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HomeMy WebLinkAbout0122 WHITMAR ROAD i s zl,oz of eriV9L17l,9s(oo0 9L•�00 $ Mr zo 109Z0 dIZ S3MOt3 h3Nlid <3Jd1SQd-S(1 #' .. ri+*.}• m m co �o _ ---- m m (Domestic Mail Only, . Provided) a� -1- -:1- � � � L U u•t u-t m m Postage O O Certified Fee r-3 E3 C E3 .Return Receipt.Fee Postmark(Endorsement Required) Here O O Restricted Delivery Fee r—1 r•a (Endorsement Required) -- CO to _ C3 M' Total Postage&Pees �e C3. r3 Sent To orPC o.; ' --- , •----- 'PS Form ��.V LILT. I :0i i0 CD '2 See Reverse for Instructions t1 U CU L ` V N O r U CIS' O (o N O l_ i1 Town of Barnstable Regulatory Services * snxiv MASS ` Thomas F.Geiler,Director �Fp �0. Building Division Thomas Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 August 10, 2012 Richard Capen 122 Whitmar Rd. Cotuit, Ma. 02635 Dear Mr. Capen, w As you may recall, permit application number 201103228 was issued for an above ground pool and requires successful completion of all required inspections before use. Inspection of the above referenced property revealed an above ground pool installed with no barrier. This is a serious life safety violation and must be corrected immediately. Thank you for your immediate attention in this matter. Failure to bring the property into compliance will result in further action by this office; including, but not limited to, filing a complaint with the State. Respectfully, jje . Lauton - Local Inspector jeffrey.lauzon e,town.barnstable.ma.us (508) 862-403.4 pop rliyl�zOG�. - COMPLETE •N i COMPLETE THIS SECTIONON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sig item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse A Addressee so that we can return the card to you. B.deceived by(Prin Name) C D f eve ■ Attach this card to the back of the mailpiece, .CJfl,�� (on or on the front if space permits. K D. Is delivery address different from Item ? es 1. Article Addressed to: ' f' If YES enter delivery address below: ❑No I V- i air I 3. Se Type �Au kjr1 AAA, 11 L—v� J ed Mail ❑�less Mail ❑Registered WR m Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (transfer from service label r r r; { t:' 7 CI OQ6t 0 814' O O O t] 3G5 2jq C 3 8 3 PS Form 3811,February 2004, Domestic Retum Receipt 102595-02-WlW UNITED S "Op TAT m e �FA@,%'aify II • Sender: Please print your name, address, and ZPP+ in this bo'x' w TOWN OF BARNSTAHLt i �'�. �4UtL�1INa D�'VISIC?W a��ry' I 200 MAIN 3% HYAN GSr MA OM i} t I �f?diif.l�3:111llifflii fill!131 Postal mCERTIFIED MAIL. RECEIPT m (Dotne&ic Man.9nly;No Insurance Coverage Provided) For delivery information visit our website at www.usps.cofflo Ln m Postage $ o ��PNNISa M Certified Fee CReturn Receipt.IF n Postmark ere TO (Endorsement Required) fV I�?01� Q O Restricted Delivery Fee w r 1 (Endorsement Required) CO C3 Total Postage&Fees $ ,*!!N S O Sent To C3 orPO Box . ..... .. _ Spate,Z/R+A A—PS Form u (p :ri June 2002 Cerfified Mail Provides:.• A mailing receipt ae(a� ay)ZOOZ eunp'ooes W,o=l sa • A unique Identifier for your mailpiece A ■ A record of delivery kept by the Postal Service for two years 1100ortant Reminders: • Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. • Certified Mail is not available for any class of international mail. ! NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. • For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811•),to the article and add applicable postage to cover the fee. ndorse mailpiece Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required, ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". . ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. WORTANT:Save this receipt and present it.when making an inquiry. Internet access to deliveryinformation is not available on mail addressed to APOs and FPOs. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 676 Application 03 6��z� Health Division Date Issued t 7� Conservation Division Application Fee 6 Z. Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address a� W k I+�-ncr ad. Village Coto l 1}' Owner ri Gh ar(A + Sharon ( AVjfn Address 5�Yn.e. Telephone Permit Request nml 9,0 X Li VAL, td� ; Square feet: 1 st floor: existing proposed 2nd floor: existing • proposed Total new Zoning District Flood Plain Groundwater Overlay /`—Project Valuation Construction Type rot 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 r new —� 9••»fi E� .