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0088 HILLSIDE DRIVE
A il� 11 4h N M"M N5 ggm IN wit z� q—e-i v �VA 00M Him- v X4, A Elm iiq g i�j 1�� N At T A. om_WW —n A Q NOW E 40 ll. W,Q— VDLWIP-11 I SIM -z�,�V A� gi" v man y Wx", fl, ,Z V0 0 Im- Jay pp—q--Q� fAl. �W no �W M WE CIL ARCO mum ,t4wM m� 0�6W""'I W zj W-Q A Pont.. Sly �S At ON All .......... fault ,fm!�P, 71, WP� g qq �1�j,-, .-p �5 16 �q Mom ME -fflW I qq KIWI, AN oil' TN2 A loan an UNN IR ...... N11 M" AT, mom g�, NOW vjUjj@,! U1 11" -75 Z,11X-x1--�-'- UN mmmy man Al ii� - I I MW WS. I" cuts MI W�� q p- A 9=1 lag MO Ur gs z A MUM lki ma m q F �Ijl�� cowl ........... U!F; 40, I, y Now IRE W I N- NNW%Qw,&Z -1, 4� �`:" soma 11 ,", " 0 r"'g 'T, TWO 14 k�. lgl somg", mv ',n ............. oFIKE fit{. Town of Barnstable *Permit Zaoz Tres 6 mom hs om issue date Building Department Services Fee G . BAMSrnsr.E, . an Florence,CBO f p BUS �' ildin g Commissioner AlFpMp`1�, 00 Main Street,Hyannis,MA 02601 JUN 2 7. 201 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 TOW EXPRESS EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ` Not Valid without Red X-Press Imprint Map/parcel Number Property Address J � OW V8" Residential Value of Work$ �I Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 6�7 e S "A:rgurW Contractor's Name d`n6_�re 1 �= -t-O 0�ak Telephone Number � 0 f��� Home Improvement Contractor License#(if applicable) l 77-2 y 74C Email: � e `-o" Construction Supervisor's License#(if applicable) tJ—/1/3 Q 5 ❑Workman's Compensation Insurance C one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name �L�L / I V Workman's Comp.Policy# .Cl Copy of Insurance Compliance Certificate mus�ccompany each permit. Permit Request(check box) �J ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to / C_Vi^,,4-CL jD Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) e-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the me Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\build' it forms\EXPRESS.doc 08/16/17 A ® DATE(MM/DDNYYY) AC� CERTIFICATE-OF LIABILITY INSURANCE 1/24/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE 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 have ADDITIONAL INSURED provisions or 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 BRYDEN & SULLIVAN INS NONE CT 88 FALMOUTH RD PHONE FAX A/C No Ext: - A/C No), HYANNIS, MA 02601 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: LM Insurance Corporation 33600 INSURED INSURER B: BEL ISLANDS HOME IMPROVEMENT LLC 204 CINDERELLA TERRACE INSURERC: MARSTONS MILLS MA 02648 INSURER D: INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: 40046413 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 RE ISSUED OR MAY PERTAIN. TH:":.INSIIRANCF_ 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 SUER POLICY EFF POLICY EXP LIMITS LTR I /Y POLICYNUMBER MM/DDYYY MM/DDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO CLAIMS-MADE OCCUR PREMISES Ea occurrence)nce $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ ' GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PE O- LOC - PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILELIABILITf COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY - Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I RETENTION$ -$ A WORKERS COMPENSATION WC5-31S-615667-017 2/11/2017 2/11/2018 STATUTE EORH AND EMPLOYERS'LIABILITY - ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N NIA E.L.EACH ACCIDENT $500000 OFFICER/MEMBEREYCLUDED? (Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE $ 00000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$500000 } � UESCRIr-TiOtJ OP U✓Eni+TiOidsi LiiCA i iviJS 'vcniCL`co ji.CvRD SOS,Add7:iarai n�.o.