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U-Value (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.H'istoric,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. V copy o the Home Imp ove ontractors License is required. TURF: :xpmtrg 306 / /� • 1A q ✓�2C VO'�h/IYCO�IZLIM� �a�C�LUO�LIO � -. Board of Building Regulations and Standards Licence or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR befor(�the expiration date. If found return to: i 1 Boarii of Building Regulations and Standards Registration W1,12977 One Ashburton Place Rm 1301 { Expiration 5/7/2009 Tr# 128790 Boston,Ma.02108 � a l yQe In4diividual MICHAEL J DANGELQ. f 3 rt _ MICHAEL DANGELO / 105 HORSESHOE CENTERVILLE,MA 02632 Administrator Not valid hoot signature i The Commonwealth of Massachusetts Department of Industrial Accidents ~ Office of Investigations ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLilaly Name(Business/Organization/Individual): . l 61 Address: IDS d?APis .a-e City/State/Zip:L/ ou". . —4&4. �y�O 3 Z Phone:#:�SO�J 77, w 7y .Are an employer? Check the appropriate box: Type of project(required):. 1. 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 shipand have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' comp.insurance.t' 9. ❑Building addition [No workers'comp.insurance P• required.] 5• ❑ We are a corporation and its 10.❑Electrical,repairs or additions -'3..❑ I am a homeowner doingall work officers have exercised their 11.El 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: Vd 4/ f r-7 Policy or Self-ins. Lic.#: 7�,Lk Expiration Date: O lob Site Address: foCity/State/Zip: (J Attach a copy of the workers' coifipensation 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Si afore: Date: Phone#( sla') 776-' 3 709 Official use.only. Do not write in this area,to be completed by-city or town offrciaC 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#• Information and Instructions Oz?, 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 hire, express or.implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the renei ortruustee-of an individual.partnership.association or other legal entity,employing employees. However the owner of a dwelling.house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §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 buildings in the commonwealth for any applicant who has not produced;acceptable evidence of compliance 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, it necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or.license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their 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. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questionsplease do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial A.cc di mts Offaec of Investigatioaks 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 446 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.govldia I _� . ��F�►+e'r o . Town of Barnstable " Regul.atory Services 9 Mnss. Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstabl e.ma.us Office: 508-862-4038 Fax: 5 08-790-62.3 0 Property owner Dust Complete and Sign This Section If Using A Builder IA 4te�- ,as owner of the subject proper ty hereby authorize / to act on my behalf, in all rnatters relative to work authorized bythis building permit application for: . cSrCGu �� (A dress o Job) S' nature of owner 4at 47 � Print Name QTORNS:O VTNBRPbRMISSION 7 Client#:3860 2DANGELOMI Qn CERTIFICATE OF LIABILITY INSURANCE 0DATE 4/13107°"""' PF&DUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling &O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR g y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 222 West Main St.PO Box 1990 Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA• Travelers Insurance Company Michael J.Dangelo Building INSURER B: American International Companies &Remodeling,Inc. INSURER C: 105 Horseshoe Lane INSURER D: Centerville,MA 02632 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUREMENT,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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER PDATE IOLICYYMM DO P DATE LICEX'PI D TION LIMITS A GENERAL LIABILITY 168084331-1175TCT07 01/04/07 01/04/08 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGES(Ea occurrence)RENTED $300 000 CLAIMS MADE a OCCUR MED EXP(Any one person) $5 000 X PD Ded:500 PERSONAL&ADV INJURY $1 OOO O00 GENERAL AGGREGATE s2,000,000 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PE 0 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO - ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) IHIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC1766359 02/19/07 02/19/08 X WCRY I IMIT -OTH- EMPLOYERS•LIABILITY E.L.EACH ACCIDENT $100 000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1 OO 000 If yes,describe under E.L.DISEASE-POLICY LIMIT $500 000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATK DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL . I Q DAYS WRITTEN i° 'bZ�.�+ "' 3 � NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR pR REPRESENTATIVES. AUTHORIZED R PRESENTATIVE ACOku ca�cuvuvs 01 2 #47256 LS1 ©ACORD CORPORATION 1'