Loading...
HomeMy WebLinkAbout0353 GREEN DUNES DRIVE .,. -�. u�✓3' �r �1 .�Cii�-ems l�k� e �, . � ,. y r. — e 0 � u o � _ , 9 ., o � ��� e _ �Y -- _ Assessor's map and lot. number r �` y `3©- 7`1 Sewage Permit number.. ....�. ��1�;r............. �oFTHETo�y TOWN OF {BARNSTABLE P i BJSHSTADLE, i "6 ,e0� BUILDING INSPECTOR /to APPLICATION FOR PERMIT TO .......................................................................... ....... TYPE OF CONSTRUCTION ......... ,L!l!11!'� '.c'� ...... ....y/d✓ ........................................................ .....................1 3 19........ � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: /11*eell l�vtf �t . J,�l. �v�T Location ................................................................................................:.....,....................................................................... ......... ProposedUse ...................Y/ '�►..................................... ...................................................................................................... ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner .... ..................Address Name of Builder 0:G11k1+ -^�' � ::`. ..10 C Address ....:.....,. �`. 1 Name of Architect /'/C' f 'y'� - "� '........................................tt /5........Address .....................:.............................................................. Numberof Rooms ..................................................................Foundation .............................................................................. Exlerior ....................................................................................Roofing .................................................................................... Floors ...................................................................:..................Interior .................................................................................... Heating .................'................Plumbing .............................................................................. ..................................................... Fireplace .................................................... ..............................Approximate Cost .................................. t........................... Definitive Plan Approved by Planning Board ---------------_---------------19________. Area ....../....X...�.1-........... � da 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 the Town of Barnstable regarding the above construction. Name .. .1 /.ft'l c.�...�T.•... .......... ... KDLLEY/ GORDON M. 01141 17485 private swimming No ................ Permit for .................................... l?cml --- .---________________. Dooea Dr1ve Locoton ����������—.---'--------- We t 1 t --------_.--�.—.���uoza�or------- � d �Y �elle Owner -�-'--.00�'mu'-./----.y.-----.. ^ Type of Construction ............frama.................... ................................................................................ '—._,---- Lot ................................ Permit Granted ---.�utohec.3.U--]g 74 Dote of Inspection ..................................... � Dote Completed ------------'lA ' � ' � � ^ � � PERMIT REFUSED � ^ � � ----.----.------------. lV � � ~ -------------'------------- � —'~----^—^-----------------'' � .--~---------------.--..---- ----------------^-----'---~' ' � Approved ---------------- 19 -------------------------''' ^ ---------------'----~---^-- � � / Assessor's map and lot numbed .::.. -�;.:..���� " � /oh, 02 Sewage Permit number .......................�..�-.......................... . INEr°�. TOWN OF. BARNSTABLE SS i 339HHSTdDLE, i "6 0 ,e�9 BUILDING INSPECTOR Y{1Y M Cows J,�-,Vad -wil DixeA-i�c, APPLICATION FOR PERMIT TO ..................................�J:... ......5..........�............;r.............................7. TYPE OF CONSTRUCTION .................!�".d�`.!.......... ?.. ........................................................................ ............... ,.., .n........197 4 TO'THE-INSPECTOR OF BUILDINGS: .. The undersigned hereby applies for ayy,�permit according to the following �information: � �- Location 9 01-I f-e l;!I V11 E'>�....'��!Y'.G....�..:. o*.�.�........ '.