�.._.....:dulG,cap t3:.L'ached if ecru cracc i=rrquircd; -" WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION STRAWBERRY HILL CONDOMINIUM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN C/O CAPE COD & ISLANDS PROPERTY MGMNT ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX-1144 " OSTERVILLE MA 02655 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD,25(2016/03) The ACORD name and logo are registered marks of ACORD 40046413 1 1-615667 117-18•WC I n027U58 r,1 1/24/2018 9:21:57 PM (PST) I Page 1 of 1 , Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standard Constrkwd6n Sapervisor CS-111305 k ires.: 06/0'1/2021 ANDRE YARMALOVICH - e 204 CINDERELLO TERRACE MARSTQNS MILLS MA 02648 Commissioner nIN Irz4Jrlr• •.-. {'PZti.;.ha 4:e�.r Qffice of Consumer A s 11 i egulahQn' r - ,-HOME IMP}. MENT CO,NTRACT,'. Registrah 17b2476 T Pe' Expi_ 7?f201.8, pBA BEL Ifl NOS HO E 10 01iEMENT ANORLI YARMALO '. 204 CINDERELLA TER . MARSTONS,MILLS 10 8 ndersec%f ry The Cozi womrreaWt of Massrrdrruetfx De p=tirrezrt c�,f rndtrst id AccidTadg 600 Waslaiugtorrt.,street _ Boston,CIA 02111 ' t�rvi�mass:.�trv�ciizx Wailers' Camp ensafimInsn-mce Affidavit BuffierJ-CanfractarsMeefdci ns lumbers f-ml 1ilf(gTII1,3tihn Flease•lI in Na=Cgusine��m&66haW-, �JE&t-t 14-C-0 /I/CA Addres 2 0 6/1 0�0 °e ao 7r—C,411�-e Tire_ yo'u� empIGTer?Checkthe apprffpriate barn ' Type of project(reT�e* L am',employer ✓ ❑I am a gauezal cantisctor aacf I 6. ❑New const mcdcn employees(frill aa&or park-time)* 1 ave hiredffie sub-conlractws 2.❑ I am a sale propiietar arpartuer- Tisted oathe ached sheet.. ?. ❑RPmadedaug These smb-cos�actars have shEp and have no employees &,❑IJemolifiort -voddng forte in any capacity emplayees mdhave wodmrs' 9. ❑Building addition jldo wpdmrs' comp.insurance comp-ins an l required-] 5_ ❑ We area corporation and its 10❑Electrical repairs or addifozzs 3.❑ I am.a homeormner doing all woik officers have esercised their 1 L❑MmAxingrepaiss or additions. a of exemption per MGL �seLfo wofk='� - C. 1 amdwehaven�o L--7 ❑Roafrepairs . i nsux nce required-]i , ( employees.(Nowodcess' 13-❑Other comp.msaamce required_) •may apg&��t cbec sbos it moat also Mcuf*e swfioab9VwSbntdn9 ai&wa2me campeasaliaapoHcginffirmsuatL I Samcovraerswlso sub=&dtis ai�dae+h i g Huey adet3ffing slf�ra¢ic and tfieahiie autsidecoatsctarsamst snHmitanew�d t indicating sack fComrac{n6�ZC�9&ihisb=nsustrftarh aaaddid—A shed shavimgther—ofdmsab-cantxctommdststewhedmarnaftseenddesbwe employees.If themffi-c atxctmsknmmnplayea%dw}' tpmuideth•eir vmdtea'tomp.paliyatnbw- I aui ari einplofer Brat is prauidirrg workcts'coarpemrdimi irzsrirztirea for my employees. $eradv is t7re paficF arzd f eb srtta informathm Issurance CompanyName: 'Poficy�or Self ins.I.ic_���� �--Gl i�6•�'C�f'�- �,i�aDafe: 2 �//lZvi�" Job T Addr = L �<<'C �! � f/—' f CifylS#atel .tg: u�/ Af#ach a copy of the workers'compensationpolicy-declaration page(showing the policy number and expiration date). Fannie to secure coverage as.requiredunder Section 25A,of MQ.c.157-can lead to the imiposifioa of criminal penalties of a fine up to$UOG OG m&Gr one-year impdsonmwerit,as well as ciO penalties m the form of a STOP WORK ORDER and a$ire of up to$25100 a clap against the vijqAtar. Be sdrised tip a copy of this stateaaeat.m ay ba faxwarded t a the Office of Inestigaflc=of the DIA far ins a coverage mrifrcati= Itt'o herby cedyy&er t1w#a arrdrpgrzalii a get aczy ti eale irrfbMza#ron pray rTed abates A trim and carrect 2 ��Jf Siffiature Date O 7` �/;Z Phone k/-7-T 0 O, al irss arzF,� Da ztat errrta in tip axes,tct be crr�upfete�d by�'artan,n n,�rcurt City or Town: Perm itUcease g Issuing A 1hor€ty(curie one): L Board.of Health 1.Building Department 3.CSty,Town Qerk 4.Electrical Inspector 6.Ph=,bmg Inspector 6.Otherr Contact Person: Phone 9: --- 6 information and Lastructions Maeea�_rhrz Greaal Laws chEpter 152 req=an employers to PVMde '=:13P=Mtion for their employees_ Pm-snantiD•this sfatafe,an CUq7layee is defined as¢.sverypcasonin.fire service of anoffia ader any cor±laot ofhire, express ar>Mplie(:L'oral or wtitt=-7 Am e�Toym is defined as_an i affin aal,partner,association. Po�on