� Q Number of Bedrooms: existing _new O Total Room Count (not including baths): existing new First Floor doom Count" -� Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other v ' Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood coal stoke: ❑ s ❑ No 50 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 1 r J Sham oi. Telephone Number H Z z�J�v'3 3 Address ���' '� iGt 6?16C License# Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE to i•C FOR OFFICIAL USE ONLY c — = APPLICATION# DATE ISSUED ` MAP/PARCEL NO. I�4 e t : 1 x 'S t ADDRESS VILLAGE G OWNER Y, DATE OF INSPECTION: 4 FOUNDATION ti FRAME y4 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 'i GAS: ROUGH FINAL r FINAL BUILDING g 12 I� lq�lZ 4 1 t DATE CLOSED OUT r ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Departtrient of Industrial Accidents Office of Investigations a 600 Washington Street -Boston,M4:02111` www.mass.gov%dia Workers' Compensation Insurance Affidavit:'Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): R_t_ W4V_J 6 i Address: City/State/Zip: y'Vyi �1 ( S Phone.#: 5� . ��L : "' 19 3 3 ��- 02=3 Are you an employer? Check the appropriate box: ;Type of project(required):. 1.❑ 1 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 listed on the-attached sheet. 7. ❑.Remodeling 2.❑ I am a•sole proprietor or partner- These'sub-contractors have ship and have no employees 8. ❑Demolition, ' employees and have workers' working for me in any capacity: comp, in 9. ❑Building addition surance.$ [No workers comp.insurance 10.E].Electrical rep airs or additions required.] 5. �.We are a corporation and its 3I 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 re aired. t c.`152, §1(4),and we have no" q ] 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 anew 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.Lie. #: Expiration Date: City/State/Zip! Job Site Address: 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 a 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 Date: _ �Lo.� Si mature: G Phone#: 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#: 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 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 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 shalltwithhold the issuance ort 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•cornplianee 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 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 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 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 questions, please do not hesitate to give us a call. The Department's address;teleplione-and fax number: s The_Qom onwealth of Massaalxusett Department of Indlustdal Acddi mts Office of nY.es-tIga#tons 600 W?sllingf6ii Street Boston,_MA Q2111 TO. # 617-72:7-4900 ext 406 or 1-877-MASSA.FE Fax# 617-727-7749 Revised 11-22-06 . wwv.mass.gov/dia Town .of Barnstab..le Regulatory Services Thomas F. Geiler,Director MA-M 1639. �� Building Division PrfD �k Tom Perry,Building Commissioner . 200'Main'-Street,_Ayannis,MA 02601 R'Wv.to Wn_b arnstab l e_ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOV ER LICENSE EXEMPTT011 Please Print DATE: JOB LOCATION: � °L�L t.J���YvY,� V c.d✓�c� ��\ 1 number street vil}age . "HOMEOWNER": 1\ 1. -?/(/� 5_68 '4 ZF (533 (AT7 25 name home phone# work phone# CURRENT hIAILING ADDRESS: city/towa state ap 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. DEFIhMO1N OF HOMEOWNER Persons)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 be/she shall be responsible for all such work performed under the building permit. (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-Ahe understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. 1. Signature of Ho owner 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. HOMGOWNER'S EXEMMON The Code states that "Any homeowner performing work for which a building panvt is required Shan be exempt from the provisions of this section.(Section 1D9.1.1 -Licensing of construction Supcnrisors);provided that if the homeowner engages a person(s)for hire to do such work,that Such Homeowner shall act as supa-visor. Many homeowners who use this exemption art unaware that they are assuming the responsibilities of a supwvisor(see Appendix Q, Rules&Regulations for licensing Construction Supervism,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 responsrb)e. To ensure that the homeowner is fully aware of his/1ra responsibilities,many 66mmunities require,as part of the permit application, that thehomcowncr certify that hrlshe understands the msponnbilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/rcrtifrcation for use in your rDmmunity, Q:forns:homecacmpt • 4 -THE rti Town of Barn-stable f f Regulatory Services ores $ Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner- 2 00 Main Street, Hyannis,MA 02601 Y ww.town.barnstable.ma,us Office: 508-8624038 Fax: 508-790-6230 7 f ,, Property Owner Must. C } Complete and Sign Thzs Section FI-i I tlf Using A uilder as Owner of the subject.property hereby authorize to act on my behalf, in A matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date t) Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. :FORM S OwNERP Q ERMIS510N L. X 10 LO 1FIE INCH //' p/ - 102eg1 - him I✓ r 6L .. IN, ; i I i 3Z ' _ r.. ..... ........... . _ -- t .. l If , I .G a CQ T/O/t/ GsWit/ O.�T.E .- EQU/,eE�-1EiC/fS :OF T.