�..!1... ......................................................I • .... .................. `� l 1 1- Proposed Use t/..l.U,e+/i �(� ................................ Zoning District Y� •� ...............Fire District ��?4 {....................................................V�` �`E' + .. � r.�........................... (""'�a , ���1-P .....................Address r•D t�4l� Name of Owner .....!............tll... ....... .............`� .......................................�.......................... ............... Name of Builder .. ����L..L1vC'fOry1f//e.s... !!?��,..Address�Z�2.C� lU.'SfvN (' e.!�'I�f1/. ... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms (0...............................................Foundation ....P�'e.r C� t~�'►!r�u .................. .................................................................... WOO Sqi �.1�5 ...Roofing ..... jA �Jr�,J r G Floors +. /^'�`�' Interior -....54<� ts�� ,\y................................................................ J ,..... ... o � Heating .........Plumbing .............. ............................L........ ........................... Fireplace ............. ....................................................Approximate Cost ............................................................... s f . Definitive Plan Approved by Planning Board ________________________________19________ . Area .....:.... ..... .....,.,... ... ............ Diagram of Lot and Building with Dimensions Fee ~' SUBJECT TO APPROVAL OF BOARD OF HEALTH v ul ACIL CA v _ O� \ AQ J & r' hereby agree to conform to all the Rules cnd Regulations of the T,owrv�of�B\arnstable regarding the above construction. ` Name .......... . . I. f ....... ..... ......................... 'Kelley, Gordon --- 17161 1 1/2 stor No ................. Permit for ............................Y...... single. famil .............. y dwelling..................:.. LocatLocatio�) reen Dunes Drive ion�J .......................................................... ......................... est Hysnniso.ort................... Owner Go.rdon. ..M Kelle. . ..... . ...... ............ . . ..Y.... . .............. Type of Construction frame .. ........ Plot ............................ Lot ..................#9.......... Permit Granted ...........June 20 19 74 Date ofInspection ....................................19 Datt Completed ......................................19 4 PERMIT REFUSED ........................................ .................... 19 ............................................................................... ................................................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... s •,,FEE-' �-� ba 4 -1 1 TOWN OF ARNST LE, MASS. 61 �b a x ,974 -wam THIS IS TO CERTIFY THAT A PERMIT IS HEREBY GRANTED TO ea.O 0 d ' coi ' �lntt 9^11Imr �}�strt3� t�.^ "Ifi r-A . __. ' _^ O ✓' :� (PROPERTY OWNER) - (ADDRESS)TO t Ep ............................ ......... ....... ......... _... ' pTj (BUILD) (ALTER) (REPAIR) �acs .... _ 1ntk ................... t9� (TYPE OF BUILDING) (APPROXIMATE SIZE) cat � # r rLOCATION r*_t '0 . ...... ........ a L d (STREET AND NUMBER) (VILLAGE) a ,NAME OF BUILDER OR CONTRACTO �-- .. ---- . .. . ... 441* d APPROXIMATE COST � I HEREBY AGREE TO CONFORM TO L HE RULES AND REGULATIONS OF, THE TOWN a s. OF BARNSTABLE, REGARDING THE ABOVE CONSTRUCTION. d omaA 3° ._....M. :..�....._._........................ ............................... _....._« ......... .................................._.: ..................... ..............._ Veld _ (OWNER) - (CONTRACTOR) CIS . ; 026 Apra e. � t r fiY BUILDING INSPECTOR _Subject. to Approval of,.Board of Health. .;. c.::. a.,,�:<......0r ,k'. '.':£4 t...�.1."': ..k.st9u� +:•:S•� ,. . � y. ........4-}.a ,,- b.. ... r � r ... � -:�+» ,x ,+,...xt is ` r 'r:d.»f YBI 7 e r� t F4 r x r "s v - a P„ ( S � _ . .. - r y..,f.,� -mac:_. {� ., - • „�� o v KELLEY$ GOMM 11. $10100 FEE �C5 a � TOWN 'OF BARNSTABLE, MASS. t October 30 19 74 d p THIS IS TO CERTIFY THAT A PERMIT IS HEREBY GRANTED TO _............................... __..._. ........... ........ ........ _.... _......._....._ _ O. � r (PROPERTY OWNER) (ADDRESS) p IIui14 privato �t7itl�7;1 poolO k a TO'.............._............ ......._............._..._... ......_..... ._..._____.---- (BUILD) (ALTER) ��� _ (REP �AI R_) Accuary to itili ........ ....... ....... ... ...... ................ _ _ - (TYPE OF BUILDING) (APPROXIMATE SIZE) ., Gro cu I6ne s Dr vo/ anindaport op LOCATION .... ............ ... _._ ... _....._..._ _.... _._................_...................... .. .. _ ..._._. _ ___. ..... .._. _.._...._._.._. ._... �I (STREET AND NUMBER) (VILLAGE) NAME OF BUILD OR CONTRACTOF��. �' J. ��0�'"' I�' �ew P4 - A ,APPROXIMATE CO\RE- ARDI.NG _ __.__._._. '' +s ..._..._....._..............____. ... ___._..._________...�_ o I HEREBY TO CONJORM TO ALL THE RULES AND REGULATIONS OF THE •TOWN k m OF BARNSTABLE, THE ABOVE CONSTRUCTION. - .......................................... __..._..__........._._.._.._....._.................. .____.•_.____..___..............................................._.._ a � i !OWNER (CONTRACTOR) I s� �• -------- ------ .._ ..._._'......................._.._................_......... BUILDING INSPECTOR Subject to Approval of Board of Health, .TM F alvA _"-'%. L .:..-a - ..,jam - O , r!s,. r to i - � 11 TOWN OF BARNSTABLE BULK RATE COUNCIL ON AGING . U. S. POSTAGE PAID 198 SOUTH STREET NON-PROFIT ORG. HYANNIS, MA. 02601 PERMIT NO. 2 h I r _.., ��f^ �J �� C�-en���es �� � : _ i �. 1 1�^ �. r 4 i i ..�...-^----•�...,.-.��-••--...-�.-,...,..—:`=^-•....-,^.--...�-.w..�-�'^--�-^-.�.......r.. .-_r.-. :.,,,--.....,....�..........ram--"-...._.,.�._r..-��. ..�, ....-- .,.•...•---r.-r_..e._ _ _-,- /� Assessor's map and lot number ... BE INSTALLED !>V COMPLIANCE /.. WITH ARTICLE d1 STATE Sewage Permit number ��'�{/. .. ..,�... �`�" SANITARY CODE AND TOM `VifrTOWN OF: BARNS' 4 SARX§TAILE, i G " q�.• YF D U ILL D I HAG I N S P E C T O R V J s,"� �- I' �����/ •� APPLICA -FOR FOR PERMIT TO ............. .. ..." ... .......... ............................ TYPE OF CONSTRUCTION ...........:.....�fJ��..... � �1�t........................................................... ............... Y �� ... .197 y TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............ .J�..... !:e�`al.....C�'b1 �?... '��..... ............... .................. ..... .... ....e......................... ProposedUse ..................... w. �... .......................... ................................................................................................. Zoning District .....:..... .........Fire District t ...............................................................IP4 " 1. ............................... Name of Owner ��. .�' Address !.`..��o ..:'........................' ....�1^�............. Name of Builder .. ! i/®`bd11.5... �S�..Address at Calm/1� ✓� �!°.11...R � De. �.�r.. Nameof Architect ..................................................................Address ..............................................:..................................... Number of Rooms .............................................Foundation .....�...... "wC .................................. Exterior .....!�`�'.�'�:4.. !��.hr:l`.�..........................................Roofing ......... ....�.....`.. ... .l.�t� �.5�............................. Floors P/ � .........Interior ..�?:-....5'/l:� r ....... ...� -loci............:....................................� � . ,k ............ .... ... . . ..... .... Heating ! rpr4llr.�i..l�!�Lt'.�'... �5�.........Plumbing .....�..... � .......... Fireplace ............. ?.�.r.............................................. .Approximate Cost �?`. ..................................... Definitive Plan Approved by Planning Board -----------_------_-----------19_______. Area ..�/: CJ...... .......°. Diagram of Lot and Building with Dimensions Fee �?.!.. �................ . ........... SUBJECT TO APPROVAL OF BOARD OF HEALTH ctt AL$ �- i .% hereby agree to conform to all the Rules and Regulations of th w ' arnstable r'e ardi the above construction. N ... x. ..... ..... ......................... 0 Kelley, Gordon M. I ,,,..;. ► No ...1Z.161... Permit.for �,. . dug 1:�..:Eam3.l.y...dFt ............ ............ �r + Locatia .........GrAeu..Dun ea...Drkxe................ ''¢• 1 s Owner ............Go.xdon.l`4...Kp-IIgy................... Type-.offConstruction ........fxmnle....................... ............!............................................................... ''e Plot ....