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HomeMy WebLinkAbout0245 OLD CRAIGVILLE ROAD rr •,``,, _ ' p., r r.;i ,: �., ..., „ r --., ,- ,.: .. ,, 1 � ..,-s y ;r EY,Y�a �., r�,a .,, ,:�-..�: .. .-.. �3:.,,_. c '.� ? :., ...,` a F5b , of •"t," a � rq'. Ail ��, r�i t� �,th t a, 't -'�., s use'" Ia �e TiAi zaa Sx{� syaF f J ke•wr",� ? '�E F a '-%6 d r ' ( r ?Wk"' h y a. v r V 1t Y ^J s n ` : �M 0 5, ` f Y , , r e y,. a a 9 t � a � a 17 #�- I�-I Town of Barnstable *, Perm t Expires 6 months from issue date Regulatory Services Fee sniwsrnBi.E, . A vi�l 16yg A,O�' Richard V.Scali,Di (P rF0 MA't I Building DivisionAPR Tom Perry,CBO,Build Commissionne>� $7 200 Main Street,Hy Syr �g www.town.bamstable.ma.us t 1. 8 IAB Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number J ctoevvi Ile Property Address ? "[S CQ.(4kr r\j l Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name VELL!-A Telephone Number 50 f5 5;Q 4 4 b q Home Improvement Contractor License#(if applicable) Email:Email: V-Z-4- \(0-&,QC L-1�(ti- L >6 Construction Supervisor's License'#(if applicable) o L'J Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner Z'I have Worker's Compensation Insurance Insurance Company Name ACA51� &MA Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Regy ft(check box) f 14 Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) - ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance ofthis 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 Home Improvement Contractors License Si Construction Supervisors License is required. r SIGNAT C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary In met Files\Content.Outlook\2PIOlDHR\EXPRESS.doc Revised 040215 The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information PIease Print L Obly Name (Business/Organization/Individual): Address: <�5 City/State/Zip: + la phone k .501�>- 150 i L4 LL{ Are you an employer?Cheek the appropriate box: Type of project(required): 1. I am a employer with_ A_employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work 9. ❑Demolition ❑ g myself[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on m5'pro Perry. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees, 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp,kmranm: 13.ERoof repairs 5.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4�and we have no employees.[No worker;'comp.insurance required.] any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information 3omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such !ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have aployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site formation. surance Company Name: )licy#or Self-ins.Lic.#: In � , � Expiration Date:_5 ' b -b Site Address:2_4S ttJri,D LG,Q ILL.. City/State/Zip: JJ_ 2 LA4,,V_Z 40-0 ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 id/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a ty against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance average verification. do=erebthepais and p es f perjury that the information provided above is true andcorre 2d !7 Date: zone#: 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 S.Plumbing Insbector 6.Other Contact Person: Phone#: L " mi 0// C� �j,a���� f IW�_ ' 1 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 128957 Type: Individual Expiration: 6/14/2017 Tr# 266936 Oliver Kelly Oliver Kelly 8 Rhine Rd Yarmouthport, MA 02675 -' Update Address and return card.Mark reason for cha sCA 1 is 20M•05111 Address 0 Renewal F Employment Lost C`/�r,'�r,wrnarerietc�l�a�Cll`aur�c�i%i%lli .Office of Consumer Affairs&Business Regulation License or registration valid for individul use only "? #10ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: tq Vigkegistration: 12g957 Type: Office of Consumer Affairs and Business Regulation Expiration: 6/1412017 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 Oliver Kelly 'j=— Oliver Kelly 8 Rhine Rd. Yarmouthport,MA 02675 ", Undersecretary Not valid without signature • Massachusetts Department of Public Safety Board of.Building Regulations and Standards License: CSSL-099167 Const��cCtirsr SiapzrViSorSpecialty OLIVER M KELLY. 