Loading...
HomeMy WebLinkAbout0027 HARBOR HILLS ROAD ., r _ .. . .. _ __, _ . , �, � � , �� i 6 � s z a .. a Qo �\�$\�`� o �� ,; e � ° o � � ��a � � e o o _ , — o � a. a _ � r, .. ,. .. � 4 o '•: '. .., - y s .. a .. e � a a {- a e' ,. _ ,.> —; .. Y c _ � - � � � '� _ o - - a +i ,, �- .. �. j ,. n. o ,. n a .. - � 'i ` C � �4 � � � e � � `I " a _°d :.. e o :, , e u a R o a ,, e i. � ,,fie f-, � n o �. � m @ e ., a. o a P _ o �. � a r. � c .. - e �' d �, r 6 . Town of Barnstable RcEIPT 200 Main Street, Hyannis MA 02601 508-862-4038 ga taa� Application for Building Permit Application No: TB-16-3231 Date Recieved: 11/2/2016 Job Location: 27 HARBOR HILLS ROAD,CENTERVILLE - Permit For: Building-Siding/Windows/RooVDoors Contractor's Name: Richard S Tupper State Lic. No: CS-069058 Address: West Yarmouth, MA 02673 Applicant Phone: (508)778-0111 (Home)Owner's Name: LEWENTAL,MICHAEL&KATZ, Phone: (339)224-7278 LUDMILA - (Home)Owner's Address: 19 BOWDOIN ST, MEDFORD,MA 02155 Work Description: Remove existing patio door and install new Anderson slider', remove existing bow window and install new Anderson picture window in opening. Total Value Of Work To Be Performed: $5,000.00 r Ta Structure Size: 0.00 0.00 0.00=' Width Depth Total Area . I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Richard Tupper 11/2/2016 (508)778-0111 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $5,000.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $35.00 11/2/2016 $35.00 XXXX-XXXX-XXXX-i Credit Card 3713 Total Permit Fee Paid: $35.00 , - -�-'li 7 � � zx TEIIS NPE� ITS �r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a Map Parcel 0 p�� Application # _ — 396a Health Division 0 Date Issued It-Z/-1 GVd Conservation Division 6V�` `O Application Fee Planning Dept. '�� ��® �1 Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address �j 7 1' 6Y r Village ✓' / G_. Owner // og',<- /l Address W 60/ ✓ Telephone ('mac! " Permit Req st Aa: 71-1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Or'o' Two Family ❑ Multi-Family (# units) Age of Existing Structure / 0� 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 Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ 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 G Telephone Number ,��4123 7 73 ��l Address - License # eJ A�m � �� Home Improvement Contractor# l /7 Email hi��o &��C/L' w Coln Worker's Compensation #(/���J �® ALL CONSTRUCTION D RIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO pa WiC SIGNATURE DATE / 1 �Ao/ FOR OFFICIAL USE ONLY APPLICATION# �. DATE ISSUED MAP/PARCEL NO. ' ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. P posed 6x16 deck with pergola 3 oR band to be 2x10 pt Joists to be 2x6 pt 6x6 post wit pb66 conection 11: AI 12.sono tube :with'footing attached 4'deep i t CONSTRUCTION CO.LLC 546A Higgins Crowell Rd West Yarmouth, MA 02673 Phone 508-778-0111 Fax 508-778-5010 Registration#178434 License#069058 Date: Z l� Attn: Building Department I hereby authorize Tupper Construction Co., LLC to pull the permits necessary to complete the project described on the attached permit application form. Thank you, fl Owners' Signatures Print Owners' Names: 1-n oll"ll Street Address: 14. k P! ���1/�P 8VA - DATE(MM/DD/YYYY) AC RD CERTIFICATE OF LIABILITY INSURANCEF�� 10/3/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS QERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lora FitzGerald NAME: Southeastern Insurance Agency, Inc. PHC% Ext: (508)997-6061 FAX No:(508)990-2731 439 State Rd. E-MAIL ADDRESS:lfitz@southeasternins.com P.O. BOX 79398 INSURERS AFFORDING COVERAGE NAIC# North Dartmouth MA 02747 INSURER AArbella Protection Insurance 41360 INSURED INSURER B Boston Insurance Brokerage Inc Tupper Construction Co LLC INSURERC: 546A Higgins Crowell Road INSURERD: INSURER E: West Yarmouth MA 02673 INSURERF: COVERAGES CERTIFICATE NUMBER:2016-17 