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HomeMy WebLinkAbout0020 WESTBURY WAY a© c��s-�b� w � � t \ +h •Cape Save Inc. { 7-D Huntington Avenue South Yarmouth, MA 02664 - Tel: 508-398-0398 Fax: 508-398-0399 6/27/12 Town of Barnstable Thomas Perry CBO - Building Commissioner 200 Main St. Hyannis,MA 02601 - RE: Building Permits , Dear Mr. Perry, This affidavit is to certify that all work completed for 20 Westbury Way, Cotuit has been inspected by a certified Building Performance Institute(BPI)Inspector. ; Ceiling: R-19 cellulose Ventilation: 8,4x16 soffit vents with air chutes All work performed meets or exceeds Federal,and State Requirements. Sincerely, William McCluskey ' Y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application #090t 3� M,. Health,Division Date Issued 16a5 �/ Conservation Division Application Fe Cn Planning Dept. Permit Fee �S Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address WEST' r Village C, ±IAA ± Owner 0kMS±A11e lyoy'.ne NIAWI+V Address r Telephone Permit Request �� �_�- 19 cell v.k ose +o 4e &. \i c-J :leetr_co e a i c J'en'�.la �6(i to c:a c�C'�—�il;-+� S6'Wi+ Je�1'1'S. N i c- sP�►� ��e aC�i C. o�on Pr amien 4- eov Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay r �-oo Project Valuation a i 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 ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other -� Basement Finished Area (sq.ft.) Basement Unfinished Area(sq ft) Number of Baths: Full: existing new Half: existing 1. new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Court Heat Type and Fuel: A 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 4No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name VMIIA. k0iks6 ve -,.Telephone Number 5 O ' A8 - y 3 9 a Address - (1 ��p� Y� License# 10 Home Improvement Contractor# 1 3?_0 Worker's Compensation # I Wr, 110 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE _ 1 ' FOR OFFICIAL USE ONLY APPLICATION# DATEISSUED MAP/PARCEL NO. ` t ADDRESS VILLAGE OWNER i R . t DATE OF INSPECTION: M ` FOUNDATION FRAME INSULATION' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL R A' GAS: .x• • ROUGH<<: • E FINAL FINAL BUILDING l ' .X 1 G DATE CLOSED OUT ASSOCIATION PLAN NO. 1 .460 West Main Street 4, Hyannis,MA 02601-3698 T (508) 771-5400 F (508)775-7434) ® TTY on all lines n F�®rasing '° .hamxe,*ecodo ,assistance Corporation Cape Cod Free Weatherization ! •; cp do,Your tenant'has requested and is eligible for weatherization �our ���, p` rental home through government funding. This will be prow dAt:no.b,, . cost to you. Program regulations permit us to spend aroun 4;(Zo Qi $10,000 in materials and labor per dwelling unit. 611, Program regulations require us to weather-strip and caulk doors an windows; insulate attics, sidewalls and floors. All work is professionally done by established private contractors. We will conduct a final inspection to make sure that all work is completed to.specifications. If you request, you will be informed of the estimated 'measures before they are done and provided with a list of the actual measures and costs following the completion of the work. We also need proof that you own the property. A copy of a CURRENT TAX BILL OR DEED listing you as the owner will satisfy this requirement. t I Please fill in all blank areas of the enclosed agreement and return with the proof of ownership as soon as possible. _ If we do not receive the enclosed form within two weeks, we will do a basic energy audit of the home, but no weatheriaation work can be recommended or done. If you have any.questions please call Cathy Finn at 508-771-5400, ext. 105. LAINDLORD t, TENANT �Ct� �13- � y PHONE I PHONE 6_ The Property Owner and Tenant authorize the Agency to receive a statement from the fuel suppliedutility supplier as to the quantity of fuellutilities used at the above address in each of the past three years and the future three years. The information is to be used only to determine the cost effectiveness of the Weatherization improvements. 7. The Property Owner agrees that the rent for the dwelling unit will not be raised because of any increase in the value thereof due solely to the Weatherization work performed. 