�YE '7'o1-Iiit/��" , I BAXT.E.CE 4if/ .EEG/STE,e�� L.q,c�Q SU.eY6y2�r_� - � I I t P Hi c€ gn ` « Y WN ,• 4 r 4 Intex 20' x 48" Ultra-Frame Backyard Above Ground Pool Item Description Cool off in your own backyard with this above ground pool. It features a 1500-gallon filter pump and a ladder with a safety barrier. Plus, you can start the fun right away — this above ground pool is easy to set up. Intex Ultra-Frame Backyard Above Ground Pool: • 20' x 48 above ground pool • 1500-gallon filter pump • Ladder with barrier • Debris cover • Ground cloth • Deluxe maintenance kit • Volley ball set • Above ground pool requires assembly Town of Barnstable *Pe rmit#1'`- L�f'��7 Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director Building]Division b� Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESSTERMIT APPLICATION' RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address l Z2. a P-- —t pi AIL_ Residential Value of Works 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Ci- tLc� S44t,2--VIs _bO u i—( Contractor's Name L-C Telephone Number Q q 4�Lg 402Y Home Improvement Contractor License#(if applicable)_/4 2 -2 Construction Supervisor's License#(if applicable) C L�3 �Workman's Compensation Insurance Check one: ❑ I am a sole proprietor IT I am the Homeowner X-PRESS PERM I have Worker's Compensation Insurance 2008 777"' S p p Insurance Company Name /'Lgri--)1 A- 1 A•l U il�f1->�Cr='� Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will.be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) '`~---._ *Where required: Issuance of this permit does not exempt compliance with other town department regug ft.et;iistoric,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permissie�._t, 11 �Cf} d—�,� (� � Home Improvement Contractors License is required. 'r` ' t�a SIGNATURE: a Q:Forms:expmtrg Revise071405 4 The Commonwealth of Massachusetts • • . •� . Department of hidttstrial`Accidents , office of Investigations . 600 Washington Street Boston,MI 02111 www-mass gov/dia Workers' Compensation Insurance�idavit: Buflders/Contractors/Elect;iciaris/Tiunn]bers licant�form.ation ' Please Print Le 'bl s/Orgaaizationlfadividnai)'' 60-f�I DG Go7�-,puSAS Lcr s Fame( ines Address: 3 • ' tate%Zi�''ir �L Zv�u<� �-�a v P]ione#:' : S"U� '�• ��Q2� _ • .: City/S . P• kre you an employerT Check the.appropriate box,. -Typo of project(required): Z am a employer with A ❑ I an a general contractor and I _6, []New construction (full and/or p -time).* have hired the kb-contractors : �. ❑Remodeling employees listed'on the attached sheet $ .❑ I am�a soleproprietor or partner- Demolition ' andhaveno employees. These sub-contractors have .$• •❑ slip workers' comp.insurance. g, ❑ Building addition working for me in any'capacity. iasmance 5. ❑ We are a corporation and its [No�'°rk cam' officers have exercised their 10.❑Blbctncal repairs or.additions required-] right of exemption per MGL 1I.❑ Plumbing repass or additions 3.❑ I am a homeowner doi_4g an work c. 152,§1(4),and we have no.. 12. Roof repairs myself-[No workers camp. to ees. o warkersL insurance regafred.]t �p Y 13':❑ Other ; camp.insurance required] Any appg=tthaf checks box#1 must also fill outthe section-below showing their workers'compensation policy iafo:mation: `. . Homeowners who anbnjiitWs affidavit indicating they an doing&//•work andthenhire outside cantraeltrtq must submit anew a$davitmch h Contraclots that check this bna,must a#=hed an additional sheet showing the rime cf the sub-contractors end thaw worktirs rvmgkpokie�r' f am an employer that is providing workers,compensation Insurance for my employees.'Below is the policy and job site Information-' [nsurance•CampauYName: 1�L� S U . Lic. Expiration D ate: Policy#or Self-ins Job Site Address: (22 (;t/ � p�l I�it1 ZF-t'I City/State/Zip: �C�3 �'- Attach a copy of the workers, compensation policy declaration page(showing the policy number and•expiration date). FMIMto.secure coverage as reguiredimder Section 25A of MGL c. 152 cadleadto the imposition ofciiminalpenalties of a fine up to$1,pO,.OQ and/or one-year imprisonment; as well as.civil penalties in tke form of a STU VO M ORDEP,and a fine of up to$250,06&day against the violatdr. Be advised that a copy ofthis statemenim0e forwnded to.the Office of .' Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of pe►jury that the Information provided above is true and correct. . Si stare: Date: " � '�S• . Phone# 5�$ Q-28 Q O2g Oiclal use only. Do not write In this area,to be completed by city or town official. City or Town: PermitUcense# Issuing Authority(circle one)& 1.Board of Health I Building Department 3.0ty/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6,Other CoataetPerson: phone Irk and Instructions. .J Information . . for their loyees. ' ter 152 t Hires all employers to Protnde workers comPensatian �F Massa General Laws chap arson in the service of another under nay contract of hire, mute, an e1+pioyee is defined is"...everyP exprPursess us6r�li�o�or written." or more { ratio oration or other legal=tity,or any two, ' An employer is defined as-I:4 iAdt!ridP�•PAMeqVP'',asso f P or the' the legal representatives of a deceased employer, ed in a joint enterprise, and inclu3mg to to HoRteyer: e of the foregoing,engaged association or other legal entity,employing emip YM- receiver or trustee of as indfvidua],partnership, artznents and who resides therein,or.the arcapaut of the owner of a dwelling hour a having not more than ftlree ap ' house of another who employs persons to do maintenance,construction or repair woil�tin such dwellingohouse dwelling other.appurtenant thereto.shall not because of such employmeatbe dee?ned to be amp Y or on The groundsor MGL chapter.152!�25C(6)' also states that:"eye'ystate;or local licensing agency, shall withhold the issuance or cease or peter to operate a business or to construct buildings in'thee t'c�Ye agoawiee required' •renewal of a Ii produced acceptabie eyidence•-of compliance with the ins applicant Who,has not p states"Neither the commonwealth nor any of its'polideal subdivisions shall AdditionaIly,MGL chaPteT 152,125C('� • into any contract for the performance of public work until acceptable evidence of comPkaace with�e insurance enter havtbeen resentedto the contracting authority." =eq#emeuts of this chap P Applicants ; ' to nr situation and,if. ensatiou affidavit'completely,by checking t oboxes that apply y4 Please fill out the workers' � name(s),addresa(es)and phone numbers) along with their certificates)of necessary,supplysub-contractors) with no employees other than-the insurance. Limited Liability Companies(LLB or Cleated Liabilit}i it fmrtn railee.(i f, We not required tc9 car; workers' aompensatioa insurance. If,an LLC or LLP does have members or partners, be submitted to the Department of Industrial employees, &.policy is required. Be advised thatthis affidavitmay . The davit should on of msnrance coverage,.'�llsb be'snreto sign and datethe Ada not the:Depar6meat of Accidents for confumati.tM that the application for the.permit.or license is being req tech _ be returned to the city uestions regarding the law ar if you are required to .- Industrial Accidents, Should xon have any g anies ahonld'=ter their,. compemationpolicy,PleasecantheDepartmentattheuumberlistedbelow.. Self-insuralcomP self-insurance license number on the appropriate line. r City or Town Officials ace at the bottom davit is complete and printed legibly. The Department has provided a sp please be sm'e that the affidavit haslicamt. f lvestig2tons of the affidavit for you t. fiIl out in the event the whichffict w�be used as a refereace member. In addition, an applicant Please be sire to fiIl in thepermitll cease nwaber which le =3it/license applications in any given Yen,need only submit one affidavit indicating current ity o thatm must submitz�tiP P or information(if necessary)and under"Job Site Addr 3p ed or applicant t should or��lmay beep ovided to the policy davrttbathas been of5cially stamped or mark. by c�tY ,A�),"A cCPy oftho' licant as proof that•a valid of fida-A is an•filo for;fat)ze permit orn ed to any ass or commercial venture app year,Where a home owner or citizen is obtaining a license or p ie.a dog license or permit to burn leaves etc.)said Person is NOT- required�o complete this affidavit ( k you in advance for your cogperation and should you have any questions, The Office of Investigations would like to than..y please do nothesitate to give as a call. TheDeparimeafs address,telephone and•faxmimben The Commonwealth of Massachusetts . `' •„ Iep aztment of IndustriaLAccidmts • ' . . .office of T.tivestigatiops , .600'Washingf on Street <<.:ta Boston,MA 02111.• 'Tel.#617-727-4900 ext 406 or'1-877 MASSAFE Fax#617-727,.7749 „____a r ��s5 ,�racray.maGs.�ov/ilia . ilk o A 7�t Town of Barnstable ti Regulatory Services • BnxxsxeBi.E, i Mnss. Thomas F.Geller,Director �E039. Building Division. Tom Perry, 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 _(!fWCZ 1(- 70�-PJUS(55 (PLC to act on my behalf, in all matters relative to work authorized by this building permit application for: VL W-h-WA-e�2',V, G�u i 7 (Address of Job) Signa of Owner ate I&C WAD Print Name C Q TORM&OWNERPERMIS SION Client#:51439 .f A-CORD,. CERTIFICATE OF LIABILITY IN CAPEENT S RA C E DATE(MIrpDDmm) PRODUCER 04/15/06 Rogers&Gray Ins. Plymouth THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 341 Court Street ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O.Box 3700 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Plymouth,MA 02361-3700 INSURED INSURERS AFFORDING.COVERAGE NAIC# Capewide Enterprises LLC INSURER A: Firemen's Ins.Company of Washington PO Box 763 INSURER B: Acadia Tnsurance --------------- Centerville,MA 02632 INSURER C: INSURER D: COVERAGES INSURER E: 