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE F OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ 9520045208 11/1/2016 11/1/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 1020009389 12/1/2015 12/1/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PROPERTY YtDAMAGE $ HIRED AUTOS AUTOS Uninsured motorist BI split limit $ 250,000 UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 000 000 OFFICER/MEMBER EXCLUDED? N/A B (Mandatory in NH) WCC5005593012016A 10/3/2016 10/3/2017 E.L.DISEASE-EA EMPLOYEq $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Informational Purposes.Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tupper Construction Co. , LLC ACCORDANCE WITH THE POLICY PROVISIONS. 546A Higgins Crowell Road West Yarmouth, MA 02673 AUTHORIZED REPRESENTATIVE Ashley Paiva/AMP ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD IINS025 r9n14011 Office of timer A �x e le.e e�'Ilj' -1 Cons Affairs and Business Regulation 5 , 10 Park Plaza- Suite 5170 Boston,'Massachusett s 02116 Home Im ro p vement Contractor Re Istration g _ Regisration: I78M Type: LLC TUPPER CONSTRUCTION CO,*LLC, 'i�a°"' 4/t13/2018 T ,_418291 RICHARD TUPPER - — --- ---�w..- 546 A HIGGINS ROWAL W. YARMOUTH CMA 02673 RD 1lpdate.A"resa and retum fo re card.MiiNc ssoii —~t r, 2w"Sitt for. _ Address Renewal ,i. Employmept 'Lost Card � Office of Coasaaier Alftilrs e$6uro� Aem ela >� t<oa Lierase or a r HOME IMPROVEMENT CONTRACTOR before the resod valid for Individual tuseo: eaty �'. l�gle�atlon: 1784� 0p defy If found return to: Type: 015"of Consumer Affairs and Business Regulation Expiration: 4116 018 LLG IQ -Salle 3170 TUPPER CONSTRUCTION CO,LLC, Win' RICHARD TUPPER 548 A HIGGINS CROWELL RD W.YARMO rrK MA 02879 �. .. Undsraeer aTY Not d wiihaut signature BUILDING PERFORMANCE INSTITUTE,INC 107 Holies Road,Suite 210 Matta,NY 12o20: - (SM 274-1274 www.hPI.org Richard Tupr BFt I,. CAE REVERSE&OF FOR DUAWONS AND EXPMOON o4TES) Unrestricted-Bu' i MaSSARCh _u t�itngB of any u!�group q s®tte �s3®rtmeti#of:'uk+Iie Safety oo sin less than 35,000 cubic feet(991m)of Board of Building Regulations and Standordz enclosed space. C''0111i uctu,n sup4„I,,,t* Licenw,MOM Richard 8 TAPSr 546 A W=hn Walt Yatmttit KA Failure t o possess a oermrit edition of the LuafthusM .,.•� State Bulming Code is.cause for reiaocatton of this[kxnse. +�� XYiraFi�!t For OPS Ummh%nt=n+aftn*Itt www.mftLC, vj0p5 Conanisetoner 1?/3112jF18 00, 00 LOT 46 8, 498 f S. ,- V, (� rN >9.7• � v5 D 1 ul SHE N goy N3 0'90 WILLIAAA ma', gg WILCOXEn No. 31341 �Fss�GJST>rR JQJc' At LAND S TO THE BEST OF MY INFORMATION, "AS-BUILT" PLOT .PLAN KNOWLEDGE, AND BELIEF THE BARNSTABLE, MASS. FOUNDATION SHOWN ON THIS PLAN LOT 46, PB 103 PG 127 HAS BEEN LOCATED ON THE GROUND DATE 10f7L2016 SCALE 1" 20' AS INDICATED. JOB 7782-00 CLIENT MORRILL 10-12-2016 SWEET'SER ENGINEERING 203 SETUCKET ROAD . DATE PROFESSIONAL LAND URVEYOR fl� 50°38-6900 SOUTH DENNIS, oz8 FAX. 508-385-6991 C: 1 S8 1 PROJ 1 7782-00 1 dwg 1 7782-CPP.DWG 0 2016 SWEETSER ENGINEERING The Commonwealth o.f Massachusetts Department o.f Industrial Accidents 1 Congress Street,Suite 100 Boston,.MA 02114-2017 ►vww.mass gov/dia Workers'Compensation.Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO.BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/organization/rndividual): Tupper Construction Co LLC Address: 546A Higgins Crowell Rd City/State/Zip: West Yarmouth, MA 02673 Phone#: 508-778-0111 Are you an employer?Check the appropriate box: 10 Type of project(required): I.U✓ I am a employer with employees(full and/or part-time).* 7 ❑New construction . 2.❑1 am a sole proprietor or partnership and have no employees working forme in S. E]Remodeling any capacity.[No workers'comp.insurance required.] 3.�1 am a homeowner doingall work myself 9. ❑Demolition ys [No workers'comp.insurance required:]? 4. homeowner an we rin contr•actors to conduct ail work on m 10❑Building addition ❑1 am a ho and b hi g: Y Property. I will ensure that all contractors either have workers'compensation,insurance or am sole. 1 l.F Electrical repairs or additions proprietors with no employees. 12:❑Plumbing repairs or additions I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sib-contractors have employees.and have woekeis' 13QRoof repairs 1?comp.insurance? 6.❑We area corporation and its officers have exercised their right of exemption per MGGe. 141t0ther slider/window 152,§1(4),and we have no employees..[No workers'conrp.,insurance required:] 'Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all.work and then him outside contractors must subnrit a new affidavit indicating such. tContractors 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-connectors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the poliey and job site information. Insurance Company Name:AEIC Policy#or Self-ins.Lic.#: WCC5005593012016A Expiration Date:10/3/17 .rob Site Address: 27 Harbor Hills Rd CityistatQ/Zip: Centerville MA 02632 Attach a copy of the workers'.compensation policy;deelaration page(showing the policy number"and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as:civi.1 penalties in the form of a STOP WORK ORDER and a fine.of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the.DIA for insurance coverage verification. I do hereby cera s er airs and penalties of perjury that the information provided above is true and correct. Si nature: Date: 10/28/16 Phone#:508-778-0111 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#: a I Town of Barnstable Building • "� -'=Thi' Card,�So That i --=is Visible,:.From°�ttte Street, �A rouede;Plans Must be^,Retained on"Job and this Card Must`be KQpt� Post „ s t HAR2i'!TC`ABL& � •«r,�, .� 5��. ,� '' `:`:�' Grp P �' �.,,�' �' � � � � `� � n � � � Posted�Unt1 Final Inspectlgoy.n Has:BeenMade � �`„ � � :��� - � � � � -�� 3 �� � e i6�p•Rt *,; �� a;', , � �� � d,<ia. ,s y .. Permit iHi�t Where a Certificate`of O.ccupaneyas,Required,such,Buiild�ng shall Not be�Occupieduntil aFin�al Ins�pec�t�ohasbeenmade Permit No. B-16-1426 Applicant Name: michael lewental Map/Lot: 247-048 Date Issued: 05/31/2016 Current Use: Zoning District: RB Permit Type: Alteration INTERIOR Work Only-Residential Expiration Date: 11/30/2016 Contractor Name: Location: 27HARBOR HILLS ROAD,CENTERVILLE Est Project Cost: $ 1,000.00 Contractor License: Owner on Record: LEWENTAL, MICHAEL&KATZ, LUDMILA Permit Fee .x $85.00 2 Address: 41 PARK ST.,APT 404t Fee Paid �$85.00 BROOKLINE, MA 02446 Date 5/31/2016 Description: Convert garage to playroom Project Review Req : u' 9" Building Official This permit shall be deemed abandoned and invalid unless the work authorized by this permit is,commen ed within six months after issuance. All work authorized by this permit shall conform to the approved application and�the a pproved�construction documents four which this permit has been granted. �,. All construction,alterations and changes of use of any building and structures shall be in compliance with thealocal zoning by laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signiatures by',,the Building and,Fire Officials are provitled 66Ffhis permit. Minimum of Five Call Inspections Required for Al Construction Work., 1.Foundation or Footing , 2.Sheathing Inspection ' ,3 3.All Fireplaces must be inspected at the throat level before firest flue limngis.installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) ' 6.Insulation IAt 7.Final Inspection before Occupancy J, Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. 1 "Persons contracting with unregistered contractors do not have access to the guaranty fund""(as set forth in MGL c.142A). Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable �REcEiPT `+ tth�I�I'ABL.L. 200 Main Street, Hyannis MA 02601 .508-862-4038 Application for Building Permit Application No: TB-16-1426 Date Recieved: 5/24/2016 Job Location: . 