� ............... Lot .......#9..................... i- h ✓ r Permit Granted ........,June 20 i 19 74 • yr{ e� y / Date of Inspection ................. ..`.19 Date,Completed . . ........19 t i r PERMIT REFUSED zl�.....................t ................................................ ` J.....................................................� ................ A ,.+ •T Xi1TY ,fir}, 3`Tv "t*t r , .r ..................... ......................................................... r ,r-•✓,/v'.Y......ems ••.1/-�.vr.�l..`/a•..J`r"'W.+l..,v-•.•-r•+✓wVr..r�/�taM.1+1'V.••/.Y�+r..yr.,.+i.p�•�V L„�•.l n�..�..�ya - . 7A/ AssMor+sArnap and lot number s ...... SEPTIC SYST 9 MUST SE IN! 001k:1-9713A."ICE WITH H '�t 7� � R B "i 5'��:T!E Sewage Permit number ... .. ,, 9 �• 5�,�,�iTfn N C,1130i:—. XrD TOWN REGULATIONS. ,:..... ..... INEr TOWN OF BARNSTABLE Z BARNSTABLE, i "6 9• .•01 Y BUILDING INSPECTOR 'FN PY a' APPLICATION FOR PERMIT TO ......./ ......... ................. ................../ ......... . . ..... TYPE OF CONSTRUCTION v ���G� f`� .... ........19.� TO THE INSPECTOR OF BUILDINGS:- the undersigned hereby applies forma permit according to t�hAefollll 7in,/g� information: Location ..............C.Y /61 fJrJl2c�1'................................s�•.... l� 1�!'.....1..!..y{....�..................................................................... .l ProposedUse ............ ......................................................................................................................................... ZoningDistrict ......................................�...................................Fire District .............................................................................. Name of Owner " ' �............Address a �� �1+ � E: ... �9 Name of Builder .. . ..... : .. Address Name of Architect + ... e41��4 f!-� ....Address ....... .... Numberof Rooms ...................................................................Foundation .............................................................................. Exierior .................................................:..................................Roofing .................................................................................... Floors ......................................................................................Interior .................................................................................... Heating ..................................................................................Plumbing ..................�................. ODO Fireplace ..................................................................................Approximate Cost .......... .../............................................. ...... Definitive Plan Approved by Planning Board --------------------------------19--------. Area ......1 .. ..3.L-.......... 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 the.Town of Barnstable regarding the above construction. Zia Name c.............. �........ ...... Kelley, Gordon M. nm pool ...----v~ ." . Location .°�—. ----- ~~~^ ' ^—^--------' Owner .............Qordoo...0i._Kell ................. � ' Type of Construction -- t�.���l--- � ................................................................................ � . . � Mct ---------. Lot ----------' ' - October 30 74 Permit Granted l� ` -------------. � � 'Date of Inspection --.]g ' ! Date Completed . ^� ---lA � � ' { PERMIT REFUSED ` ; � -----,----..----------.. 19 . . \ � � '-------------------------'' ! ' � ^ ' --.-----.---------~.. —. / � --' ''..--' | l ------------^^------'------` � � , —,---.----..-----..—.--.—.—.~—. ` � / ` ^ / Approved _—.------------.. lA . ` . � -------------------------.. ^ . � . ' ----------------.~.---........— . . / ^..:�"�.�.,Q RAJ Iff UPC Soc r /e fa1+�1,�� —hex PE CN+er A��, Fcr TO hCEr) Die IYr"w�7y LC�Yar- } iir Srtz i T km kodAV O I r oF �� _ - .. — `3 •--�--c--� .9e a .. w+.