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 MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT POLICIES.AGGREGATE LIMITS S EJECT T OR SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. O ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH LT S TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLIC EXPIRATION A GENERAL LIABILITY CPA0215624 LIMITS X COMMERCIAL GENERAL LIABILITY 04/3OIO8 O4/3D/O9 EACH OCCURRENCE $1 000 000 . CLAIMS MADE-Q OCCUR DAMAGE TO RENTED. $250 000 MED EXP(Any one person) i5 000 PERSONAL d ADV INJURY S1.OOO OOO GEH'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE.17-1 ;2.000 OOO POLICY J Ca LOC PRODUCTS-COMPIOP AG G '32 OOO OOO B AUTOMOBILE LIABILITY MAA021562510 04/20/08 04/20/09 ANY AUTO COMBINED SINGLE LIMIT ALL OWNED AUTOS (Ea accident) $1,000;000 X SCHEDULED AUTOS BODILY INJURY X HIREDAUTOS (Per person) $ X NON-OWNED AUTOS BODILY INJURY (Per acddent) S PROPERTY DAMAGE GARAGE LIABILITY (Peraedden0 3 ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC .$ B EXCESSrUMBRELLA LIABILITY AUTO ONLY: qGG $ CUA021562710 04/20/08 04/20/09 EACH OCCURRENCE . X OCCUR CLAIMS MADE S2 000 000 . AGGREGATE s2 000'06w . DEDUCTIBLE S X.. .RETENTION $10000 B WORKERS COMPENSATION AND WcA025019610 EMPLOYERS":LIABILITY 04/14/08 04/14/09 X WC STATu- OTH 3 ANY PROPRIETORJPARTNER/EXECUTIVE OFFICER/MEMBEg:EXCLUDED7 E.L.EACH ACCIDENT $560 000 If yes,describe_under SPECIAL PROVISIONS below E.L.DISEASE•EA EMPLOYEE $500 000 OTHER E.L.DISEASE.POLICY LIMIT $500 000 - DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICL.ES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE-CANCELLED BEFORE THE EXPIRATION Town of Barnstable DPW 200 Main Street DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 4n DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE To D0 SO SHALL Hyann(s,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS CR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE - ACORD 25(2001/08)1 of 2 #S35390/M35379 DAC O ACORD CORPORATION,..., i r �/re �aninzo�uueallL o�✓�aaaac�uiaelfa Boardof Building Regulations and Standards HOME+IMPROVEMENT CONTRACTOR 143358 8/ 010 TrW 726,2 II 2 2. 7 {, 8/liability.Corpor j CAPE l*+1 f: f 02fi35 Administrator r st cmae (ond floor): )number ................................r � �� d� p SEPTIC SYSTEM MUST THE ro`♦ INSTALLED IN C®MPLIAW . . oard of Health (3rd floor): . �� °3! tewage Permit number �' ...................... . .... WITH TITLE 5 t BAUSTADLE. !,,,pEngineerinjg Department (3rd floor): —/ F111 J� t ' °�@ ®�ME�T�L ®® oo i639 \e�� House number ........................................... ........................... i _, r d ,sue APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only, TOWN OF BARNSTABLE BUILDING INSPECTOR �-��t APPLICATION FOR PERMIT TO ..Ca.hf.S. ................�1�/.K.�r/�..�i�f,�??i�i,{A�4t,............................................ TYPEOF CONSTRUCTION ./�#Me...................................................J................................................................ ��. 3.. .....i9 .7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies ���i l:� applies for a permit according to the following information: � I(�Location .......4 �... ...... t�lvl i?/�.... .P.4.4.... ProposedUse ..4).f.!)( (. !hr.ly...l..'.�.f?-........................................................................................................................... Zoning District ......... ....i. .................................................Fire District ..C,0&,.t............................................................ Name of Owner ...R�..t1 �............................................Address ` /.R.�aXl/�..�ll��..../..!�7RiY/✓/5��. Nameof Builder .............. .......... ..........................................Address ... ................ ......................................... Name of Architect ./.Y°!-gilwQ,.•!!!SP� t...............................Address Number of Rooms ..pa.6mjs.........t......................................Foundation ..P,6.Ltf:'4..60wgt,e ' ................................... Exterior n .�/.!Yq/eS.. �i¢�t?o ..� .QeQ. ................Roofing .../.1. ..1.. /�Q1ltYC . -S'.......................................... I n U lFloors ......... . ...CIA...... .�.....T.t6.....................Interior ... 5 . o. ....................................................... ...........:Plumbin ....�.l;V.v..... .t?..f. Un��.S.....................:. rieating ..`. . . g Fireplace ...1: 10�....................................................................Approximate Cost .1... v�..�.�.�....... /(L� Definitive Plan Approved by Planning Board l 19°__J— Areat/.ay.S2J20f:.....Pa�^Cli.A2, p \ Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH ��C V ® ,d O OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name I Construction Supervisor's License .. .. .. .......................... ROBERT C. .3.1.5.34. Permit for ...1....Story.................... .. . .... .. .... Dwelling & Garage .......................................................................... Location ....Lot....