27 HARBOR HILLS ROAD,CENTERVILLE Permit For: Alteration INTERIOR Work Only-Residential Contractor's Name: State Lic. No: Address: Applicant Phone: (857) 205-3713 (Home)Owner's Name: LEWENTAL,MICHAEL&KATZ, Phone: (617)416-6255 LUDMILA (Home)Owner's Address: 41 PARK ST.,APT 404, BROOKLINE,MA 02446 Work Description: Convert garage to playroom - Total Value Of Work To Be Performed: $1,000.00 Structure Size: 0.00 0.00 '0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C:G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the bJ ct of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a p it i ,issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or ute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accura the best of my knowledge and belief. All permits approved are subject to inspections performed by . p esentative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: michael lewental 5/24/2016 (857)205-3713 Applicant Date Telephone No. Estima Construction Costs/Permit Fees J Total Project Cost : Date Paid Amount Paid Check#Yor CC# Pay Type Total Permit Fee: 785 ..:_ ....... ...... . .....Total Permit Fee Paid: �I �� HIS�I lQT�A PELT y • �tit . L-- a Deck „ Bath Dining Bedroom#2 room Room r Kitchen Hall Smoke „ Detector Smoke O Hall Detector OD , Bath Living Bedroom#1 room Room.,' G ,)o Deck Bath Dining Bedroom#2 room Room Kitchen Hall Smoke Detector --i Smoke O Hall Detector Bath Living Bedroom#1 room Room Garage f— CYCY� f 17ze Conirnorrivealth of-Vassachusetts ` Department of rndrrstrial Accideniv f3,ffrce o,f_£xn gadOM { _ 600 Washington Street y Boston,AM 02I11 " myri.massgovldia Workers' CumpensatienInsurance Affidavit$mlder-.lContractors/EIectricians/Plumbers' ' Applicant Informlation Please Print Legibly Name(Busine anizationl addvidnal): Address- IT Y11'v._5 5 City/StatelZip:_-_ ' � G LU)'1Phcne-,"_ (Dn Are you an employer?Check the appropriate box: Type of project(requited)- I.❑ I am a employer uith. ;4 ❑I am a general contractor and I 6. F]New construction employees(full audlor part-time),* bave hired.the sub-contractors I❑ I am a sole proprietor or partner- listed on:the attached sheet. 7. ❑Remodeling ship and , employees. These mib-contractors have' g D booth fl0 Demolition �P ,• ❑ employees amdha�a workers worl'`ing for rne in any capacifl� q. El Building addition worker&'camp-insurance comp.insuranmi ,recFued_] 5. ❑ We are a corporationand its WE Electrical repairs or additions 1 I am.a homeoumer doing all Work t officers have exercised their 11_0 Plumbingrepairs or additions set£ o-workers' right of exemption per MGL � �F- 17-❑Roofrepairs i*+s ce requiredl T c.152,§1(4h andwe have no employees.[No,workers' 13,❑Other comp_insurance required.] *Amy app@ic=dbat cberks biox 91 must also 5ll out the section below showing theirs w2er'compensatioUpQHU information #Homeowners who submit this affidavit indicating they are doing sll wcA and dim ham outside contractors nmst submit a new affidavit in hC=n,-Md fCantrwfors t%r check ihois box must attached air additional skeet showing the mute of the sub-ca wractara and state whether or not those entities have employees.If thesubtGutildoishave employees,they amstpmvide their workers'-comp.pGl cy number. I am art eetplo.yr tliat is prat dirzg tvarkers'congmLsa oti inrrtrance for my encptol em. Belosv is the paiicy and1ob 5&e information. Insurance Company Nam: Policy-,Ak or Self-ins.Lic. Expiration Date: Job Site Address: CitylStafe TV: Attach a copy of the workers'compensationpolicy declaration page-(showing the policy number.and expiration date). ' Failure to.secure coverage as required.under Section:25A of MGL c 25I can lead to-the imposition of criminal penalties of a fine up to$1,500.00 and,ror one yeerimprisonnreut,as Krell 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 maybe forwarded to