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HomeMy WebLinkAbout0373 STRAWBERRY HILL ROAD W,a -71 JW )#A ep r ht KIM, OMAN WAY gwapp-il MAT Oil 101 4A k, "ANA " "i"Im MIR"1 4 W&H &.Mims Wr. S i­k"�Ip r7r, MIR Ulm, all MOM NU01,14"'i, ffl,'-I VilT @"tit i,fi(ik fN' ;'V110 IN MIMI#nj�V 3.1,1 N'l 1 Tx� ZV'A p�A. f MOM WPM! NOW w- Ana- qvq -N AI 10, Vii W16 MAUR AW10 P1 11A I(I ,� 11 if 1 -1,'j tg�ru,3 IOU NAMUR% K JIM" 1�7 t Nil milt RON NED MIR 7 M"� mgm.--A awn Ulm Kill JPWANIV,�I; nag Mfg KRA Y9 Aiw t"'," gx I'Tr 1; 1 V, Hit Bid va 3w,. .1A !;pimp,WN AMR IV j jj Im .Nag 1q, ,liphr?"I 00 ft.,Wffl!WIS �Afi P, Al PIN 4g, 9 MM rin n V Q "'Ev"Pup IN IN rI"-Q,4-,U�li)l i�gV�I Ali Ilk 14�jv- r�i P W MOM " ,I I -j� 'R,� ,gg og NADI 1, 1v Of j�AI�Xfi IMOF1 M4PW,§%RrR0wfi ANN MIA ' Town of Barnstable Building �.,a;,:m h,_. r ' .� �.�,.�', �4,e„�..�,�%. y"�'k•. '�.�,",�t $ -� s � Z �, � .: � � t;.:3 '�,,. � ;�'�-.;;;.:�". .: r.tl `,`� '� f - a •. Post This Card So That�t;is Visible.;From,the,Street-°A roved:Plans;Must be;Retained on Job and°this.Card Musi be;Ke t ■AR.Nf1TAi63bLM&. M"�' Posted Untd',F,mal Inspect on' lias"BeenMade -, ,' ,� �', P° W er6 a.Certificate of Occu an �sRe erred"such Buildin shalLNot.be®ccu ied until a'."Final;Iris ection has bye and n5` ermit Permit NO. B-18-1583 Applicant Name: Oliver Kelly Approvals Date Issued: 05/23/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/23/2018 Foundation: Location: 373 STRAWBERRY HILL ROAD,CENTERVILLE Map/Lot 248-048 Zoning District: RB Sheathing: Owner on Record: HAPENNEY, BARBARA A ESTATE OF � A Con'tiactor;Name Oliver Kelly Framing: 1 x Address: 135 GRANITE ST Contracto ,Jcense 128957 2 MEDFIfLD, MA 02052 Est P ofect Cost: $7,900.00 Chimney: Y Description: re-roof-yarmouth transfer F e�mitFee: $40.29 _ Insulation: 21 FeeSPaid $40.29 Project Review Req: _ 9 Date 5/23/2 018 Final: Plumbing/Gas ' Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application rid the'J% approved construction documentsJcir which this permit has been granted.- All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes.' Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open foe public hsoect o'n for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable sign tureslby the Building and Firej0fficials are providedFon this permit. Service: , Minimum of Five Call Inspections Required for All Construction Work Rough: 1.Foundation or Footing M , 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy - Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Y - - f - Application number. .:f .-l •••• DateIssued�.. ...........�. ...... ... ................ MAW T� AY�1 ? tuilding Inspectors Initials............ ........ o p�. Map/Parcel........................... .................................. [3 V&`fig TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 3�3 `^� -�`� ►%I ER STREET, VILLAGE Owner's Name•.p Phone Number Email Address. �� �+��� QisPe^� Cell Phone Number&aa�2 5� Project cost Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK E-1 Siding E-1 Windows (no header change)# � E-1 Insulation/Weatherization © Doors (no header change)# ' Commercial Doors require an inspector's review Roof(not applying more than 1 layer to shingles) Construction Debris will be going f ' Y CONTRACTOR'S INFORMATION . Contractor's name Home Improvement Contractors Registration(if applicable) # (attach copy) Construction Supervisor's License# I % (attach copy) Email of Contractor��T�c. � C �/ Phone numberc5b8c509 7 6`L o ALL PROPERTIES THAT HAVE STRUCTURES OVER,75 YEARS 61D OR IF THE SUBJECT PROPERTY IS IN -rA RAI I�,[T/T�►/• A060nVAI aFGnRF a P.FRMIT CAN BE ISSUED. APPLICATION NUMBER ................................................. .... _ *For Ten - is Onl Date Tenn(s)will be erected` Remo d`on . A number of tents total Does the tent have sides?Yes °�`, .' No . . _ es lease attach floor�Y . P plan with exits marked Dimensions of each Tent X X { ,e X . , Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit. ', non-profit event Check one: Food served Yes No r Flame Spread Sheet-of-each tent must be attached.Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial-events'may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# §1VIode1/I.D. Fuel Type - Testing Lab F Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION . Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR'the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. . e Signature % Date 4 5" APPLIC SIGNATURE Signa�LL Date 57 V ' All permit applications are subject to a building official's approval prior to issuance. r :k The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington'Sh" et _ Boston,MA 02111. .mass. www ov/dia g lectricians/Plnmbers Workers' Compensation Insurance Affidavit:]Builders/Contractors/Electricians Print Le 'b Applicant Information ---------------- p Name(Business/Organization/inc ividual): Address: City/State/Zip. Type of project(required): A9mou an employer?Check the appropriate box: general contractor and I 4. ❑'I am a g 6, ❑New construction 1. am.a employer with have hired the sub-contractors employees(full and/or part-time).* listed on the attached-sheet. 7. ❑Remodeling 2.❑ lam a sole proprietor or partner- ; These subcontractors have . g, ❑Demolition ship and have no employees employees and have workers' 9. ❑Building addition working forme in any capacity. insurance. o workers'comp•insurance comp. 10:❑Electrical repairs or additions [I`I 5. ❑ we are a corporation and its required.] officers have exercised their 11.❑P bing repass or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 12. Roof repairs myself[No workers'comp. c.152,§1(4),and we have no 13.❑Other insurance required.]t employees.[No workers' comp.insurance require] #Arty applicant that checks box#1 mast also fill otrt the section below showing their workers'compensation policy u�formafion t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating loch tContractors that check this box mast sifached an addr<ional sheet showing the name of the sub-contract°rs and state whether or not those entities have . they mast provide their workers'comp•Policy uumber. employees. If the sub-contactors have employees, and job site I am cut employer that is p rovidin workers'compensation insurance for my employees. Below is the policy I information. < [ A,a(� Insurance Company Name: t C Expiration Date: ( l Policy#or Self-ins.Lic. Qom, �i City/State/Zip:' Job Site Address: the oU number and expiration date). Attach a copy of the workers'compensation poli y declaration page(showing P �' penalties of a Failure to secure coverage as required under Section 25A of MGI�c.152 engties in th furffimf a STOP WORK position of ORDER and a file fine up to$1,500.00 and/or one-year imprisonment,as well as civil p the violator. Be statement maybe forwarded to the Office of of u advised that a copy of this p to$250.00 a day against verification. Investigations of the DIA for insurance coverage fthe in ormation provided above is true and correct I do hereby c- under a pains and penalties of Date: S" Si e: Phone Official use only. Da not write in this area;to be completed by city or town official Permit/License# City or Town• Issuing Authority(circle one): Inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical 6.other Phone#: Contact Person: 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 id the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual, assoc iation or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides there the m,or occupant of the dwelling house of another who�PIoYs 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,if necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLQ 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/licer se 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"alI 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 questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. T ; The COmm=Wealth of l�tassachizse4ts . NPMI =t Of Industrial Accideutti fie of lnvestigatiam 600 Washingtoa Street Bosta,MA 02111 Tel.