✓''��. �' - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map d Q Parcel 2e Permit# 0 Health Division Date Issued Q Conservation Division Fee Itz Tax Collector 1 Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address -G �— Village Owner Address <U Y Telephone 6 a — 6 --7 Permit Request nn V L C14 U� Square feet: 1st floor:existing proposed 2nd floor: existing proposed _ Total new Estimated Project CJ. ' 6 Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size �� I;, An6r, Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family lid Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes On Old King's Highway: ❑YesLWOZ-111 Basement Type: luoull ❑Crawl alkout ❑Other ` c 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: ❑Gros Lit iI ❑ Electric ❑Other Central Air: ❑Yes Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:�❑eisting ❑new size Pool: existing ❑new size Barn:❑existing ❑new size Attached ara •( i 'garage: ex sting ❑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 ` kBUILDER INFORMATIONName4� D� Telephone Number 7 7 Address 1P la4v License#A CA r1,341!�t Home Improvement Contractor# Worker's Compensation# 0 g ALL CONSTRUCTION DEBRIS R ING FP 0M THIS OJECT WILL BE TAKEN TO 0 SIGNATURE DATE SM1 FOR OFFICIAL USE ONLY - PERMIT NO. DATE ISSUED ; MAP/PARCEL NO. ADDRESS Aq, VILLAGE OWNER '' 1 DATE OF INSPECTION, FOUNDATION ; =- FRAME . INSULATION - FIREPLACE ' x' ELECTRICAL: ROUGH FINAL L PLUMBING: ROUGH •FINAL GAS: ROUGH FINAL - FINAL BUILDING t J i DATE CLOSED OUT ASSOCIATION PLAN NO. ti w t -- y t htit` � ' i s Lhr ti3at3 ttl ,P• -�i 2 2 t , '2ti } 2 2 h t � e 2t r ij ff lSsi i T1. BOARD OF BUILDING REGULATIONt License: CONSTRUCTION SUPERVISOR • Number. CS O49915 Expires:07/21/2000 Tr.no: 6696 - Re 000d To: 1 G STEPHEN J GIATRELIS 106 CAPE DR «,:�, MASHPEE, MA 02649 Administrator ,7 r. iix>s;cits,^ise:x:s;l:;r;r..t,;c:sit:<:;;iktir,<ist>ict?:+t?il;f>ctca.:;:ins£+iikt�2iRiii3�?i3Rtn?!r'i3f?t3;t;lilfttr',r �-7y . � �i e'A�a�s+r.oraeall.�i c�✓l(aeaaa�ueeQ'a �ci�.>;:�><;!<tsolftSi;�>,Kis£cisif?ilsi>�i25�•: HOME IMPROVEMENT CONTRACTOR ? Registration 125460 Type - ORA Expiration 12/22/99 STEPEHN J. 6IATRELIS, BUILDER 1� STEPHEN J. GIATRELIS ��40(�CAPE DR noti+�w£srnatua MASHPEE MA 02649 The Town of Barnstable 'ma ' Department of Health Safety and Environmental Services Moss' Building Division ' 367 Main Street,Hyannis MA 02601 ' Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date 7 h1m AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERN[IT 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. ,h/) Type of Work: G Estimated Cost at/U Address of Work: /ey1JVLA— Owner's Name: klevIA "I/A Date of Application: _ 6-klq 6) I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 oBuilding 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 ply for a permit as the agent of the owner: Q ` "l Dat Con or Registration No. O Date Owner's Name gIbmis:Affidav The Commonwe[th-ofMassachusetts -- Department of Industrial Accidents . . -- -_ Ol/lceollovestigadoos 600 Washington Street - ` Boston,Mass. 02111 Workers' Com tion Insurance Affidavit r name: location 6ecl(A &Ltqg city a hone# ❑ I am a homeowner perhorming work el£ ❑ I am a sole etor and have no one worlin in achy ❑ I am an emplopF.pro!viding workers'compensation for my employees working on this job. �OtnD nY .............. ..:.:.:.:................................. .:::::..::::i::::•:::::::::::::::::::•: ::.:_:::.?:v:::::.?.::.�::::.�:::::::•:.v:.v:::::::::::::::.::.v.�:::::::::::::::.4......•..............................�.. }:??::i:?•: .�.v:::::.v.�:::'%?4:i(trTTw::::-TTT:!T}i!::..........}i}......?!:!>:}:?a;::yT!T!TiT:>:?....................................................................................................................................... ::.::•:•::..:............•:::::...................::•:..:.;...........,;...:.:::::•::: F.:::;!:ri::?;`:i:'t::::r:is i::Y?::;%;ii::::ii:: :::..................................: :•:; •::is:::'{•:::!i::::;.`::;: . . ...:;,...................................................... .;: ::;}:.;;::;::!:;•::<?::}:%;a:s;:!::: ::»::>?':;::::`:; :;::::;:! :;:;::::. ... ... ...... ......... ..:........._: •. • .�. • . :.......................................................................................................................:...... .:...r...... ... .............:....................................................:::.�:::.�::::.�.:::..::.:: .......................................................................................:.::::: : city..:.: ::.,..,...:......:............ .... :.:...... ......:..:::.:..::.;:.:::. ....,nhnne:#.::::::;:.::'.