or 0 legal entity,or any two or more of tip fnr egoi og engaged m a joint •and inclnd'mg fhe IegA=p=enft&w of a deceased employes,or the Tweim or troy of en bsii IIal,partneasbip,aSsociafion or otherIegal entity,employing employees. However the owner of a dwrU!ngho=e bavmgnotmo¢�e thin t = arse and�ho resides thereni,orfhe occ¢p�t ofthe- dweIImg hDUSO of anon who employs persons to do ce•.ca,,art;on or repay work on mch dweIImg hawse or on,the grounds or bBr7.dmg agp thereto shaUnotbmause ofsurh employmemtbe d"medto be an en3.ploym A MGL chapter 152,§25C(6)also sues that aevay sty or local Ticensing agency shall withhold$e issaance or reaew-al of a hcease or P P' ermit too erne a business or to contract buadings to fiie commonwealth for aay aPPlirant Wb.o has notprodnced acceptable evidence of cdmpL-mm wn tb:e ft=ranca coverage regnired_ Addi ionaib,mar,chapter 152,§25cM sfai =ND tbcr the nor any ofits political sabdirisicns shall enter mto any contrast for the pm-E ance of pubho wont unfit acceptable evidence of compliances the insurance._ regv>r==fs of this chapt=bane Been presemtudtD the comrarimg.amibozity_, Applicaafs Please flI oil fhe workers'compeasafinn affidavit completely,by chug the boxes apply to your sitnajion and,if necessary.�P13'�-o r(s)��s)' es)amdphonenxmnbes(s)aIongwilhthea=t f caie(s)of ���_ I, red Liab y Companies(LLC)or I.iarited Liabllitp Parfnessl�ips(. LP)�n° �IOY of..cr than th e members or par[ners,aim not rued to cant'workers'compensattcm i mmmm If an TLC or LLP does hate Beadvisedfiatthisaf�dayitmaybes�edinthoDepartzaentofrndmstrial empIoyees,apolicyisregmired. Accideds for Con n of irmmance coverage Also be sin a to sign and date a af�daYih The affidavit should beretomed to 1he city or towth natthe application for the pemmit or license is being requested,notthe Dr-partment of LdustrTal_A c:denntt• ShMMyou have�•Y q�� g the Iaw or ifyon are regred in obt�a workers, compemsation policy,please caa the Departtaent at the numberlisterlbelovr Self-insured companies should enter .their e as the line, self-;,,c„�-n ce Iicens appropriate City or Town Ofad2k r Please be s[ae timt the a$davif is complete andprmfPd legibly. The Departmenthas provided a space at$ie bottcm of the affidavit for you to fill out is the event the Office oflnvm igat< s has to co�tYOu the applicant P lease be m=to:Ell in the penD.i l r,=Se mrnber which-mM be used as a reference amber- In addition,an aPPhcant that must submit multiple pen license apphcat=s many gm.year,need.only submit one affidavid con indicating rut policy in�bm atioa [iEnecessaiy)and under"lob e Q�rt&*the apphCan t should wrii��sII locafiCrIlS in—(Cy or berovided to$e town)--A copy of-the aff davittliat has beep,officially stamped or mm ILDd by the city or t oY m may p applicant as proofthat a valid Hffidavrt is on MD for fat= peunits or Iiceuses Anew affidavit must be filled oil rash. year.-Where a home owner or citizen is obiammg a license or pe=it not related to,any business or commercial Ye a (ie.a dog license or pa= t to bum.Ion=etc.)said person is NOT reed to COIMPICb-,f ais affidavit Tie Office of Ind ons wouldhke to thank you a a rmce for your cooperafian and shouldyou.have any questions, . please do nothes>feteto givens a caIl. The IIepartm eut's aAa=s,telephone and faxrnmmbes: - ' mmarx-wed of Ra�ch��s , mt cif hat AmUenta face rf�blvedkA Lo= 4 Win BastmsMA Oil II T(�L CI'- -4.9W Qit4-1f or 14 MA%, Fax#617 727 7M Bevised¢24-07 Tnae9 9PTIER. i ' WE Town of Barnstable Building Department Services ` emu' ` Brian Florence,CBO 163S �`� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. - If Using A Builder as Owner of the subject property hereby authorize to act on my behalf; in all matters relative to work authorized by this building permit application for. (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is ins d all final inspections are performed and accepted. 7 tore&Owner Signs e A cant Print Name Print Name Da Q:FORM&MMERPERMISSIONPOOLS Rev:0&116117 Town of Barnstable Building ]Department Services Brian Florence,CBO ' qp Bolding Commissioner 200 Main Street, Hyannis,MA 02601 sn�srwars, : . >�a www.town.barnstable.ma.us �i639. p M� Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: cityhown state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the buildingnermit. (Section 109:1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Deparhment minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully Yaware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q;\WPFILES\FORMSIbuUding permit Iiums\EXPRESS.doc 09/16/17 J Town of Barnstable �1HE Regulatory Services Richard V. Scali,Director BAMST,B Building Division BABSTABLE 1639. .• Thomas Perry, CBO 639_zo< QED"AAA. Building Commissioner 200 Main Street, Hyannis,,MA 02601 www.town.ba rnsta b le.m a.us Office: 508-862-4038 Fax: 508-790-6230 February 12, 2015 Oceanside, Inc. Attn: Peter Laroche . 217 Thornton Dr. Hyannis, Ma. 02601 RE: 88 Hillside Dr., Centerville, Map: 193 Parcel: 053 Dear Mr. Laroche, This letter is to inquire on the status of building permit application number 201400712 issued to remodel the above referenced property. As you may recall,this office issued a building permit on or about March 5, 2014 and to date there is no record of a final building inspection. Please contact this office to arrange for inspection or provide an update as to the progress of the work. Thank you for your anticipated cooperation in this matter. Respectfully, WLon Local Inspector jeffrey.lauzon@town.bamstable.ma.us (508) 862-4034 a""ems +ry g e4 It -� C Town of Barnstable Regulatory Services Richard V. Scali,Director Building Division BARNSTABLE Mesa �. �n����°• 163q. �m Thomas Perry, CBO 1639.2014 �fDN � Building Commissioner �77� 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 February 12, 2015 Oceanside, Inc. Attn: Peter Laroche 217 Thornton Dr. Hyannis, Ma. 02601 RE: 88 Hillside Dr., Centerville, Map: 193 Parcel: 053 Dear Mr. Laroche, This letter is to inquire on the status of building permit application number 201400712 issued to remodel the above referenced property. As you may recall, this office issued a building permit on or about March 5, 2014 and to date there is no record of a final building inspection. Please contact this office to arrange for inspection or provide an update as to the progress of the work. Thank you for your anticipated cooperation in this matter. Respectfully, L. L Local Inspector jeffrey.lauzon@town.barnstable.ma.us (508) 862-4034 s TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 3 Map Aq Parcel 033 Application 1 ,( Health Division Date Issued JWNAI Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation /Hyannis Project Street Address �g l't1 l�Sic���irl�e Village Owner Qu►�ts�� re) Address M19 "8eh Sf enfflbyimf N C)ZI�B' Telephone U 1t qu hq ou . 'Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District & Flood Plain Groundwater Overlay Project Valuation 1�000 (90 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes L'No .On Old King's Highway: ❑Yes WrN* o Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) WOO Basement Unfinished Area (sq.ft) Number of Baths: Full: existing 2 new Half: existing new Number of Bedrooms: existing i new Total Room Count (not including bathe): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil �lectric �ther c Vd Central Air: ❑Yes CaKo Fireplaces: Existing New Existing wo:eo coal stoly: ❑ s UKo Detached garage: ❑ existing ❑ new size pin existing ❑ new size _ Barn: 7x sti nevi size_ Attached garage: �isting ❑ new size L;h ❑ existing ❑ new size — Other:( N Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ --� Commercial ❑Yes 0'No If yes, site plan review # + n . Current Use �Sj ,T1G Proposed Use N m1�4 de"P a APPLICANT INFORMATION (BUILDER OR HOMEOWNER) LtcV A �C,tUb � a IY1C Telephone Name � � ry Number Address 1`6eQa6Q_1)QA OnJeYui lle t4 A UULicense # U4 S b9l- U tay ntia AIGIVIVI►S Home Improvement Contractor# 0O Z Worker's Compensation # CFq(, eW()L45i 1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE �ae_� DATE FOR OFFICIAL USE ONLY - - APPLICATION# DATEISSUED MAP/PARCEL NO. } ADDRESS VILLAGE OWNER DATE OF INSPECTION: , }. _FOUNDATION FRAME s INSULATION FIREPLACE 'r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. k The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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/Individual): 0 C(20,' -n, 1 Q Address:_c� 1 7 Thqr-r&or) bi 1�P City/State/Zip: k-1� aftn i Phone#: 50 7 71 - Are you an employer?Check the appropriate box: Type of project(required): 1.L! t am a employer with < 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' 9 '❑ Building addition [No workers' comp.insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ 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, $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have 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 policy and job site information. Insurance Company Name:fz \/e r-e.2A. M a—L orY"6 C 6 l'Y1 nC�Xl Policy#or Self-ins.Lic.M F/-/44)C 0 U V IV 5 ' / Expiration Date: ( 1 Job Site Address: og S41cCy City/State/Zip: C URVUl H A (jl�3Z Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fonn of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerli it er th a'r and penalties ofperjury that the information provided above is true and correet. Si nature`` Date: Phone#: &0)n _7 _ I j Official use only. Do not w to 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 A.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#: 586925 20CEANSIDEIN ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYM 01/31/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE 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 end'orsement(s). PRODUCER CONTACT NAME: Dowling 8 O'Neil PHONE 508 775-1620 FAX 5087781218 A/C No Ext: A/C,No Insurance Agency EMAIL 973 lyannough Rd., PO Box 1990 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis, MA 02601 INSURER A:Arbella Insurance Company INSURED INSURERB:Everest National Insurance Comp Oceanside,Inc.217 Thornton Drive INSURERC:Safety Insurance Company Hyannis,MA 02601 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. LTR TYPE OF INSURANCE NSRL WVD POLICY NUMBER MMIDIDYrYYYY MM/DDYIYEYri LIMITS A GENERAL LIABILITY 8500061423 1/01/2014 01101/2015 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occunence $100 000 CLAIMS-MADE OCCUR RE EXP ZAny one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 riPOLICY JE° LOC $ C AUTOMOBILE LIABILITY 2434628 1/01/2014 01/01/201 COMBINED SINGLE LIMIT Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident A X UMBRELLA LIAB X OCCUR 4600061424 1/01/2014 01/0112015 EACH OCCURRENCE s2000000 EXCESS LIAB CLAIMS-MADE AGGREGATE s2,000,000 DED I X RETENTION$10000 $ B WORKERS COMPENSATION BINDER369533 1/0112014 01/01/201 X TORYLI IT OTH- AND EMPLOYERS'LIABILITY YINFIR ANY PROPRIETOR/PARTNER/EXECUTIVE - E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under t DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ✓J"" � - . ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S124076/M124075 KKM Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction 'Supervisor ervso p r . . ,.License, CS-073097 PETER A LAROCLE - a 18 CEDRIC ROAD ' Centerville MA 02632 cXplrdilQn �m;ssiC'.ner 11103/2014 L�(j nce of Consumer Affairs'&Business.Iiegulatitin ME IMPROVEM#NT CONTRACTOR egistraho' �� �;�, Ezpirati We, OCEANSIDE;.INC supplement t - r1 i TI PETER LAROCHE z 217 Thomton br v r" _ Hyannis, MA 02601 Y1ude0gcretat! . r License pe ri egistration:Va.id`for ifidividul.use only before the expiration date. If found return to:. Office of Consumer Affairs and Business Regui'ation + 10 Park Plaza-Suite 5170 r•ard. Boston,MA 02116 Not valid without signature i - aprsuPaOoVNE 10:36 AM Oceanside NvlT : II anz/bloz/sz/IoIYUZZ11 tT9s ou �niaoax TMPIGHTCHOICE Swe 19 O,�ice Us®Only / Commimmsideg Restoration !