#617-727-4400 ext 406 or 1477-MASSAFE Revised 4-24-07 Fax#617 727-7749 www.mass.govldla Ac o� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 05/18/2018 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 be endorsed. N 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 NAME: Joanna Bednark _ DOWLING&O'NEIL INSURANCE AGENCY A/cC No EA: .(508)775-1620 aC Noll: E""AIL jbednark@doins.com A DDRE SS: 9731YANNOUGH RD INSURE 5 AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURERC: INSURER D: 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 270686 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 UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MMIDDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISES a occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JPERO LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acddent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per acddant) $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS Per acddent UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION X STATPE UTE ER TH- AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/F�CUTIVE Y 1 N E.L.EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? NIA NiA NIA 6S62UB8H08580918 05/10/2018 05/10/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 1 yes,describe under 0 SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space 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.govnwd/wortcers-compensationfinvesbgations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street 1 AUTHORIZED REPRESENTATIVE Hyannis MA 02601LL Daniel M.CroM/�y,CPCU,Vice President—Residual Market—WCRIBMA 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD T OKI/ 94 = 0066 of Consurner=Affairs.and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 J = Home lmprovemeal—,C- actor Registration Type: Individual a flLNER KELLY — Registration: 128957 ,� _ ,{ E) iration: 0611312D19 8 RHINE RD ti YAR IOUTHPORT,MA 02675 4 Y� s` Update Address and return card. Mark reason for change. A Tess . Pl F-olowr►?r+t List Card c9C==mwPJfeb5& Region fil±lllfEi0i1l81i COfITRAGTOR _ Registration valid for Individual use only Ir TYP in before the expiration date. H fours return to: €� Office of Consumer Affairs and Business Regulation 06113=19 10 Park Plaza-Suite 5170 { � -' — - B st n�Il, 02116 � Not valid without signature Y&FIMO Ti Hr OFi',MA 02576 Undersecmta� g r Commonwealth of Massachusetts Division of Professional Licensure Board of Building.Regulations and Standards 5 ConstructlAo�t;Sr r Specialty CSSL-099167 a , ires 09/28/2019 : Y � ? oLafER M KI`EI.Y 8 RHINE ROAD. y . YARMOUTH PORT MA�675 *' � s. Commissioner` tie' KELLY ROOFING PH.508 509 4640 8 Rhine Road MA C.S.L#099167 Ywrmouthport MA H.I.C.R.#128957 MA 02875 May 2 2018 Proposal aubnlMed to Mr.Torn Hapanney of 373 Strawberry KH Road Cantmille MA. We propose to supply ae materials and labor required to remove end replace the axWdng asphalt roof at the address above , Protect all walls,Windows,shrubs,plants ak-during roof strip. U 3 C ) AN debris to be removed to town trans*, p 80 White Aluminum Drip Edge to be installed on 9 ell eaves. Ln Ice and Water damage protection membme to be installed on f1mt Sic feet of all eaJ.and �, m around all protrusions. Cr- Remainder of roof deck to be covered with#f 5 felt paper, ' Install limited lifiatime warranty Arohitict style Shingles,dolor to be specified, All ahingles to ba storm nailed (6) Fieplaca plumbing vent pipe boots with new. Repair/Replace all flashings as necessary including Chimney. Install Shingle Vent II ridge vent with hand naked caps. . Complete Clean up off all areas including aB gutters and al nails after project complete At a total cost of$7900 Payment Schedule;Balance upon Completion 4 Proposal Submitted by_Oliver Kally Proposal accepted by: p2. f4 DateX/N/2Q18 This proposal is valid for 45 days from date eve, Pic l se call to verify thereafter. n1 s . • �a' 7�J1. Enp'neehng Dept.(3 floor) Map Parcel :(9 _ Permit# House# Date Issued Board of Health(3200r)-(8:15 9:30/1:00-4:30) —2 Conservation Office(4th floor)(8:30- 9:30/1:00=.2:00) maw-Qe�� Planning Dept. (1st floor/School Admin. Bldg.) �1NE rq Definitive Plan Approved by Planning Board 19 RNSTABLE.�` MAS& 039. TOWN OF BARNSTABLE f Building Permit Applicatio Project Street.Address zcz Village - Owner. Address Telephone Permit Request — (0 t �b cc� � a-ft ok e 4Z— 4pe Q_9— ,> 2 First Floor Y square feet Second Floor square feet Construction Type Estimated Project Cost $1�:& Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: &V_ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sqA.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Total Room Count(noFNo 'ng baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Oil ❑Electric ❑Other Central Air ❑Yes Fireplaces: Existing / New Existing wood/coal stove ❑Yes 21 0 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Attached(size) l ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE_ PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE - DATE �z1,1 Z BUILDING PERMIT DENIED FOR T'HE FOLLO ASON(S) AVa ,.� FOR OFFICIAL USE ONLY PERMIT NO. { R. A- DATE ISSUED -MAP/PARCEL NO u ADDRESS VILLAGE' OWNER DATE OF•INSPECTION: .FOUNDATION FRAME - INSULATION FIREPLACE - " , 1 ELECTRICAL: ROUGH ' FINAL PLUMBING:. ROUGH FINAL GAS: . ROUGH FINAL,' FINAL BUILDING DATE CLOSED OUT, + t E + • i ASSOCIATION PLAN NO. �.,,. Tlrc• Ctrnrrtrurtn•caltlr of:)taslucliusctrs �� -� pepartirrerrt of ludurlrial.4cciderrts 3 ! Offic���layesll�allons + 600 if ushbigrurt Streer Busturr. .91uss: (12111 «orl;crst Come ensntion Insurance Amdavit — Pi / l iicrrt infnrnta inn- _...-• nc--inn- tJ _ I am a homeowner penorming ail wort:myself. 1 am a sole proarie:or and have no'one working in any capaeiry I am•an empiover providing workers* compensation for m%empioyees working on this job. A i 1 cmmiiani' n:rmt•' 1tlrtrr�c• • - Clri" nflnne if, fln11Ct in<nr^nrr rn. - -- - i am a soic ;.ronrie:or. senerai contractor. or homeowner(circle o»e; and have hired the contrac:ars listed be:o« '�'r e the `Oilowin^_ _vcrkcn* compensation polices: c'mmn:rnV n ,rnr nrirlrr— cir ftnne a• rn<nr-nrr rM cnmr,,m n:,rnr. ;ttlr'rr<<• rtt�" ftnne 0• nnitf'� A11--ch additional Shea if ncccz!nry _-�-- ..�... -' •-• - •���'��- -_ :�•^� F:i,iurc to�ccurr cu�•cra cc as required aucr tecu on:.`A of N I G L ISZ can Iead to the imposition of crtmtnaf penaities of a line up to SLSOUX0 anu;c: unc cars' imprisonment a. ,tell :ts cil-il pcnaltics in the form of a STOP WORK ORDER and a fine of 5100.00 a dad•against me. I understand thct cop! isfci rhi� .�rtremcut rna� be furls ardrd to the once of Im•estisstions of the DIA for covera�e rerifieatton. 1«o irercnt ccrrir III ' r rlir wrrirs rrrrrr perrrtltics nfperjun•that the information prorided above is true u/td correct. Oate j/ ///2S/�R ;7 Prig. :::..^„c Phone>~ aRciai a unly do not st rite in this area to be compieted by city or town ofliciai r nermitilicense rs r Uuildin:Department city or town: QLiccnsinZ hoard — cnccic if immediate ret;punsc is rcuuircd [•t�cicetmen +Ufticr '. rjlcatth Dcparttncrt . phone it• r•Uthcr :entac: crsnn: per . . ble The Town ®f Barn.sta Department of Health Safety and Environmental Services BuiIding Division 367 Main Street,Hymmis MA 02601 Ralph Crosser- Office: 508-790-6227 Building Comm Fax: 508-790-6230 For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four registered con rs nits or to structures which are adjacent to such residence or building be done b th certain exceptions,along with other requirements. Type of Work: ESL Cost Address of Work: Owner's Name Date of Permit,application. I hereby certify that: Registration is not required for the following renson(s): Work excluded by law Job under S1,000. —,Building not owner-occupied _ Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABR RAM OR GHOME �ZJA OVEMENT WORK Do FUND UNDER MGLo I4ZA � ACCESS TO THE ARBITRATION SIGNED UNDER PENALTIES OF PERJURY I hereby apply fora permit as the agent of the owner. 1 Czrr� a Registration No. Date ��