8. In consideration of the Weatherization work hereunder, the Property Owner further agrees that upon the effective date of this Agreement and during a period extending through 2012/2013,approximately one yearfrom the time the work is completed,, a The esent-rent:$=: ' er mpn will not be raised for an reason. The } lm ,:...... Y rent amount must be filled i6ni) inc uded in rent?Yes_ No,.,,,�� However,this Paragraph(8a)will be waived by the Agency.in writing if,and only if,the premises are leased under a state or federal rent subsidy program,in which case the actual rent charged by the Owner shall conform to the. standards of the rent subsidy program Please state which Housing Subsidy pro ram your tenant is on and through which Agency: b) The Property Owner will not institute any summary process action for possession except in the case of non-payment of rent or other good cause related to the a Tenant(or any successor Tenant). c) In the event the Property Owner decides to sell the premises, Property Owner I shall comply with.one of the two requirements below: " I ,-The Property Owner shall not sell the premises unless the buyer agrees(with a I copy forwarded to the Agency)in writing prior to sale to assume all obligations of the Property Owner set out in this Agreement;or The Property Owner shall pay the Agency an amount equal to the cost,as certified by the Agency, of the Weatherization materials installed and labor. I performed in the premises as of the date of sale. Said amount shall be paid to j the Agency immediately upon sale. 1 9. (Applicable only if Tenant's heat is included in rental payment and blanks are filled i In) At the end of the period set forth in Paragraph 8 above,the rent shall not be raised. more than %per for an additional period of one year, and the provisions of 8b and Sc above shall continue in effect for such period. However,the rent provisions of this Paragraph 9 may be waived by the Agency in writing if, and only if,the, premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program. 10. The Parties agree that the terms of this Agreement are incorporated into any other lease or agreement between the Property Owner and the Tenant, and between the Property Owner , and any successor Tenant, and if there is any conflict between the provisions of this Agreement and the provisions of such other lease or agreement,the provisions of this Agreement shall govern. However, if such other lease or agreement, including without limitation a lease or agreement under state or federal rent subsidy program,contains stronger protections for the Tenant,such stronger protections shall apply. r ' 11. For breach of this Agreement by the Property Owner, the Property Owner shall reimburse the Agency in an amount equal to the cost, as certified by the Agency,of the Weatherization materials installed and labor performed on the premises, as well as attorney's fee and court costs. The Property Owner may also be liable for damages to the Tenant in accordance with applicable law,in such instance,the Property Owner shall reimburse the Tenant for attomey's fees and court costs. Without limiting the foregoing,the Agency may at its option terminate this Agreement, by providing written notice to the Property Owner and Tenant, in the event of breach by the Property Owner or Tenant 12. Performance of the Weatherization work hereunder by the Agency is contingent upon the availability of funds to the Agency from the commonwealth of Massachusetts and the federal government,as well as the eligibility of the Tenant under WAP program requirements. The Agency may terminate this Agreement, by providing written notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility of the Tenant warrants termination. 13. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement Pxert}rOwAr's 9gnat urrv, '' �m•� C1,eC i�h Address: MOT �1�t ABLE HO -co to. ;�vi•� �Q G��2. 'ICJ Cw/Y�{�J 146 Sn► HYAft,MA WW' Tenant Signature_0 Date �2 Agency Approved Weatherization Company �� S6L ✓ All C nergy Caliber Building & Remodeling Cape Cod Insulation Cape Save Frontier Energy Solutions Lohr&Sons Resolution Energy Agency Signature Date ` TENANT/PROPERTY OWNER/AGENCY WEATHERIZATION AGREEMENT 1. The Parties to this Agreement are the following: '(hereafter known as Tenant), (print your tenant's name) (hereafter known as Property Owner) (print your name) R and Housing Assistance Corporation(hereafter known as Agency). In consideration of the mutual promises hereafter stated,the Parties agree as follows: 2. The date of Agency's signature will be the effective date of this Agreement. 3. Prope-4 Owner and Tenant consent and agree that the Agency may do the following with respect to the property located at(street,town) o : hu'Aw-:g W&Y unit# and currently IeaAd or rented to the 1tenant: a) Enter the premises for the purpose of performing a Weatherization inspection. b) Enter the premises to perform Weatherization work which the Agency determines in its discretion is necessary and appropriate as a result of the Agency's inspection of the property and in accordance with the appropriate priority list for the type of dwelling. The Agency and the Agency's contractors may also enter the appropriate common areas of the building for the purpose of accomplishing the. Weatherization work. The Agency and representatives of the Commonwealth of Massachusetts, Department of Housing&Community Development(DHCD)may further enter the property to inspect any and all work hereunder. The Agency will provide reasonable notice of the timing of the Weatherization work and inspections. The Weatherization worts will be performed in accordance with the- Property Owner's consent as further specified below: "*'`IPiITIAL ONLY ONE OETNE FOLLOWINfs I consent to performance by the Agency and its contractors of any 3 Weatherization work determined necessary and appropriate by the Agency as a `^ result of its inspection of the property. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of work. I will provide a separate consent to performance by the Agency and its 4t contractors of Weatherization work following my receipt of the Agency's inspection report and a statement of the estimated work and associated value. This additional consent will be sent under separate cover as Attachment A. i , understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work 4. The Property Owner understands and agrees that any and all work,including related ' repairs for which the Property may also be eligible,will be performed at the Agency's discretion. The Agency estimated completion of the Weatherizabon work by the end of. 2012. 5. If the Property Owner is required to make repairs to the property prior to the commencement of Weatherization work by the Agency, the Property Owner will be notified by the Agency and will be required to make the repairs as soon as possible. Except where:, t the Property Owner receives a written extension from the Agency, time is of the essence in the performance of repairs by the Property Owner. The Cominon wealth of Massachusetts Departineizt of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ivww.nzass.gov/dia J Workers' Codrpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): C p g Sl g,vt n G. Address: ke, {�vcn City/State/Zip:sou,-}\+ yac-MoltA, Phone#: 508- 3 0 - 039 S Are you an employer?Checks the appropriate box: Type of project(required): 1.9 I am a employer with ` 3 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.# a 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 I I.❑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 13.W Other _T n S u.,aV t o n-employees.[No workers' 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _Teo n O l 0 T6 S%m-an ae, C M .n _ Policy#or Self-ins.Lic.#: T w C 3 3 l 9 Expiration Date:_ y 1 9 13 1 L Job Site Address: �� + 1� A City/State/Zip: ` tk�l-f Attach a copy of the workers compensation olicy decla ation 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 certt(y under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: _ Phone#: J O(� - 3 9 i'*IX0.3 �� a Official use only. Do trot write in this area,to be completed by city or town official City or Town: Permit/License T 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#: DATE(MMMD/Y Aco 4f CERTIFICATE OF LIABILITY INSURANCE 5/10 YYY) /2012 TH�RTfFICATE 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 BEL6w. 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 ONTACT Risk Strategies Company. NAM Risk Strategies Company PHONE (781)9B6-4400 FAX (781)963-6620 15 Pacella Park Drive E-MAILADDRESS: Suite 240 INSURERS AFFORDING COVERAGE NAIC A Randolph MA 02368 INSURERA:Selective Insurance INSURED INSURERs:Safety Insurance Co an 33618 Cape Save, Inc INSURER C-Technology Insurance CO ari 7 D Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02 644 INSURER F: COVERAGES CERTIFICATE NUMBERCL125948081 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 POLICY NUMBER MM/DD EFF LTR PO DDM'YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY 11O 000 PREMISES Ea once $ � A CLAIMS40ADE E OCCUR PPS1994480 0/16/2011 0/16/2012 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY AprT PRO LOC $ AUTOMOBILE LIABILITY COMBINED ac dentSINGLE LIM $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED 6208200 1/6/2011 1/6/2012 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS E AUTOS Per accident �( Underinsured motorist BI s lit $ 100,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS UAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED I I RETENTION$ PPS1994480 0/16/2011 0/16/2012 $ C WORKERS COMPENSATION WC STATU- O R AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE� NIA E.L EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? C3318007 /9/2012 /9/2013 E.L.DISEASE-EA EMPLOYE $ 500,000 (Mandatory In NH) If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMB $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Issued as evidence of insurance. Issued as evidence of insurance. Thielsch Engineering, Inc. is listed as additional insured as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION msong@capelightcompact.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN . _ ACCORDANCE WITH THE POLICY PROVISIONS. Cape Light Compact Attn: Margaret Song AUTHORED REPRESENTATWE PO Box 427/SCH 3195 Main Street Barnstable, MA 02630 Michael Christian/RAM ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved. INS026 onimmi m Tho Arnon name anri Inn^are ronla*nnul m2rirc of arnian :Massachusetts- Depurtrttent of Public Sllfe'N' 11W Board of Building Regulations and Standards Construction Supervisor Specialty License License: CS SL 102776 , Restricted to: IC WILLIAM MC CLUSKY 37 NAUSET ROAD WEST YARMOUTH, MA 02673 _ Expiration: 6/28/2013 _ f: 102776 Tr - Office of Consumer Affairs and 2uesiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - - _ Registration: 171380 Type: Corporation 3 Expiration: 3/14/2014 Tr# 222184 CAPE SAVE INC. WILLIAM McCLUSKEY =_ _ 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 ' Update Address and return card.Mark reason for change. L Address ❑ Renewal. Employment ❑ Lost Card PS-cA1 0 50M-W04G101216 J/ze�O'�"ZO""`� a�a�uaPlYd License or registration valid for individul use only �, Office of Consumer Affairs&B siness Regulation g (_ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:--171380 Type: Office of Consumer Affairs and Business Regulation Expiration 3/14/2014 Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE SAVE WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE.=, -N SOUTH YARMOUTH;MA;02664' Undersecretary Not valid wit o signs Engi}neering�Dept.(3rd floor) Map - O o Pv Parcel ' 033 Permit# House# '- d-0 Date Issued GX.� " Board of Health(3rd floor)(8:15=9:30/1:00-4:30) Fee $"' Conservation Office(4th floor)(8:30- 9:30/1:00-2:00)' - Planning Dept.(1st floor/School Admin. Bldg.) - THE Definitiv Approved by Planning Board 19 BARNSTABLE. MASS ' �lED MAy a` TOWN OF BARNSTABLE Building Permit Application Project Street Address W ES I iZ v rLy wA�l Village Lo--C. Owner ?NAn ..PI Able, hous104 Ayybop"! Address ►°-lb &ovt)ii s ne 1 j y�N NeS .Telephone P ,,'� Permit Request p-yVFW( a,s4hcz1i $Tn,:o 4 � ^pa t )1 �c► f �4 i First Floor 100 square feet Second Floor N square feet Construction Type i v U u 0 Estimated Project Cost $ 6(10-o6 Zoning District Flood Plain Water Protection Lot Size ,yl g 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: '�J Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) l vo 7 Number of Baths: Full: Existing 1 New Half: Existing New No. of Bedrooms: Existing 3 New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: '�j Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes 12INo Fireplaces:Existing New Existing wood/coal stove ❑Yes -'No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 'gNo If yes, site plan review# - Current Use U4-%mt NJ kX, Proposed Use o)w)(,All- Builder Information Name re,►r�� /�eCr1�Sid, � �(® (�, Telephone Number Address 0, K, 1,pt di R A. License# 3 5- ?3 n,�d.,.ri�h, �/9• :t 6 3 1 Home Improvement Contractor# Worker's Compensation# fxJ i 'Z 0 MS S 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 A.wJ.ST, IN C , SIGNATURE DATE 0-3 1 1-7 BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) a. ;. FOR OFFICIAL USE ONLY PFQtMIT NO. U _ DATE ISSUED - MAP/PARCEL NOS t _ ADDRESS VILLAGE OWNER DATE OF INSPECTION: 1 t = r FOUNDATION- FRAME INSULATION FIREPLACE + ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL •. GAS: ROUGH FINAL; FINAL BUILDING - t E DATE CLOSED OUT ASSOCIATION PLAN NO. Y N L d � Z W V H J •• O� H ti d ¢ •p W S W L O m - ... O ^ C 1 y V Y S CC d H 2 r-; d N V L a d L y O m � y U � u E m i O O A A d OI C N N y m C m C N O Ca m O Y = N OI m �1 f O( • d,TMe ' The Town of Barnstable • �,$ Department of Health Safety and Environmental Services � . Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-790-6227 Building Commissic 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,•r, modernirition, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing t one but not more than our owner occupied area ng adjacent ofning at such reside ce or building be don by (registered dwelling contracto with structures which are ad)a certain exceptions,along with other requirements Type of Work:- (Lvr' ^'S Fit.Cost Address of Work: ' 1/nw WA`� SA/U Iva r Owner's Name 2Anmfi-ATblc ]�eV-J,'% Date of Permit Application: I hereby certify that: Registration is not required for the following reasoa(s): Work excluded by law Job under SI,00L Building not owner-occupied _Owner pulling own permit Notice is hereby given that: OWNS PULLING THEM OWN PERMIT OR DEALING WITH UNREGL ITXM. � CONTRACTORS FOR APPLICABLE ROM GRAM OR G�iJARANFUN WORK Do D UNDER MGLO 142A� ACCESS TO THE ARDITRATI SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. r�/ :3 / 97 �32n�_ -� ���9r Contractor Name Registration No. Date �� �fly�� - T/rc• Cunttrrurn1'calt/t of.1 fassaclluscttti Dclpartnunt of Industrial Accidents Va Oflice a/lavestlgallvns iii7{ �I•' 11 .•hOO lf'ashiu„tun Street %F..•.�.a-•� ':. Bustun.,lluas. 03111 Workers' Compensation Insurance Affidavit �liplirintinformati�n• P1cTse PRINT 61 name! Incotion- city Phone `® I am a homeowner performing all work myself. I am a sole proprietor and have no one workings in any capacity I am an empiover providing workers' compensation for my employees working on this job. coninany n•imt•• G.1'LAlS1 �Gk+bj �'+�BV ee�.lc ) addr"� - `7Es Coyy,l U-rn<:e ' . citv.. Fl knAlrlt f � nhnnc t!• ,�oF 7?1 ��z Z incnrnnrc ^n N.010 LU•C Gmvyp I my.r\ nnlim.0 WI 03 0 2 36' 1 am a soic proprietor. general contractor• or homeowner(circle one) and have hired the contractors listed below who ra% the following workers' compensation polices: cmmmamv nnnnc• adrlrrc— cir—. incur-nrr rn nniic� >l 17 cmmninv nninr- adtlrrcc• city nhnnc#• incurnnce rn 7-177 neiie� Attach additional sheet if necessary ._.., _ ,;,.:.. ..� _.. .. .•,....._; ......�. •.......:._-.++r.a y.�._v: _= _..a Failure to secure covcrncc as required under Section 11A of AIGL 152 can lead to the imposition of criminal penalties of a line up to 51.500.00 ndrur uric ears' imprisonment:1. %ell:13 cit•il penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a dag against me. 1 understand that n copy of tllis-statenicut mnt be funs aided to the Ofrce of Investigations of the D1A for cot•erare verification. 1 do herehc ccrrifr under the pains and penalties ojprrjun•that the information provided above is true and correct Datc I1 3 R Print name Z 1161 R174 AYbI)ITO-X) Phone# T) I -7 o(iicial use only do not write in this area to bc.compictcd by city or town official ` city nr tot%n• Permittlieense# r'ttluilding Department ❑Liccnsin;:Board tt (] check- it immeJinte response is required ❑ Seicctmcn-s UfGcc t 1'. ❑Health Ucpartment k coninct person: phone tJ; rlUthcr �` i Information and Instructions Massachusetts.General Laxvs chapter 152 section 25 requires all emplovers to provide workers' compensation for:, employees. As quoted from the "fa��". an cniPlut•er is defined as every person in the service of ant)tlier under any contract of hire. express or implied. oral or written. An emplurcr is defined as an individual. partnership. association. corporation or other legal entity•, or an}' two or ;r„ the Foregoing enraged in a joint enterprise. and including the le-al representatives of a deceased employer. or the rccci\•er or tntstce of an individual , partnership. association,or other legal entity, employing employees. Ho%vevc: owner of a dwelling_ house having not more than three apartments and who resides therein. or the occupant of the dwcllin�_, house of another who employs persons to do maintenance ;construction or repair work on such dwelling or on the __,rounds or building appurtenant thereto shall not because of such employment be deemed to be an empio" MGL chapicr 152 section 25 also states that even-state or local licensing agency sliall withhold the issuance Of- of a license or permit to operate a business or to construct buildings in the commonwealth for any icant who has not produced acceptable evidence of compliance with the insurance coverage required. Adc::ionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfornt::nce of public work until acceptable evidence of compliance with the insurance requirements of this chapter been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and to the Department rtment of �- �, address and hone numbers as all affidavits may be submittedp su i m_ con arty names. a p PP . _ P Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tire "Ja\,it should be returned to the cite or town that the application for the permit or license is being requested. Accidents. Should you have any questions regarding the "law" or if you are recui ;he eitt f'Industrtal , q - n Departm o ;o obtain a Nvorkers' compensation policy. please call the Department at the number listed below. City or Towns Plea-e he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the ar'davit for you to fi11 out in the event the Office of Investigations has to contact you regarding the applicant. P1 be _ : to fill in the perrnit/license number which will be used as a reference number. The affidavits may be returne -pie Department by mail or FAX unless other arrangements have been made. The Office of Investi=ations would like to thank you in advance for you cooperation and should you have any questic please do not hesitate to _=ive us a =11. Tile Department's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents "` ' =• office of Investigations =u; 600 Washington Street Boston,Ma. 02111 fax r`: (6177) 727-7749 phone �.i: (617) 7'27-4900 ext. 406. 409 or