8 RHINE ROAD - YARMOUTH PORT MA'.02876 L"�'� CA— Expiration: Commissioner 09/2812017 I aL IL Y Ac�V CERTIFICATE OF LIABILITY INSURANCE DATE(MM'DDm" 05/27/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TH CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICII BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE 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 the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to t certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Christine Davies DOWLING&O'NEIL INSURANCE AGENCY PHONE (508 775-1620 A No: ADDRESS: CdavieS d01nS.com AIL 973 IYANNOUGH RD. INSURERS AFFORDING COVERAGE NAICr HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO I 2266 INSURED INSURER B KELLY ROOFING INC INSURERC: INSURER D 8 RHINE ROAD INSURER E; YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 56798 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERT( INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TI- CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERN EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR L TYPE OF INSURANCE Nsr,' POLICY NUMBER rn POLICY EFF MM/uDD EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMSAIADE OCCUR DAMAGER N D PREMISES a occurrence $ MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PROT- ElJEC LOC PRODUCTS-COMP/OP AGG $ OTHER: I 1 $ AUTOMOBILE LIABILITY I COMBINED SINGLE UMrr $ Ea accident ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS NIA BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR iCLAIMS-MADE NIA AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION I$ ER AND EMPLOYERS'LIABILITY Y/N X 5 ATLITE ERH RIE �� EECUTIVE E.L.EACH ACCIDENT S 500,000A OFFICER/MEMBERIUDD WA WA WA6S62UB2E90137116 05/06/2016 05/06/2017(Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE S 500,000 DESCRIPTION OF OPERATIONS below ` E.L.DISEASE-POLICY LIMIT I S 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more apace Is required) Workers'Compensation benefits will be paid to Massachusetts-employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage:Coverage Verification Search tool at www.mass.gov/lwd/workers-compensationfinvestigationsL CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Hastings Meadow Condominiums ACCORDANCE WITH THE POLICY PROVISIONS. 135 West Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights resen ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Proposal accepted by; Date 04 /10 /2017 If acceptable please si and remit one copy to the address above, keeping a copy for your records, this proposal is valid for 45 days from date above, please call to verify thereafter. 12/01/2009 13:58 FAX 978 685 5900 CARLSON-13MAC 1�1 002/004 E�KEr� Town ©f Bair'><1stlble- ��'�-rmitl/ ' O r, a - S � C` I i CC �'V i ® I+nnllYrA%r, �i s MABH• g •I li n13F F.G-alcr, I IVOCII11' Buildinz Division.* o)A, I tim I'm rv_!1.0. Emil-ding Cirrnmissioncr ;1CIO \tarn Hyannis, NM 02001 - y� NI4:7,�,.Y.S:S:3:A171C.ITTiLU$ /, Fax; 50R490-6230 l�XIIIZI1I'SS )'T,RNII'I' APIDLICr1TION RESMENTIAL ONLY ` VnT L riitr-t-ircnur Rrd.X-Press Imprint Mrya/Ilrlrcrl Nlutthrr � `�� �� ` , l'rl pony A(lclrc L IS- C)ld C42A1 :\•Ii Ili r„r,n, foe rif 5' o0 frrrwork under$6000.00 �ci n2- 01 ICI Nu ", a •culr, �I++1 • ,., - ••- _- I vnl n, nvl�n+unr trrn,. 