the Office of Investigations of the DI A,for vasurartm coverage verification. I do hereby ce fly rzndgr they pains andpenattieso peg that the irrfbr atiorr prodded above.is bare and correct / Sit�sature-- � fC� / Date: �- Phone 97 O f jacird use only. Do not write in this area,to be completed by racy onto officiat City or Town: PermitT ense'# IssuingAntlgerity(ci de one): ' 1.Board of Health 3.Building Department 3.Citj1rown Clerk 4.Electrical Iuspector S.Plumbing Inspector 6.Other Contact Person: Phone#: baformatzan and Inst-nc-lons Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation far their employees. parsuant-to this statute,as employee is defined as.'-.every person in the service of another under any contract ofhfir, express or implied,oral or wrif m:L" An emmpooyer is defined as"an individual,partnership,association,corporation or other legal entty,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 ttnstee of an individual,parbamsbip,association or other legal entity,employing employees. However the owner of a dwelling house having not more the three apartments and who resides therein,or tine occapant of me . dwe,Mng house of another who employs persons to do m a7ntm ce,consfzur tion or repair work on such dwelling house or on the grounds or building appur-traarrtthereto,shallnotbmause 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 bu fldiags is the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage requa'ed_" Additionally,MGL chapter 152,§25C(7)states`2Ieither tine commonwealth nor ray of ifs political subdivisions shall enter into any cont act for the performaace ofpublicworku atiI acceptable evidence of comp liancewithfha h isr„-ance. requirements of this chapter have Been presented to the conirar ting aofaoiityf : Applicant PIe:ase full out the worker'compensation affidavit completely,by checking ithe boxes mat apply to your situation and,if necessary,supply sub-ontractor(s)name(s), address(es)and phonenumber(s) along with their certificate(s)of ; sura:ace. Limed Liability Companies(LLC)or Limited LiabilityPartamsbips(LLP)withno employees other than the members or parfneus,are not required to cazry workers' compensation Tn sur-mce. If an LLC'or LLP does have employees, a policy is regaire - Be advised that this affidavit maybe submitted d to the Dep&-t meat of Industrial Accidents for conformation ofmsorance,coverage. Also be sure to sign and date+he affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the DeParfinent of Ln-dustrial Accidenfs. Should you have any questions regarding the law or ifyou am requ ed to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies Should enter their self-in�ce license number on the appropriate lime. City or Town Offficials t Please be sure that the affidavit is complete and pried legibly. The Deparfinent has provided a space at the bottom of the affidavit for you to fill out in the event the Of of Investigaf ions has to contact you regarding the applicant_ Please be sure to fill in the pernitllicense number which will be used as a reference number. Ia addition,an applicant that must submit multiple per itUcrose applications in any given year,need only submit one affidavit indicating current policy ia�rmation Cif necessary)and under"lob Site Address"the applicant should write"all locations in (city or town)_"A copy ofthe•affidavit that has been officially stamped or marked bythe city or town may be provided to the • applicant as proof that a valid affidavit is on file for fuse permits or licenses A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture Cie. a dog license or permit to burn leaves etc.)said person is NOT req¢¢ed to complete this affidavit The Office of Investigations would like to thank you is advance for your cooperation and should you have any questions, please do not hesitate to give us a call- The Departments address,telephone and fax number. Thu CG.Grtwealtb�of MassaahusaM Degarbnmt of k dustzal Accidents Gfitoe of 4ve&tintio.A 64�.