,� '41k M f4tVv.Kf. 4 Is I M 6 Y �f KJA IPTATIRKEN viAW" Hdmilvw"w !, �014`1;It` mul -� , , T � U An t H_rf - W"?1"'! 113l, 0 quo 111 you f KIM if!fi ill 1,fIf W Qpj if; __'1,�,"I" , *q if iT Jr utnwo Vol , Q` INT 5 Any No!wu,,�I qiij "y'l,li",v V If MOP I'll, N IX 44,,r MAV Pig I-A" I g" It .1 _iL I "," M, it to VIA 10"HiRi P r'I,,s jag ;g MO. q!jf. ;�!,Q= M-M jjjY �Iv 0W, ""CIE al V,I MIR i"P P7":".� %!"t, 1;1 1! If-),i�'i � p -!,'4;711� VAIJAWNTI, Kmg JIM JP�,,-I i 3�!� W 4111111AUUNDA" q INN 0 low to X� Most QUINT h WWI Inn w 4f NX wvhm',� Y� -MR-ONG ArT,4!P1!qw, 'A", V;FRI Jim KHT Y, " " :11061 Ww"v"WQ01 IIA�YA rp, sll� newl Ml "TA 1,5 ..j 3 4TV, 'i -,� . ;g,�, " WNW- fam 'IV 41 P11 Kill M wo Yi A'fj� i(j, 'WIF (will Arm ON, WHOM I , I , I It", A vi Ault '11T k,.Ff TWO i Th�,NAP WWI VA 11� x I MUM 1valm"HIM14 a�!,.[ 37;Ptl IM I F, any 1,7�jJ "Old jl�ii f" non N IM GOMM 1TfAl rill -OPTS ADQ614WN 01p%y f j Opp ;gNmMy gag �Y. 1411 10 vAilml f kgp er vy IV"Y vp lonamse" WNW* 41 Pitt,9011 AF/ -C Assessor's map and lot number ................................... Sewage Permit number .......................................................... yoF'It 14 E TOWN OF BARNSTABLE 33AWST"LE, NOW& 639. 039 BUILDING INSPECTOR IT TO ..rA4ze 4"� APPLICATION FOR PERM .............. ........ TYPE OF CONSTRUCTION ......... ............. ............................................................................................................... .................i....... ............ 97 TO THE INSPECTOR OF BUILDINGS: The undersigped hereby applies for a permit according)to the following information: Location IWI.... A�� .............................. ... ........................................................................................... ProposedUse ......... .......................................................................................................................................... .......................... . .............................. Zoning District .......... ......................Fire D strict ..... ........ .......... Name of Owner ...... Address A . . .................. ............ Name of Builder .....Address .... ............................................. ............ Nameof Architect ..... .......Address ...................................................................................... Number of Rooms: * .................................Foundtion I ......................................................... Exiej-io .. r ..................................................... ..)..........................Roofing ........................_......I... .....:^......................................... Floors .................... ...............................................................Intericr .................................................................................... Heating .-f:.............................................. ...................Plumbing .................................................................................. Fireplace .......... .......................................................Approximate Cost .............�t?-6�fD , 6D ................................................ Definitive Plan Approved by Planning Board ----------------------------------9-------- - Area ..... ...I......................... Diagram of Lot and Building with Dimensions Fee I??) ............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH / I hereby agree to conform to all the Rules and Regulations of the Townof Barnstable regarding the above construction. Name ......................I e- . .......................... ... .............. Ginn, aomoall E. \ _*� u=1 9 1.�\1* 4* l8627 oneto No ................. Permit for ............... o1hgle family dwelling ' - . . ' --------------------------. . U� ~�� Glmneaglm Qrive ^ ��conmr ^"-------------------- ' ' ' � uentervi^ , _ ` ' Russell E Ginn ' Owner — '' ' ` | o* Co Construction ' ...................................../................ ....................... . . . � ' ' — --------. � r , Aug Permit— — ----' ' '-- ' . ' Date of Inspection ' ` °"'= C" "p==" PERMI/REFUSED ' ' lA ' .. . —.--.—.��-------------- ` ` / � ` �— ... ^-----------. . � ' � . � - .......................... ' . --------------.---, . - ^ ............................ .................................................. ' ` . Approved lA . \ . ~ � . [,,0 ' -----.� �---.. .---------. . . . —\��---------'--~—' YQ ° | . � _ � Assessor's map and lot number O�/ ...... '.7...... SEPTIC SYSTEM MUST BE li'�STr.�t3 `z d� LED IN COW ge-Permit number ..........:. PLIANCE, Sewa • - V'JI'fl-I :� .TI�`:E If STATE _ j SANITAgy�CjpnFF AND TOWN *THE Tp�o i TO �1 1 O F B L R N S ` -,- 7 E��JJ.- BABASTOBLEJ Y ` BI11DI ` INSPECTOR �Ep.v h• 0 t" r LL %i Q �J APPLICATION FOR PERMIT TO. .. .........4/j " TYPE OF CONSTRUCTION ... .... ! . .. . .... :........ �7 ............. .... ............197 TO THE INSPECTOR OF .BUILDINGS: The undersi ed hereby applies ,�j a permit accordin to the folio ing information: va.p Location .. .. ............... " ..................... ........................................ ,................................................ ProposedUse ........ .. .. .... ................................................................................................................................................ Zoning District .Fire District t... •' . /A Name of Owner . ..................Address 1.�. ...........:................. ....��...........................:...... .. Name of Builder ... :+....1. . .......Address .:. !r .................................................... Name of Architect ... j.... ..... ..... . ........Address ..........� Number of Rooms i, ........:. ....... ..........:......................Foundation ./ . `. ...........-. ................ .................................................. ......................................................Exterior ......... ....... . ....:..:.....:...Roofng :. ..... Floors . . �......................................................Interior .......... . ........................................ Heating' .. ..... . ....vv........... . %. .....Plumbing Fireplace .Vf-)e ..................Approximate Cost! eo 6...�..................................... Definitive Plan Approved by Planning Board --------------------------------19_______ . Area r.... Diagram of Lot and Building with. Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all.the Rules and Regulations of Shof Barnstable regarding the above construction. Name ............... . ............................ Ginn, ` . � _ 18627 - one story, . w g --. _dwelling_ -----... ~ ' . *\ leneagle Drive ^"^.=A ........................................................ ' Centerville ^ _—.----.-------------------.. ^ Russell 8 Gixum C�wvne, --------_—.�---------_—. . . . ' frame' Type of Construction -------------- ~ � . �^--------^----------------' . /+P|c» Lot �l4 . ---------. . ----------.. � Z August 31 78 Permit 8ronhs6 ......................................... ' , ' ~Dote of Inspection .. . ----..`g . . !� y - Dote Complete 6 ..(.1 -----lA ` . . PERMIT REFUSED . . . . . _ - ................................................................ 19 '. , ' ' ---------.---------------.—. / —_--.--.-----------.^------- . . . - � . ^ '---'—~---------'—^^---~`—~--' - - ^ . —.--~--.--.~~.~--~.—~..—..----- -+- ^ ' ,~4 . . �� . ' Approved ................................................ 19 -' ' ' --------.-------.----..—'---. . - ' . . ---------------------^---~— ` ` ' | ok iol 7 TO IM OF BA LN`§TABU CAPE COD o T:2 �f` l,i z INSULATION 1 m C� ®®® NBEB OLASS SEAMLESS SPRAY FOAM SUSPENDED BATTS OU1Tfi0.5 '""ON C[ILINOS - 1-800-696-6611 5 J Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: 1011a l a--_ Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed& completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted- Ceilings C*Le ow 1 C Slopes ( ) ( ) ( ) ( ) ( ) Floors (X) ( ) (30 ) ( ) 00 Walls ( ) ( ) ( ) ( ) ( ) &►..a Jow"L Sincerely HTyE C sidy , President Cape Cod nsulation, Inc. i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application #o�®/ � Health Division Date Issued l Z Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH _ Preservation/ Hyannis ��►� Project Street Address Village- zef ZZ zeA Owner 1-d �1!, Z142 Address Telephone 127;7 Permit Request y�� s� / Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation <5�7�, construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family U"'_ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes , J-No On Old King's Highway: ❑Yes ,p o Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) . C7 L2 c� Number of Baths: Full: existing new Half: existing new _ Number of Bedrooms: existing _new r� , 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 0 No 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 _ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) 'Name �'48f CDg� /�f��,r�jam Telephone Number Address �,��f�7�D�/ C'i/� License #�A4 0 Home Improvement Contractor# A<? �S'G Worker's Compensation #k4me_v a%o/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO v SIGNATURE DATES 7�Z FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION ti FIREPLACE y ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING z` DATE CLOSED OUT ASSOCIATION PLAN NO. r� ?= �Cs 'I �WSIUA 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 1 211 5/20 1 2 Tr# 206433 CAPE COD INSULATION, INC HENRY CASSIDY 455 YARMOUTH RD. HYANNIS, MA 02601 - Update Address anti return caret. Mark reason for change. L_J Address Renewal Employment I_.� Lost Card &-CAI <i WM-04/04-GIUI2I6 Ott-ter,y olraumer Affairs `Bus Regulation License or registration vidid for in divide!nse t!; HOMIPR'6VfJ` ��1t1fWACTow`�1uuielGi before the expiration date. if found return to: „ Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,NtA 02116 OD INSULATION 'INC HENRY CASSIDY 455 YARMOUTH RD. HYANNIS,MA 02601 Undersecretary At ith t si ture := Mas.:nclntsetts of Public Safeh Board of Buildint; Regulations and Standards' e Qonstruction Supervisor License License: CS 100988 HENRY CASSIDY 8 SHED ROW WEST�.ARMOUTH, MA 02673 c Expiration: 11/11/2013 ('utunii„i ui`'' Tr#: 7620 No, 1605 P. 1 Client#:4597 CCINSUL ACORD,,, CERTIFICATE OF EDIBILITY INSURANCE DATE(MMI°D/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS2 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMFNI3,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A GONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZLD REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:1f the certificate holder is an AbDITIONAL INSURED,the Policy(ies)must be endorsed.If SUBROGATION 1$WAIVED,subject to the terms and conditions of the Policy,certain pollcI96 may require an endoreament.A Btatement on this certificate does not confer rights to the COrtlflcate holder in lieu of such endorsement(s). PRODUCER U IA Rogers&Gray his.-So. Dennis NAME Mar stet Young: PHONE 434 Route 134 NC,No Exl:508-760-4602 No. 677.816.2156 E-MAIL South Dennis, MA 02660-1601 508 398-7980 _INOURER(9)AFFORDING COVERAGE NAIC 8 wsOREu'y _._ INSURrRA,Peerless Insurance 16333 Cape Cod Insulation Inc INSURERB,Evanston Insw'ance Company 455 Yarmouth Road wsURERC:Atlantic Charter Insurance _— Hyannis,MA 02601 INJURER D:COMInerce Insurance Company _34754 IN9URER E: INSIJRERF: COVERAGES CERTIFICATE NUMBER: RI=VISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED OELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY C014TRACT OR.OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ADDL SUER POLICY 6FF pOLItY EX POLICY NUpraER - MMIDDIYYYY YY MMIODIYY LIMITS A GENERAL LIABILITY POLICY 410112012 04/01/201 pEAACMHoccURRENCE $1 O0U 000 X COMMERCIAL GENERAL LIABILITY PI�EMI� $ oNccu cote q 1 Dt�VUU CLAIMS-MADE OCCUR MED EXP(Ally one peteon) $5 000 PER8ONAL&ADVINJURY $1000000 L GENERALA04REGATE 12,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS•COMP/OP AGG s2,000,000 POLICY PRO- LOC S. Q AUTOMOBILE LIABILITY 12MMBCKVmK 4/01/2012 04/01/201j COMBINED SINGLE LIMIT e�act dem 1 00O 000 NJY AUTO BODILY INJURY(Pa.peron) $ ALL OWNED SCHEDULED _ AUTOS X AUTO$ BODILY INJURY(Per Audderll) $ T X HIRE°AUTOS X NON-OWNED PROPERTY oA�f� S $ B JE FIR�LLALIAH OCCUR XONJ453512 4/01/2012 04/01/201 EACHOCCURRENce $1 000 000 CC$y'LIAR CLAIMS-MADE $1 00O 000 AGGREGATED X RETENTION 10000 C WORKERS COMPENSATIONWC $ -- ANDEMPLOY1ERSS''PL,IIA�BT'INLITY WCA00525902 6/30/2012 06/30/201 X MyII U. .19 QTIi. OFFICERjMI'M80ER EXCI UOUiCUTIVE Y 1 N NI NIA E,L,EACH ACCIpkNACCIDENT1 DOO OLIO dry NMI Ir yea,deBe in and E.L.DISEASE-EA EMPLOYEE $'I 00O 000 It yen,UesCnOa under DESCRIPTION OF OPERATIONS bnluw _ E.L.DISCASE-POLICY LIMIT $1 000 000 F N OF OPERATIONS I LOCATIONS I VEHICLES(Atlaah ACORb 101,Addlilual R,l...rks I�Cheaulp,I(Mgre SpgCe le requIrea) rs Comp Information Officers or Proprietors e Holder is Included as an additional insured'und°r General Liability when required by written or agreement. CERTIFICATE HOLDER CANCELLATION Cape Cod Insulation,lnc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES[IF CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®198 -2010 ACORD CORPORATION,All rights reJerved. ACORD 25(2010/05) 1 of 1 The ACORD name and.logo are,roglstered marks of ACORD #S83849/M83848 MAY � _ The Common 1 a llth of Massachusetts Department / Irlclustrial Accidents W Office Itivestigattons ' �w 600 Vil'o h ngton Street wy�- Boszon. 41A 02111 WIVIL.tit Iss.govIdla 1Vorkecs contirensation Insurance Aftiti,r-,A: Builders/Contractors/Electricians/.Pititi..ibet•5 lltplicatit Information Please Print L,egiwy NamI (tiusiuc s/Orgatuzaliorl/l.ndivit ual): — ( t P Addicss: 5 Z4 Are ytxt Lill etployer? Clteelc the appropriate box: Type of project(retluir(d): I. 1 am a rnrployer with_..-. . 4 I am a -,rn,'1 contractor and I have 6. New construction CIIIIAoyccs ([Ull and/or part-time).''` hired the.�nh-contractors listed on 7. Reinode.litto r L l the attar h,:cl:;hret.$ ° -. _1 I all,a sole proprietor or partnership These sub -micactors have 8• El Demolition auil have no crnployer s working for employc, and have workers'comp. 9. Building addition nie in any capacity. [No workers' insuralicc.]: roulp insurance required.). 5. We are a 'n,l,Orttion and its 10, Electrical repairs Ur additions officers I,It exercised their right of it. Plurrtbing repairs or additions L� I dill a hunreowucr doing all work exemption 11,,r IVIGL c. 152§(4),and 12. Roof repairs myself. kNo workers' comp. we have ,0 employees. [No workers' 13. Outer nsurarx:r requifed..I 'r comp. in,ur:,nCe required.] w Rl r1e�IZC1 lC� Any applI ant that checks box #1 must also fill out the section below shown, ,h it workers'compensation policy infarnation. uncuwueu who sut:anit this affidavit indicating thay arc doing all wo,l ;w,.l Ihcn hire outside contractors must submit a now affidavit indicating such. !,I of it AWS that check this box must attach an additional sheet showing it,, woo, of the sub-contractors and state whether or not those entities have employees.It II,,:Huh-omnactors I,avc otnpluyccs, they must provide their workers'couyp.ljcd,ry number. l am an employer that is providing workers'compensation iusm-mtce for my employees. Below is 14e policy and job site tn,/u'nuttiun. Allusuraitce C�orry�any Name: � �"i _- 'T Policy rt of .Sell-ills. 1..,1c. #: �f/� D rj'� �j C( ' i Expiration Date: Job)'itc Address: ._ City/State/Lip: Attach a copy Lit the worlters'compensation policy declaration puga (showing the policy number and expiration date). I ailure to secure covcrapc as required under Section 25A of MOL c. 15'run Icad to the imposition of criminal penalties of a fine up to,b 1,50U.00 atu Uor one-year inrprlsunrncnt,as well as civil penalties in the form of a STOP 4VukK ORDER and a fine of up to$250.00 a day against the violator.13e advised Pal a,t:opy Of this statement ill ay e forwarded to the Office of Investig:ui ,,,,of the DIA for insurance coverage verification. t do here c if under the ins and penalties of per,jury that the information provi d above is true and correct . tit nature: Date: k'kiunett: -- Ujjicial use only. Do not write in this area,to be completed be city ortown official City Or Town: _. l'ertnit/License# lssuiug Authority (circle orte) 1.Board oPHealth 2 Building Deliartment 3.City/'Torun Clerk 4.Electrical 6.Other Inspector : S.I'lun►birtl;Inspector Contact Person: Phone#: OWNER AUTHORIZATION FORM (Owner's Name) owner of the pmpe ft located at kAq Ghk_& (Property