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Home My WebLink About0800 BEARSE'S WAY (63) � 1Beai�P1 z. L� oepd,—f. PC •'C3 C w' MM �� O 7 yi. [A O Ea O .` � (fin N � 1• .•; _. _ �. - - 01 Cn :ems The Commonwealth ofMars"huSE& Department of Industrial Accidents 600 Washington Street Boston,Mass. 02111 Workers'Compensation Insurance Affidavit panne: eon dap, t - , xn� c location: cit , r7 4f,P7 r 5 NItiG. d2 /C/ horcl� 77f-" 73�r z ❑ 1 am a homeowner performinn all work myself. ❑ I am a sole proprietor trod have no one working to any capacity ❑ I am an employer providing workers'compensation f'orr my emplovees working on this job. ram2any nnines �e Z l '!�!!'y �t/�t ! r C� %`��Z t�GN�NG•GIG, 's' sity:_ �S/' �N��GL. !/I�.Cti �. S �... Inn !E; S'�C/ — yzp insura �e �it/eAV S�V .•��r Stiri! Gv► e t . . a c� . .. . '.::Q�p,,•.:. ❑ I am a sole proprietor,general contractor,or homeowner(elmle one)and have hired the contractors listed below who have the following workers' compensation polices: ��•v name: • 'policy# nl►!9ny name ►an cih•• � Aone• . Murano co. • Qolj,¢y tl' F'silure to secure coverage as required Utldtr Scceioo ZSATrl� "52"nIOMIItdKt;t as'imprisotubentssweltasc1vflprn-In I ist fDQt and a f"me of�11>a.00 a day against toe. t aaderstand canon a copy Of Ihis statement stay be forwarded to the()nets of 7avcstigatintt�Of lbe DU fur tovernge verification l do hraehv certiJ' rrhepainxAM4enahfes ofprr%nry ghat rile information pPovided above is true d w Signeturc ate Print numc—a Letheck do not wnte in this arcs to be completed by city or town oinciat permitAicerutc M Building Department ❑t.ieensing Board ate respom is required Osclectmen's Of iceQHcalth Department phone p; —other J. (MViUd Gros rla! A. I . ii __ XnformaWn and Instructions Massachusetts G eneral Laws chapter 152 section 25 requires all employers to provide workers'compensation for their employees. AS quoted from the laP w" an em loyee 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 or the the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased ershi ,association or other legal entity,employing employees. However the receiver or trustee of an individual ,partn p 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 section 25 also states that every state or local licensing agency shah withhold the issuance or renewal of a license or permit to operaite a business 6rto construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shell 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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers as all affidavits 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. City or Towns ided a space at the bottom Please be sure that the affidavit is cempiete and printed legibly. Department to ccontactyouvrebarding the applicaino.Please of the affidavit for you to fill out in the event the Office of Invest gation be sure to fill in the permit/license number which will be used as sba emeert e number. The affidavits may be returned to the Department by mail or FAX unless other arrangements The Office of Investigations would like to thank you in advance for you cooperation end should you have any questions. please do not hesitate to give us a call. WFIRThe Department's Nresso'tcleph0n;and fax number, The Commonwealth Of Massachusetts Department of Industrial Accidents office of Unsd adons 600 Washington street Boston.Ma. 02111 fax fi: (617)727-7749. phone##: (617)727-4900 ext.406,409 or 375 1 o�VE The Town of Barnstable BARMAZIM ' �0�' Department of Health Safety and Environmental Services �Eo gi. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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 dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: /1-c►�G �z � S Est.Cost 9 Address of Work: Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the a of the o er: C 2 �he f�23 Dath Contractor Name Registration No. OR Date Owner's Name BOARD OF TRUSTEES cape r®adf 800 Bearse's Way 1WM Hyannis, Mass. 02601 1-508-775-7382 June 7, 1996 Alfred Martin Building Department Barnstable Town Hall 367 Main Street Hyannis MA . �02601 Dear Mr. Martin, As members of the Board of Trustees, we are requesting a report, at your earliest convenience, regarding the deck and stairwell replacement recently completed at Cape Crossroads Condominiums by Bill Croston Building Contractor, Box 138 , Osterville, MA. Also, please forward to our office a copy of the Building Permit pulled by Mr. Croston for the work performed on our property in 1995 . If you need more information, or if we can be of any -� assistance, please do not hesitate to contact our office. Thank you for your prompt attention to this matter. Sincerely, The Board of Trustees Cape Crossroads Condominium