#.1.6.........1.2.2...W...h..i........tma.r...Road .. .. .......... ..........Cotui................t ................................I......... J 'Owner ......Robert C. Healey ................................................... Type of Construction Frame .......................................... PlotLot ........................................... ............. Permit-GraMed ......J.an.uary...5...........19 88 Date of lnspectiorf� ..............................19 Pate ......... Completed .//7........... ... 19 0, 0 W 7: S�Assessor's offioe (1st floor): ,Ail / ^. FTHET Assessor's map and lot number ..D��......�.�..'......... �o 4913oard of Health (3rd floor):. Sewage Permit..number ................................................ 339HasTdDLE, S 6P,Engineering Department (3rd floor): -/ a 26}9, House number ........................................f.C........................ APPLICATIONS PROCESSED 8:30 9:30 A.M, and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..G.,.t^.nfs u �` !rr .f'. R ,f? ?� �. 1vs:� ............................................ TYPE OF CONSTRUCTION .6AQt Mjt ................................................................................................................... f �f' 19 c 7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ,rr - Location44 ?�!? t) ?f... ! .... ? ..... .f,f !. ........................................................................................ ProposedUse + f Jd c La t' /1,t�.�F�.. ?.Y,.S: ..................................#...................................................................................... Q............... �i Zoning District 1f . ..............................................Fire District .. nw: Name of Owner .jRsr ....Address Name of Builder7t LJ� Address ""1 .�� �ry.....,.. .,.� ............ ......................................... Name of Architect ...................................Address � ?� � 'free> .ow B...................... r� 0 11 Number of Rooms..26.fh:,5..............................................Foundation f9 .F .Fte? .f,`aar+a! ?�.................................... Exterior ................Roofing eiNR, pig /? .......................................... r� Floors ........_)./A,..... f- . .....................Interior : Heating g / l-, Ururh....................................... Fireplace ....................Approximate Cost3 l 0 -©�O . ................................................ ...a� t�t J . . ..... Definitive Plan Approved by Planning Board __ �. c/1--------_---19 u__ Area ca:S ,,.� f? ..... p.m.A. r Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH i OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name r ` '/, e' .�: Construction Supervisor's License ( ' ................... HEALEY, ROBERT C. A=056-076 No 315 3 4..__ permit for .....One Story Dwelling & Garage Location .....Lot...#16 , 1.2..2 Whitmar Road ....................Cotuit ................................................... Owner .......Robert C. Healey .................................................. Type of Construction Fram.e .. ............................. ............................................................................... Plot ............................ Lot ................................ January 5 , 88 Permit Granted .......................................19 Date of Inspection ....................................19 Date Completed ......................................19 ! art 10 X-10 10 1ME INCH Y ..T vY vk1-Ne Si,entoc riAE !O 2@C1 71 ' 1 •— j f �� NI , y i , I a i ! "! ; fdA I I r I t I ij i_.lets v ,� • :1" I { ? .i � �.. �— DTI ' r r 7 .{ _� j I _i E,e. . T �/. %EO. ; 1A "f�'� T%OTC/ %7 X 7 7 }ZOC.4 ?E4v%.�EiilE�c/TS _U�'-THE Tot�siit/�aF � ; � .eE�' CSC j 8 1 . .BA XT,E,C E.VyE /,c/C. <SEO �� I it TOWN OF BARNSTABLE BUILDING DEPARTMENT I _ HOMEOWNER LICENSE EXEMPTION Please print. w/ 3 J06 `LOCATION 1 f' 1� � ®au/� A/;f umber treet a ress - ectio off. town "HOMEOWNER �= 9 3 _ 1.9 3 a, ame k : Home p one: WorK phone_ PRESENT MAILING ADDRESS S� (D ty town tate° ip co e The; current exemption. for ."homeowners" was extended to include owner•-occupied.• .(wellings.:of six units-or less and to al low'such 'homeowners':to engage..an :in- iv uua <for hire who:does not possess a license' provided that 'the owner acts' as` supervisor. (State Building Code Section . °,'DEFINITION OF HOMEOWNER: Perso'n(s) who owns a parcel. of land on which he/she resides or intends to re- °side; on.:which there is; or is intended to be, a one to six 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 bui-iding permit. (Section . "The undersigned "homeowner" assumes responsibility for compliance with the State -:.Buildi:ng Code and other applicable codes, by-laws, rules, and regulations. _ The undersigned "homeowner" certifies that he/she understands the' Town. of , rnsnbleBuilding: Departmentlinimum inspection pH' e'dures -and' requirements Viand that he/she will comply with said procedures and requirements 5: HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL ;Note: Three family dwellings 35,000 cubic feet;"�or­larger, will be required to ,-Comp.ly .with State Building Code Section 127.0, Construction Control. .. oa -.