>:::.:. :.::.::. _..:. ;:;......:;!:_.... Xo lnsnra n >< ''alley# ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have following workers co ensation olives: the foll..........g.......................... ..:.::............P..................... ,..:....:.::.::::.:._:::.:,::::::: : ::::::: :.::::,..::::.:.:.:.:.:::::.::::.:::::::::::::.•::::::..:::::::. v:..,.. •.v. ..v,.::::::.:.. address.: : :>:! ...............................::::.......... ..... .................:} ........................................................:::::v::;. ..................... .. ........................................ .. ...... ... ............. .......................... ...................... ...........:v.........................:..•:.:.:pw::1.rY.;:.}:•}{:+•}:•ii!:;i:+.4:};.::•}%?4:i.!!:}i!!!!! ::. .::. :::::v: .....:.:::::w:::::::v..........:::::.�::. .:i::::::?n;?:.T:•i:?.T:;•T}!:•:}:•.??.:???.iRi!:i}.:v:irnv:v�::r.�vw:::�:.:.: ....................r.. ....n...;.:v::..::..v.::•:i:.v:..:.:l:..r..:::v.:,4::AJ:ii::-: ........... ...................... ..:::.�:::::::.:::::::::::::v::::.vv f' •::r.?4:'•:r: :.}w:::xr:�}:••}::!:: :.? :• ;+.•.v;�. ....v .:�:.:::;.ii: .............. ...... .... ....v :..... ::•.... :.:. ..:? :':,: ??{{,,vvim .:hog . . .v,:-:w .::.v.:v::::::.::. .. ............. v....:..... x :::.::•::::::::::::::::::::::::::.:..::.............................................................................................. vfv •.:....;v .v{;:'•{:::iii:lily:.....::.. � .:::.::?}'?4:4:??•:?•}%•TTT:�!i!TT}TTii!TTiii:�i:�T:•!}:•!:LT:•}:4:4!i:!:i%'•}!:??•TT:•i}TTT:{v:???•T:S-T:•}}:4:?4TT%ii}} i!:�T!!:?•i}T}:?:•}T}:4T:?•i}?::?:::�:!:YT}T}Tuw::•:4T!:4:4}T!:'r,::?i:�!:?4:{::::::::i::•:!}ry+• !.:{.}:..4...v4:•...v.......... camoanv name:...... .......... .. „} iL T .a�•T- :::::::::::...:.:..:........................ ::::::::::::•:: ::.v::::::v.:..:..................... ........................................... ....... .... ......tin...... ;':,i:ii:!.i:i!^iiiiiiiiii: Fi�'� �i::?::.3i ::�:�<: '. '._:.�::::••................................... ..: :w:.v:::.:.:}:::•.}::......:::: address: !::;:::................ ........:........::.•.:.:i ::::::;:;::..:;;:;.:;.;:::':.:'.:......... ?:::::;::;:: dtP %.% ... ........... :.::::.�::::v.v:::v.v:nv:•!Yi:??•%..........r....r..... v.w:::::::.....e.•:n:v:..v.:.v: :.:.;........... :v:}!:::}:n?v r:::.v::.v.:.::.�.�::.::•:.v;::::.v::......................................... ..vv:::v...••v.v.:v::: .. ......................+ .... .....v•:....... .:......x:::::::-:_'n4TYr!v4}}:4T:::}:4:v.v::.}}.:•::::::::.,,. ..................................... :TT}:?4:!}'•}!}}:•i:?.}v,{•.v:••yn}v. .....r.:1%{•:vnv......2v...v..nw..............:... r.:.................. ":` w::::.v::xv%{.}:Y:•:r•n:•.:....:..::.:::...:::•:..........•..;•v:v.::..::::::..;:::::•:::::::::::•::•:::.:::.�::..:.:..:::::::.:;:.�::::.::.::::::::::::v:.:" ���.:1:.�::�::.i::.:.i:.::.i::::.i:.i:.i:4i:?:r.:?..�.:�:::•::w::::.?!}?ii::??.r.?i::::::::::v..:......::::.:..:.....: 10 Fafiore to seem a coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine rip to$1,500.00 and/or Oran one years'imprisoroneat as as civil p ties in tiu•form o a STOP WORK O ER and a fine of$100.00 a day against me. I understand Oat a COPY of this statement may rwarded the Ofilce of In ons ottite for verage verification. 1 do hereby certify the p ' p o e reform ' n provided above is trry and correct Signature / Dateg// Print Phase# 7 official use only do not write in this area to be completed by city or town officiai city or tower: petm"Cense# OBaifiding Department 1]I�ng Board ❑check if immediate response!,required ❑Sdecmten's OIDce _ OHealth Department contact person.• phone#; ❑Other (revised 9195 Pit) L__ 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 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 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. 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 kvestigations has to contact you regarding the applicant. Please be sure to fill in the pe it/license number which will be used as a reference number. The affidavits may be zam fiR in- 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 Oiflce of Invesduadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375