Address) C ° 6A- -acp s hereby authorise , an authorized subconimcdor tar RI Engineering.to act on my behalf to obtain a building permit and to perform work on my property. o s ign re ° Date 08 MVd NOMW A"D WVH 'VHD 8 ttb5b6885 tiE:80 '.zTez/tE/1_0 w Town of Barnstable *Permit X.PRES Expires 6 months from issue date O S PERM'TRegulatory Services Fee AUG 2 1 2006 Thomas.F.Geiler,Director TOWN OF BARNSTA Building Division. ii Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �j Not Valid without Red X-Press Imprint Map/parcel Number '� ' �✓ Property Address Residential Value of Work JF0 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 14_._., � ie. Cef*_rvi l ilt/ Contractor's Name Oe_�� ov,�Itq Ij Telephone Number 10 - '✓O Home Improvement Contractor License#(if app icable) jATl' o Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance CheA one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on Me. Permit Request(check box) ' VRe-roof(stripping old shingles) All construction debris will be taken to P# ,Aq D1S ' al. m ❑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. in Impro ent Contractors License is required. SIGNAMK, Q:Forms:expmtrg Revise071405 ' f - - Q - �FIHE rot, 'Town of.Barnstable Regulatory Services • IIABNSPABLE, o v Muss. Thomas F.Geiler,Director �A 1639. �0 PfD Mpg° BuRding Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property bier Must Complete and Sign This Section If Using A Builder L Gnnn ,as Owner of the subject f J property hereby authorize \TWW--SI to act on my behalf, in 0 matters relative to work authorized y this building permit application for: (Addre)s of Job) x �- � - 8 i 0,0 Signature of Owner Date Print Name . i Q TORMS:O WNERPERMISSION r The Commonwealth of-Massachusetts Department of Industrial Accidents Office of Investigations W 600 Washington Street Boston, MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual): i& ` - Address: P. 0. ibOX JS I City/State/Zip: 4A&AN,,�, VP CdU 0( Phone#: Igo -qJ0 Are you an employer? deck the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction /mployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. $ 7. ❑ Remodeling ship and have no employees These sub-contractors have Si. ❑ Demolition working for me in any capacity. workers' comp,insurance. g. ❑ Building addition [No workers' Comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Bing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.Z Roof repairs insurance required.] t employees. [No workers' i3.❑ 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 lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirati®n 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$1,50Q.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. 1 do hereby certify under the pains andpenalties ofperjury that the information provided 9bove 's true and correct si afar . Q� p�I NCO Date: Phone#: y " 4 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): I.Board of Health 2.Building Department 3.City[Town Clerk e.Electrical inspector 5.Piumbing Inspector 6. Other Contact Person: Phone f .,. Board of Building Regulations and Standards HOME IMpst?OVEMENT CONT License or registration valid for indivi Registratlo�a RACTOR before the ex dul use only MR-1- �:24310 piration dateF -k . If found return to: Fa ( Board of Buildin Regulations and Standards }2007 One Ashb g �' � t�iWdual I Boston Ashburton Place Rm 1301 f ames Cu I � Boston,Ma.02108 Imes Curley yffimmi17 Fuller Rd. :nterville,MA 02632My8 Adrtuini�--� strator Not valid without signs re I , JL 16 j. 4 4 A�j �4 -�4 ZviX" A L4"I 4'� N- .4 4. jq, ti, fe A— 4- X, JI �Zk 4 !A, _J Akxl- I I # 7, -k io;1)zoom K- IX , -.- Z'PEA"�ONE' LOAM' 5 F A� 4 I�jj f IV P't�,N .4-V BOX-, '4 MlN GAL,-, # '�E AST mdoR,- 4,ir 4- 'OCK' 6 'B 4 A-NJ, EEAAGE PIT? m Mtm u 77� 4 Ip FOUNOArl'ON WASIAED' STONE!- -f4 41 10 'b " T- 10 N �SCALE f 4 !tNSF TES ? 8' Tow4 >EC 1514 t-t KPO,C 6 A 6t O -3 -7- 'M 44 4 aK 4F '7 tio IA� �t. Ail -4'T L 61 74 —S'pvp 74� 4L4, *+ 41 t t -44 V 44 L CA AZ 7 'A 7,110Y 17 7, W 4::;; A UA el 17 4 -%It 1�,A A T 04 1,4 'po! `4 7r -A 4.,fN f�q SOX AW -,41 ,75 & K e WL 4