�asl�ingtGu 5tc�t BostGi�MA f1�111 '` f,-L 4 617' 7-49W Qxt 4€6 or 1--977-MASSAFF, Fax 9 617 727-774 Revised 4-24-07 .maw gavldia Town of Barnstable Regulatory Services row ,Rf4i-rd V.Scat,Director L° REdId Mg WvLgoit ° F t w ,rcxHcr�sxrse f Tam P=Y,13 i&dhag CotrrmieainuWMCA ' Cnz �a`g 200 Maim Stret Hyamda,MA Q2601 ;e ED 1 W4PFP.fMYnTTarnafaf,Tr� IIS Office: 508-862-4038 F= 509-790-6230 ' - • HOMEOWI�R rrr�us�E�I•IOTI roB °",vb�x �k,��`s Cz-d c, t v;l r � C��comma- Lon-1 C�t(o �eaSS 1'1r PhD=# ' Wo�CpllOnc# . T - • CURRENT MAUMTGADDRESS: sfa� p up coda ' =and to alloy 'ed d e of six unrts or 1 . The current exe fion for`2iomeowners was extended to include owner-0ceuni w Ames , homeowners to engage an individual for Ui Who does notpossess a license,pi oyided tbat tiic owner acts as s�ervisor_ DEFII TIOII OFHOMEOW Ea Person(s)who ovms a parcel of land on which he/she resides or infmcls to reside, onwbich there is,or is intended to be,a one or two- famay dwelling, attached or Beta cd structures accessory to such use and/or farm struetmes. A person who constructs more than one home in a two-year period shall mtbe conddm-,ahomco*ner. Such Rhnmeawnce'.sha]l sabmitto the Building Official an a form acceptable to the Budding Official,that helsho shall be r�Ransiible for all sash work perfo=ed m&cl=the bmldme yeMit (Section 109.L1) The undersigne3`homcowner'asru�s responsibOy fur compliance w¢TitTie Staf,Bmldmg Code and other applicable codes, bylaws,rules and regulaianns- - The undersigned mEo-vmce cmff=thathelsbim undcW ands the Town ofBamsfable BlIlZdmg Deparfmcnt n inspectioa ce and r rds and that hclshcWW comply with said procednrrs and eats. Apprur4 ofBrfflcmgOfEcial Note: Three family dwellings co mina 35,000 cobic feet or larger wmbe requh dto comply withtbD St&,BII7dmg Coda Section W.0 Ca Lttm z on Contra HOMEOWNE'li'S E nrKIDN The Code states that= `9 y homeowner performing work for which a balding permit is resl�ed shall be exempt from the provisions of this section(Section 109-U Lir_emm�g of construction Snp.ervisors);providers that if the homeowner engages a perso .(s)for bite to do such Mork,that such Homeowner shall act as supervisor." hf=y hoineoweners who use this exemption are unaware thatthey are assuming the re:ponsffiM'es of a supervisor (see Appendbc Q,Rules&Regulations for Lim^�g Construction 5 pervisors,Section 2L6) This lack of awareness`ofica results in serious problems,.pmfmlariy when fie homeowner bites�Tcensed persons. In this rase,ots Board cannot proceed against the unlicensed person as if would with a licensed Supervisor_ The homeowner acing as Supervisor is ultimately responsible. To easime that$ie homeowner is fully aware of hislher respoasffiff tz"es,many coauIItmities requm e,as part of the P=Mit applkatinn,that the homeowner certify that he/she understands the responsr7iMd69 of a Supervisor. On the last page. of this issue is a form currently used bp,saieral towns. Yon may rare t amend and adopt such a formlcerf>fL�nn for use in your camm=fty. �grpF��.•pR��f++„�rT�pe�fr�s�HFSsdoc BLvised 06U 13 Town of Barnstable - Regulatory Services - ' E R/Tf�TCr(RrF t. cress. $ Richard V.S=Ii Mect or g �'~ BIIMing DivMon Tom Perry,Bm"Idmg COnimSSdaner 200 Mam Street Hpannir.,MA 02601 www:townl arnstabkmaus Office: 508-862-4038 i Fax: 508-790-6230 PropeAy Owner Must Complete and Sign This Section If Usina,A Builder Zt(oactonmybcLA ubject property herel�yaz�boN7P in all matters relative to work authorized b tbis builhg permit appliralion for. ( s of job) '`Pool fences and alaIms the responsib- ' of the applicant.Pools are not to be filled or d before fence is taped and all final " in$pect�.ons_are performed accepted., S4== of Owner Signature of Applicant Print Name Print Name Date . . �Far�s:owr�.Pr�smr�oors