- 8 ee .. i HOME OWNER'S EXEMPTION ------------ The Code state that : "Any Home Owner performing work for which a building permit Is required shall be exempt from the provisions of th (Section .109.1 .1 — Licensing of Construction Supervisorrs) ; .'provvidedithatcifoa Home Owner engages a person(s) for hire to do such work, that such Home. Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assumin the responsibilities of a Supervisor (see Appendix Q, Rules and Regufations for, Licensing Construction Supervisors, Section 2.15) . This lack of awareness often,,,results in serious p'>f9biems, particularly wh unlicensed en the Home Owner hires persons. In this case our Board cannot proceed against the unllcensed person as It wou"Id with licensed Supervisor.. -The Home Owner acting ;uas. supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of 'his/heJr responsibilities, man communities require, as part of the permit application, that the.'Home Owner certify that he/she understands the responsibilities of a supervisor . On the last,'page of 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. Vo ' F �o a TOWN OF BARNSTABLE Permit. No. .31534 BUILDING DEPARTMENT OC 4 �eaz� I Cash ■a. TOWN OFFICE BUILDING ,;v HYANNIS,MASS.02601 Bond ................ CERTIFICATE OF USE AND OCCUPANCY Issued to Robert C. Healey Address Lot #16, 122 Whitmar Road Cotuit, Mass. , USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. NoVember 15, 88 ............................ 19................. ................ Buildin Inspector TOWN OF BARNSTABLE, MASSACHUSETTS BUILDING . PE RM1 T.` A-;0 36-,u'6 DATE ii,t Y 1+ 19 88`a Y PERMIT r f APPLICANT , ADDRESS (NO.), (STREET) (CONTR'9 LICENSE) ..:.. NUMBER OF i STORY 3T„ A DWELLIN PERMIT TO .'1 I �'.. nl '1 G UNITS 1 �O IM _Rl ITN 1 �� N0. `' (PROPOSED IISE1. ZONING AT (LOCATION) -- 1 nt 1:1(i 1:..5 .:ra :'l''tli• D STR CT_ RE (NO.) (STREET) BETWEEN AND (CROSS STREET) (CROSS STREET): SUBDIVISION LOT LOT BLOCK SIZE BUILDING IS TO BE FT, WIDE BY FT. LONG BY FT, IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION; TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS: ioerner) $ 60t��Q0 AREA OR VOLUME S /r>; ,.,� PERMIT (CUBIC/SO UARE FEET) QQff 3p ESTIMATED COST $. � ZI).f!t��} FEE fD�.�J2.�`S�'`. _ OWNER .'i,.5- t a I r.,.r ... ADDRESS ;., BUILDING DEPT. :j� �,t �7j, BY Ff !, -.._ .. ' ��F R O M THE DEPARTMENT O F PUBLIC WORKS. THE 15 S U P.N C E O F THIS P E R M 17`D`UE S"N'UT'i:'t'C E KS"t`T'N'e R'Y"Y t'1'i;iiSJ"1'—Y'i�'fJ Iv{"'A`i'?C"2 flf `Yftlrrr-- OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR . ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHAN'ICA,L INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERS(READY TO LATH). FINAL INSPECTION HAS BEEN MADE, 3. FINAL INSPECTION BEFORE OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPEC ION APPROVALS. PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS _Z Is AIA��zc/� 3 HEATING INSPE ION AP ROVALS ENGI EKING EP TMENT OTHER Z BOARD OF HEALTH I WORK ALL NOT PROCEED UNTIL THE INSPEC- PERMIT 'N!LL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SI/ MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. I PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION. a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION, Map5'( Parcel alo Application # e�i of 76S Health Division Date Issued 0)-k < Conservation Division Application Fee ?Ise Planning Dept. Permit Fee -Date Definitive Plan Approved by Planning Board ` Historic - OKH Preservation/ Hyannis Project Street Address 122- Wf4rrmig(L Village bard IT Owner s(,0,0 Z!, l 4psAJ Address SA r, Telephone Permit Request P-iNIs14 A Po9--riptJ O"r 5Y-/STok4-; 0AS6Mg-toT OQ, Sr-oa-ACe& 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 Ae_" Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes kNo On Old King's Highway: ❑Yes No Basement Type: XlFull ❑Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing 2 new Half: existing new Number of Bedrooms: '3 existing C new a Total Room Count (not including baths): existing new First Floor l; m Count Heat Type and Fuel: XGas ❑Oil ❑ Electric ❑ Other 4 Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stove:? ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing O'new�size_ Attached garage: existing ❑ new size _Shed: ❑existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes kN/No if yes, site plan review# Current,Use - - - -__ - - Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Sag 4?L� Address IZL W IMIAn,. I) License # �i92-73 CorJ rr I rO4 QU3�1 Home Improvement Contractor# /4 335� Worker's Compensation # 0'0943'�- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 10 lo n t FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE OWNER s DATE OF INSPECTION: FOUNDATION � e FRAME 7 t INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 'FINAL BUILDINGS s 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/Co ntractors/Electricians/Plumbers Applicant Information /� Please Print Legibly . Name(Business/Organization/Individual): 1 Vd W1or, Address: (C -3 6a--e.l I; (, < i City/State/Zip: aA-64P6151 10,4. 0Uzt Phone#: SOR '4 Are ou an employer?Check the appropriate bog: Type of project(required):'. I J I am a employer with 2-2, 4. 1 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.•CKRemodeling ship and have no employees These sub-contractors have S. Demolition.,... workingfor me in an capacity. employees and have workers' Y P tY 9: ❑Building addition comp.insurance.$ [No workers' comp.-insurance required.] 5. We are a corporation and its 10.0 Electrical repairs dr additions 3.E1 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' 13.0'Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensatim policy infortnation. . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submmt a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contr wrs and state whether or not those entities have employees. If the sub-contractors have employ es,they must provide their workers'comp.policy.nurnber. I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 44,13ULA Policy#or Self-ins.Lic.M 0 0 s A S'4 Expiration Date: Job Site Address: 122 W U 1 nvFA 2- City/State/Zip: T M A 0��� 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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of,a STOP WORK ORDER andd-a fine of up to$250.00.a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ik hereby certify under the pains•andpenalties ofperjury that-the information provirdeedd above-is true and correct: Signafore: A Date Phone#: 5-0 T 44q n-4 Official use only. Do not write in this area,to be completed by city or town offu:faL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r Client#;61439 CAKeNT �: oi�t�irgiiibolrYY'n ACORM CERTIFICATE OF LIABILITY INSURANCE o4r� 1zo1T 3 ftl$b6 FICATE-lS ISSUED A5 A MAT k a tfffb121AATION OI11:Y AND CONFERS NO R1GHT5 UPON THE C1=RTaFiCA'i1 KOI F.�3. 1S- CERTIFICATE DOES.NOT AFARMATN.ELYOR NEGATIVELY AMENQ,:WEN0 OR ALTERTHECOYERAGE AFFORDED-BY THE W(U.S 8E(;OW.THIS CERTfF.IGATE OP INSURANCC DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING WtUF2ER(S),AUTH0121iED FiER $ENTATTVE OR PRODUCER,ANO THE.CERMFICATE HOLDER. MPt71R7ANT:it the ire iftgte:tiol la:an ADDfT1QNAL NSWQ1 the:pollCy(Ws).nwst lio andktgett;tf SU8R0 ON i5 W VED,9utif9�rto: - tlioterma and t6ndttloni.of the..pollij;-ceitalit:p6linie3 t►>aytdq�flro:an#itil6roemesiL A:atatar>wfntAn-tfilYc6et1t1tata:do0alnatcontsE:A4ftts:to:tM • ,cerp�caie�o[darlit•l),ou_Qt_�_u ._.. _:__.:.:.: _ ....__..._..: .-:_ _..-.. . _C?itovttcgii ^•• _ _ � 9- ers.&.Gray.Ins. .Piynwuth N1j:.�s:.398�74:�3�11 341 Coui1 Sheet P.0:Doi 3700 a PIytncstith,MA 023 t3:1.3700 _ . ' . .Luau_....:. ? -- --RD - - _ - � A�...ato F.aYEa!e4E. wadi.° ti�Ct OtJ Capewide.Eniefpfis".:h1.0 J.P.Macombef.&S:ona .. tNBVRt:B C .. PO Box•763 �Ystir'tEl:"ii`: - -,. .._..,.. -. - .. _ .. Ceti(mi ft MA 02032 .CERT FLI AT NVh$R -- Evl31oN .41A7B:ER. 'THS.IST'O.CERTIFY THAT THE POUCIES.13F WVRgNEE LISTCO["pw t1AVE BEEN ISSUED TO T?IE MURED NAMED ARM-FQ.R THT 90UCY PERIOD INDIGJ+TED.NOTYVfTHSTANDING ANY R.QVjReMEt4T:TETtM OR CONDITION OF ANY CONTRACT OR OTHM DOCl1MENT WATii R!✓ar3� Tq 1NF9GH.TKIS CERTIRCATE MAYBE ISSVM OR MAY.PCfiTA1N.T C Ia WPANCEAFF0kbM BY THE POLUES-DESCRIBEDiiEReIN S SUB.fECTTO:A.l.LIM 7Ef tdS_ EXaVS1WS AND.CON6MONS OF SVGH-POLX ES.UMfT9 SHOWNUAY-HAVEBEEN REWGEOBY.PPJ .CtRm$-. _ • tom':. �?A E Of ptHldw ' ( :q :ki? s hu,Atctia' OPP8500.050813 �Zq'i�,1 3i3/�i.'.F 1� .._ �'# {)ds. _ clntrts�F �oecua A•€� t�eba�N - : . ...... 7111 - _ - 'Crir ULWAvros Wjqr OAVyX ?S W D AUT05 is A Fv : tA - VIM o _ ANYPROPitIEt'�JUPARTNf3LfltE :Fti61�4f1` k _•4-_ oFtostt cxcl:uotm Y 'ir�A, ::• ,�.: . �t0"QOb' F— . R ii9!!.# ?EAAiitN! 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RICHARD CAPEN 4507 R RTE 28 COTUIT,MA02635 l'ndcrsccrctarj Restricted to: 00 00- Unrestricted 1G- 1 2 Family Homes Failure to possess a current edition of the . Massachusetts State Building Code ' is cause.for revocation of this license. Refer to: WWW.Mass.Gov/DPS License or registration valid for individul use only before the expiration date. 1f found return to: Office of Consumer Affairs and Business Regulation y r 10 Park Plaza-Suite 5170 Boston,MA 02116 t"Iili�,ith I. ! _1- I � i r i I ! '• I i I I I I •i - , i i----i �- i� t I i I I ; i i � ! 4- I ..{ r.. � ;r�' '` ! t 1 i i , I 14 I I i + j ! I � ilLI I I I I I ! I