'r l.lc,cnsc i (,I Irnnl�, - ----•--�• -- ,._ . ,.._ - �a_.. , ' n•I Ilion S r;rv,sor' rGr,n.0•• '`1lhhlic:tt�le) - ----- - - - ... �__J11c„rkn,nn',r C'ontpc:,.r.ruin Ineurnnc:ct l-Itcc.k rinc; , J I nili n sulr 1+rc,l�riclnr 1 1111•1 Ulu I lnmcnwncr 111>rvu Workur',v I;nn111N+t;�uir)n 1n!u�:inr:c In wriit C'I+I y of Insm-nncc C;��mplinn.tr Ccrr+7`Twur ner:nmpauv each permit: Prrmil kc(lrn:sl (clicck bnx) Its ronl'(slril,rilt t,lr.l shir,vlrc i) All crrp,swu6ipl:debris will be ukon to Ll (—] I�c•rpuf(nrtt su•inl,ili�;, f iuinl, ry��,n' t.�iA;lnct In�-cr;; nl'rtx,f) dnua (�� Itrtrlau:untcni G�Inili+��,/iltu�ra/ lillcrry, Ii=ti';1!�ac: -(rnarxGnum .44) of windows - "\Nlu:n:nxtai::d: Is;u,uu r nC+hiti l,r.rn:n rlru�ndl c\cr,p .. hii;,n;c, ish vlhl r lumen .lcliFuti+u:ni rugubuinn+,i.,+ Flialli�� Cmiir,revtlnnr ult: I'topclly 0-11cr nw1 i mpn 1'r,)pvny U..rtrr I..Ctier nl'Permission; A rally of(lie Mine Imprriverrtcul C;ontrtic-tori I.iconse &C'nn.elrncLion Supervisors C,icerise,is en-.j red. '.cif:\,.�',•L•K«_ fir a,�Y= _ �:'�,.i:'-'�},•I .:z:• n,s'IiX1'.1�1:4tillu,, 12/01/2009 13:59 FAX 978 685 5900 CARLSON-GMAC 003/004 r , � Y ON'tZC?�?lil,<►ic)a'y SCrvlCCS I. '1'hnnuly fly (.�L:ilat-, )3irector OAR KrA111Y. I41 A':t I/ l�u,ildirt1; Division , �;jED•„ r '1'nlrL h'rrry, l'iuiJlliu(, C�nnNssigltl:r r.l)�l \d)lili Succl, I lyattrtig,MA 02,60 ,Y ww,lovYn-barn stable.ma_us 1L)IN Fax: 50.8-790-6230 _ I!I;I�iril'A�!'.R l,iCBNSE[xt;MPTTO� ell Jim I.cicKn(iN: O(- y `J -. •o�� . -��: 1J _ _ ..— ..I I,)IYu�.(,tvrl:u' �O� h h Q �• '3�,I-�h . , Sd�_�a��71 .,, •-- '� nhnl,+ IunnC phony,ll �yurk r)Imnn V( c'IIItIt1::W M A I I INiiAII1>1:FSN: C,124 (lJl� ._ Kok--- —••__ ----- ---- ------- ny,l:,u, SN,Ir 7Jr Cotic I'll,np,)unt IL�(,nll>Iv�n f.,, "horn;;own�:lt;" Wax L:Xir nLl;:rl to include,r,,wllC - 1'ru�� wLllj Vf six unilA r�r 1L�yy anti Itl illl(,w htln,ra�irllra',' lu Gn.;nl,c au 111(li,I(In;:! fi)r llhv,, who dpcS rr(,t passcs:( a license,�rovidc(I that ]vi owner ncLv as . sulr,l y.%'lI uEF'INI I iON OF HOMEOWNER I'L;i:;011(4) %VIIll)-QW11S it 1)rrlCCl off•i-etlul Lill Which 1LI WIC r;S1r,Ir!5 (jr intcntls io reside, nn.whicb thcra is, ill'i3 intf-511d0d to he, k1 one ul dw(;l;irlr•;,allachc;ll or dcul(:I,(;(1 suticlurc; abccssory to such useaneVer Earn)struenxeLs. A Ipu ,fill u,}1n c(,n':I,ula', Irllyl'c lhlin n,tc horns i,, ,,„vo y':::Ir period shall notbc eonsidcrcd a bomcowner, Such "IIIo,111L)MUN"r:l,r,ll -WbUlit III Lhc 1316)(linl; O`fl;Llll oil iL folut ncruplablc to the Building Officiol, Nit he/sbr, 1.1a11 be ll 109,1.l) wl)iIL')',crl'�rn,::Ll u:•I(11'r 1,1�„III�iILtlnf;h�nn,l. (Scclit� , I Ire csl)orlsib,l,ry for compliance with the-Stalc 13u'ilding C:wli)and ulhcr III'rI',Ii1:;,1:1G CnI:C�,1)Yli,-v::, rL11CS I•rl(l ;:a'�r1;:L1h115 The UuilL:rsl),n:rl"hurtux+,vinrr" r,r.,lifir.s Lh;t Il,:ra!u;u;ld+.rstands the Towrl of Aarnslable•Buildnig Dcpartrii(mt nlinill)un, in;au,i;II)ll 1) u(;rdures rin(i ,:iuutll:u-,;nli ;17:(1 lh L hclshc will comply wish sai(l p,occdurrs Lnd I'l:rlll� ahcnt:�. d (3AA '�u;n•�ul u � Ilnnu'nwnrr hill"IIYIII of uurl',,nr t I;;ir 1,11 14n11: I1)rec I'luniIy dwell Itims w)1llnlrling l.5 0011)oubil;'Nut of largcr will he rctluirM to cui))plywiai the . tit;uc ftllilllulr,(:n;i�Sxliun 1'.-l.11 (:un::Irurlllu:, C'anhc,i. ' FXEMP'I')ON hur,,r,)w:.n•I,:r`„rinds;wry.i(for which?I building porrnil ie reouirod yblll Ile oxompl fn,rn Iho pfovkinnl of jllis tir:clipn(liCCliarl IGr/.i.l -l:i.-.