_______________ 217 Thornton nrlae,Hyannis,MASS,02601 609-771.3110 800464.3318(MA.Only),77"70.2211 pax ASSIGNMENT AND AUTHORIZATION TO PAY The undersigned, herein called claimant, has authorized and ordered from Oceanside, Inc. , the materials and/or services requested. undersigned hereby assigns to Oceanside, Inc. any unpaid proceeds due or to become due, under the claimant's policy with the insurance company to pay direct to Oceanside, Inc. or to include its name on a. check ox draft, for all requested work. In the event that Oceanside' s claim herein is not covered by, or paid by, an insurance company, claimant agrees to pay Oceanside, Inc. within sixty (60) days after work has been completed. Claimant understands that Oceanside, Inc. is working for them and not the insurance company or the adjuster. Payments remaining due and payable after the claimant has received payment from the insurance company shall bear interest at one and one- half (1-1/2%) percent per month. In the event that there is a breach by the claimant of any of the conditions of this agreement, Oceanside, Inc. shall he entitled to recover, as additional damages, attorneys' fees, costs and any other collection expenses reasonable and attributable to said breach. If payment is not received within 60 days, collection action will commence without further notice to the claiman . WE / PHONE: " 3/ -79Y' Email:_ � ' C-7' mom i 6�(e o CL T'S SIGNATURE PRINT NAME A6dAL,e-� ____ oar3� _ MAILING ADDRESS (BILLING). STATE sip LOSS/DAMAGE ADDRESS WT P tio. kW C e INSURANCE ADJUSTER' NAME/CO. LOCAL INSURANCE AGENCY AME ►� r INS. CARRIER/POLICY UNDERWRITER HO E )�OLrRBFERRED TO OCEANSIDE? l/l 6£SLVIML Sac) SSvw 3o wwoD wv SS of 8z-Uer-vloz V) qjp--w 7-/1 04f -PEI LI I&V ell U I Dif lu 8 v jolt., -J—L 1 , I F-ELL op- ...... 00 AA _� LL I�ICy 000- �_. �. _ ... �► ' r� �, ' ic, I , / �1.1 LA 7''�®__. _ � Rvcle T/ON l , l� � - CCaItTI3 � r 1�-� psib `t��l and Commercial{Builder fi ���_ r77777 f y CCARTHYC v-NM WWW October 21,2014 1 e� Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main Stret 'a Hyannis, MA 02601 s " �M RE: Insulation Permits Dear Mr. Perry, This affidavit is to certify that all work completed for permit application.#201404250 at 88 HILLSIDE DRIVE has been inspected by a certified Building Performance Institute(BPI) inspector.All work performed meets or exceed Federal and State requirements Sincerely, Michael McCarthy McCarthy Construction TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION TOWN OF BMW Map l Parcel Application # Health Division `{r� JUIM 2 J'' °� I t . �, j Date Issued /S//y. Conservation Division Application Fe6% Planning Dept. fat Permit Fee 114 Imo. , . Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address �s Village ��tru�,t�L Owner Ar. Address nL Telephone 5Lti (,y$-ate Permit Request 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 6) Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full 0 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. .—Mike-McCarthy Construction- Telephone Number- - - -- - PO Box 52 Address West Dennis, MA 02670 License# Cell (508) 280-6964 CSL-58633 HIC-169393 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEUBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 4J:k7/17 f FOR OFFICIAL USE ONLY APPLICATION# DATE-ISSUED MAPS/PARCEL NO. ADDRESS VILLAGE •- a OWNER cl DATE OF INSPECTION: 4 FOUNDATION ` FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL . !: GAS: ROUGH FINAL FINAL BUILDING DATE-CLOSED OUT- ASSOCIATION PLAN NO. -o+i3 Jun. 13. 2014 10:49AM Century 21 COBB Real Estate. com No. 0987 P. 4 OWNER AUTHORIZATION FORM ( a Name) d owner of the property located at Address) (//�'���/� (j Property - - . (propertyTAddress) . hereby authorizeQ2,2,�,ojt (Subcontractor) an authorized subcontractor for RISE Engineering,toe n my tiehatf to obtain a building permit and to perform work on my property. 4 Owe n is ature • Ll . Oate A O CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 10/16/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE 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 01962-001 ;CONTACT Bryden&Sullivan Ins Agcy of Dennis Inc 'PH N ,FAx PO Box 1497 __-___o_Ext)_ (508)398-6060 --. - _,lac.No._ (508)394-2267 - So Dennis,MA 02660 ;EMAIL --- DDRESS: ----------------------- ----------- ._ ------_.--INSURER(S)AFFORDING COVERAGE _ NAIC#___.. �NsuRERA: A.I.M.Mutual Insurance Company 33758 - --- — -- i INSURED -------- Michael McCarthy Construction Inc iNAURER !INSURER_C_;__________• P O Box 52 West Dennis,MA 02670 irvsu13ER o - INSURER E___.-_ INSURER F COVERAGES CERTIFICATE NUMBER: 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 CONDIT!CNS OF SUCH POL!Ci,:S.LIMITS SHO'A'N MAY HAVE SEEN l REDUCED BY PAID CLAPAS. _ _ ___ INSR: LTV I TYPE OF INSURANCE ADDL$UDR! POLICY E OLICY INSR p j POLICY NUMBER T - MM/DD p - _..--- ----' --� - 1-(-----�I MGM/D�/YYYY)l_.._ . .---- LIMITS GENERAL LIABILITY EACH OCCURRENCE i $ I COMMERCIAL GENERAL LIABILITY i' i j DAMAGE TO RENTED 7 - --- --- PROASES_(Eaoc_currence�---_�-----_------- -- CLAIMS-MADE . OCCUR !MED EXP(Any one person) $ j PERSONAL&ADV INJURY $ GENERAL AGGREGATE i$-- -" GEN'L AGGREGATE LIMIT APPLIES PER: ! —_ i PRODUCTS-COMP/OP AGG $ POLICY PRO LOC __JECT __...._ AUTOMOBILE LIABILITY ( I --- .__..--. -- !COM- ------ ---- — -------—•__.." . — - -. _�_.T — — •-- _ -- (EaaccdentSINGL I� ANY AUTO — E LIMIT BODILY(INJURY(Per person) $ !ALL OWNED i SCHEDULED _;AUTOS •AUTOS i BODILY INJURY(Per accident); $ HIRED AUTOS ! i ANON ; i `PROPERTY DAMAGE $ — -- (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ j EXCESS LIAB i`---- i I ! ---------- --._....------ ------- CLAIMS MADE I AGGREGATE i S ' DED j RETENTION $ - WpRKERS COpMP NSATION - - - • ------ ---- - — - j ---—--{---- WWCC ��11 H I$ !AND EMPLOYERSF`LIABILITY — — - X TORY L MITSL _'�ER ANY PROPRIETIo R/PARTNE EXECUTIVES/Ni' E.L. ACH ACCIDENT I$ A !OFFICER/MEMBER EXCLUDED? I 500,000_00 I(Mandato. in NH) I Y j I N r A VWC-100-6017656-2013A 7/17/2013 7/17/2014 -- ----- —=--=------------ j E.L.DISEASE-EA EMPLOYEE!$ tf{ es ddescribe and€r _ _ 00,000.00 D��CRIPTION OF OPERATIONS below ; I E.L.DISEASE-POLICY LIMIT IS 500,000.00' t I J DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION 'TOWN OF SANDWICH Attention:BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL ANNEX THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sandwich,MA 02563 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �. ©1988-2010 ACORD CORPORATION.All rights reserved. ,ORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Conmmonyvea7th of Massachusetts .i eparhu ent of fiulrrstrial Accidents _.. Qfce of Investigations I stigations s 600 Washington&reet Boston,,MA 02111 Workers' Compensation Insurance Affidavit:Builders/Contractors/Flectricians/Numbers Applicant Information M:k- MCCarthy Construction Please Print Legibly p0 BOX 52 Name(1�+3�mP' ni�ation/Inthvidual): West Address: Cell (508) 280-6964 CSL-5863 - City/State/Zip- Phone 47 Are Y,01 an employer?Check the appropriate box: Type of project r 4. I arni a contractor and I �' J (required): 1.;Zloyees a employer with ❑ f 6- ❑New construcbm (fall and/or part4ime}* have hiredthe sub-conttractoFs am a sole proprietor or partner listed on the attached sheet: 7- ❑Remodeling slop and have no employees These sub-contractors have 8_ ❑Demolition. working for me in any capacity- employees and have workers' 9. ❑Building addition [No workers' camp:insurance comp.insurance-I required] ❑ V,te area corporation and its 10..❑Electrical repairs or additions requrrrd 3_❑ I am a homt3ommer doing all work officers ha-m exercised their 1 L.❑Plumbing repairs or additions myself [No workers'camp- right of exemption per MGL 12-EI Roofrepairs insurance required-]1 c-152, §1(4),and we have no employees_[No workers' 13_.L�'Utlter comp-insurance required.]' *Any spphong that checks box#I toast also fill out the:section below showing their wodEn'compensation poaT infi3rmatiam Homeowuem who submit this affidavit indicating they are doing alt veA and then hire o=de contractors mosr submit a new afdavit indicating such- 4r,mtractors that rhxh this bout mast attached an additional sheet showing-the name of the sab-moors and state whether or not those mfifies bmm employees. If the sub coutmaors hwe employees,they must provide thdr wcwi-6m'comp.policy number. I am an employer that is prmiding workers'compensation inswrance for my empLayem Below is thepoUcy and job site information. Insurance Company Name: Policy 9 or Self-ins.Lie.9: ExpirationDate: Job Site Address:—X�_ I�� City/State/Zip: Attach a cap} of slue—workers,compensation policy declaration page(showing the policy number and expiration date). Failure fo secure coverage as required under Section.25A of MGL c. 152 can lead to the imposition of grim nal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as 6xil,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 fin estigations of the DIA Pr coverage verification- I do hereby certify re t pair andpenalties ofperjury that the information prodded aboue is trace and correct Signature: Date: Phone#: Official use only. Do not sprite in this area,to be completed by only or town official City or Town: Perruit/License# I Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffdv t Clerk 4.Electrical Inspector 5.P•lumbmg Inspector 6.Other Contact Person: Phone#- 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute, an employee is defined as"...every person in the service of another under any contract of hue, 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-euiploy§persons:to do;mainteii n constntction or repair work on such dwelling house . ,4". a, or on the grounds or building appurtenant thereto;shall, tbecause of such employment be deemed to bean employer." ia.` E' �' nf MGL chapter 152, §25C(6)also states that"every,stateor.Ioca�licensing agency shall withhold the issuance or renewal of a License or permit to operate %, sines or..to constrict buildings in the commonwealth for Pay applicant who has not produced acceptable evidence of com";Iiance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants , Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their cerbifcate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Depar agent of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, lease call the Department at the number listed e P P Y,P p blow. Self-insured companies should enter then self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. Ia addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affids.vit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city,or town may be provided to the applicant as proof that a valid affidavit is on file for future 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 (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would Ile to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts --� Department of 1ndustdal Accidents Office of kvestigafiGns 600 washingtou Street Boston,MA 02111 r Tel.#617-727--000 w 406 or 1-9 -MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.musgov/dia Massachusetts -Department of Public Safety Board of Building Regulations and Standards Cons Supervisor License: CS-D58633�,, , MICHAEL J MCC}AR �� r PO BOX 52 f W DENNIs MA 0267 i y Expiration Commissioner 04/10/2016 -�` ��� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration: 6/16/2015 Tr# 238121; MICHAEL MCCARTHY MICHAEL MCCARTHY P.O. BOX 52 WEST DENNIS, MA 02670 i Update Address and return card.Marls reason for change. SCA 1 Co 20M-05/11 C] Address n Renewal Ej Employment Lost Card