�nsi"q;f,;c-s;n:c;uc:5"prrv:sors);Pruvidud Iho:if the irointowncr urisiscA A poroull(N) ror hire lu(In AUu11 W"I'k,Ihar 5llph I I,niicu,ynrr vh:dl:a,ILt NL+ny Lunn!uwn,r,e who nor Ilun C.A:mIlhon arc vila wily n That Lhey;1rc arw„nrl1p ills rriponsibilitios aril Kul,rtvlSor(snn nppenJix Q, I:nh:;lr,.1(q;,(lillinn•.1'111.t.icen::irq.,C:n"suuc--lion Scction 9„1.1) Thig lock o�flwhrtneo often results in serious problems,p,rrl,Cu40y Whr.•1,I?rc h,nr)Cuwn-.i 11I:C5 I11llirrn4rd I,6rsons In This c.ve,our buarLl a,i(arnl proceed Ilgninat Lhounlienliued person as it wnuld will(n licensed as is ultinlalc.l rryp:ms lilt ._,.,. _..I:•1;?roI1I:G,vrr.ei:,P.ai; sw,r:nCh.vhr::r:S!,rrlslb,I,UCs,rn„y:ommur>+eirLrrgesl,er�sRottr,.frAarpnrmissp�9iul:vr,, Cl o Supzrvisul On the lZ;l pa sha iSti,eLl.s tars,•—_trtrtsL11Y,wz D; •r.�. .11A(nr.,nu:.,r::n_t;: ,.., :,.c:;111:a:ion rnr u-.,:w your coTlnlj. TY 12/01/2009 13: 59 FAX 978 685 5900 CARLSON-GMAC 11 004/004 l•/;!' �c'Wtn.cTrPYWfr"ldh I)f lYla.C.saCJrTll.�eld5 1 -- - l:)ecr,mme, ; „f"IrlClll,rlrirrl;�tecio�crPs ii •' 1,171,: I•,�ri ll:�LLSr:.i17,lQ/1 ��rl•1'r:'i 1'Y(n•Ic��rs' (:clmpensatintl lnsnl��;1;';� ,�,�iundl�.'„it;; �>.►1ldcrsiGoll>irectors/,l!;lecl:rft�i�l�l,ti/'I''IurLiUci-� r�.�ic�tn( lnfrlrr�l•ati�ti:�_-_ Ple;lsr. r't-itlt f,c ill'.. n � Nillllt: (I�115nu•sti�1-I11;�ulizatian!!n[li,'i�: r!"` ;r• •r �'Je INN • IT_Qa(�(plion __ 5 ©pj-S` laa I -- \1'C ylrn all [tnllllnt rr' (" ILCII 111C It)111 nl,ri;rle l,n.: Type oCprn1t!CC(1'C011llCr,l); - I I:IIII)111y!:L:!( flill: i1111,1�1i1'IIiUI tlii'IGJ,- I ;1111 l I!c"ncral onnrarnr and f G• I71 Ncw :tnaru(lctli' 11:',l: Ili]--Id Ii1P:L1t, }rr11TG ICrti l too on we II ahed shc.c.t. , 7. J.j Reuiodi; ill; shill ;►nil Ills: nu:'n;.111,',�,.[:s Itr.;c: snl,.r:r,lttrlr.lrr,� haVc 3, i)crnnlitinil wlll'I:.II11; fill 11!1 111 All y t.;1jlIICI!M' rtnd'hiivl: workcTs' 9. I � INn wmkl:r!.' '1•I"(:. 1118:11'1111r:r_ ,111a11, 111surallcit " U 13ui1f.liill;'vulcllliun r-•• \.�1 Or 0 0. [.IGGIrir`,1l rCI 1.iir.q k dditlnn!. I'lulllil'CII,l � C i.rr, ,y t;,t)TrinTilll(ln anti IC; I I 44 t, I )Iln T1 Ilnnn;nll'nr:1'doilir ;,,I( vm;- , 11-1 Plumbing, (fir.l.r:r h,'1vc,Ixr:rcls�:�l tl1'=11' g, repairs o1 mlrlilitln: lny);L:II'. I,fdl, wflAm14' L^nln!1 IIl;il► r)l I:;:emt)licln 11cr N10L I�.�;i,pOf 1't'pFlil�S I11glIPItI1rJe irrliim'fl I I 1:�, §1(11), and wC havorio (Nu wurkc•rs' la [] I'CI l: insu[nlu;p ri:gwlr-cl.] "nn,y,tpl-lir.:utl Ihn!clltcks i,)i PI -,wm aisl,;III our C',c tccu:ll?,c-In-, ;Il;wNg Ihcirwusm'compcwtion pnlicy infnroAliri,,,---_- -- 1 11111nr-wilvo.,vlm-,116inll Ibis i111u.1av11 indlca;inf ILcye;r L!nn p.,;'n:,,'!ni-W Avi hire outside conl..utorR n,1131 culnnil,ri n,;-nrr,&; ii inrtiraiinn su46. 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(Al l fnwll ( II;1'It 4. 1•.I(1cirUllollirmpullar S, Pllrml,)Ing lrispnmor The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations r 600 Washington Street S Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):- t..(_i A m f n S Address: 2�J IG� Cf?A V (� u lLLF_ Kt�, � � 0��0 City/State/Zip: � �!a f'1 n t,5, Phone #: m Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.$ ❑ Building addition [No workers' comp. insurance P required.] 5. ❑ We area 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. o workers' com right of exemption per MGL Y � P• 12`KRoof repairs insurance required.] t c. 152, §1(4), and we have no � employees. 13: Other emP Y]o No workers ❑ comp. insurance required.] Any applicant that checks box#I 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: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: . 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 form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' nde t ai a p alties of perjury that the information provided above is true and correct. Si nature: Date: Phone M is®2) �co o AA 9t 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#: