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0025 HARVARD STREET
���� ��- �� .c-- __ .�---- _ _ _ _- --- ---- 3 i • _ -- =-- Town of Barnstable Building .� _ .w ,Post This Card So That it is Visible From the'Street Approved Plans Must beRetained on Job'and this Card Must be KepHARNMBIZ M^S• Posted Until Final Inspection Has Been Made .Where a Certificate of.Occupancy:is Required.'such Building shalt Not;be Occupied until a Final Inspection has_been=made er it Permit NO. B-19-4087 Applicant Name: E.F. WINSLOW PLUMBING & HEATING CO. INC Approvals Date Issued: 12/19/2019 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 06/19/2020 Foundation: Location: 25 HARVARD STREET, HYANNIS Map/Lot: 307-147 Zoning District: RB Sheathing: Owner on Record: JUDD, DARRELL B Contractor Name: E.F. WINSLOW PLUMBING & Framing: 1 HEATING CO_ INC Address: 261 CENTRAL ST 2 Contractor License: 132379 STOUGHTON, MA 02072 Chimney: Description: renovations to kitchen walls&ceiling re-frame rough opening for Est. Project Cost: $ 15,738.00 window. replacement of totted window,insulation sheetrock Permit Fee: $130.26 Insulation: n Project Review Req: Fee Paid: $ 130.26 Final: -Date: 12/19/2019 a 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 and the approved construction documents for 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 for public inspection for the entire duration of the work until the completion of the same. .; r•�-- = Electricals The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:" Rough: 1.Foundation or Footing r 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 Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Perso contrac ' with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department fi� Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 318ViSN8V8 JO NM01 Application Number........ 40).............. .... ...... . 9 IMMST.468IX MASS. 610? 330 Permit Fee......... .......Mer Fee,....................... 16,39. ld3 9K TotalFee Paid -i............................................... ...... TOWN OF BARNSTABLE Permit Approval by...Alf-6--cel<...........On... BUILDING PERMIT . .......par=,....... Map................................. .. . ...................... APPLICATION Section 1 - Owner's Information and Project Location Project Address25' Hr+(2VtAQ-D 5 T Village H L4 AtJ KI 65 Owners NameDAaagu- , yuoD Owners Legal Address Z!S ' �IAQVACD 6r city. HwPtQtJVS State MIA zip ozool Owners Cell# C-781 I -'J0J(joE-mail Section 2 -Use of Structure Use Group_ ❑ Commercial Structure over 35,000 cubic feet ❑ Q Commercial Structure under 35,00-0 cubic feet R"Single Two Family Dwelling Section 3 - Type of Permit F] New Construction MOe/Relocate EJ Accessory Structure ❑ Change of use El Demo/(entire structure) ❑ Finish Basement El Family/Amnesty El Fire Alarm Rebuild El Deck Apartment El sprinkle.r.System ❑ Addition ❑ Retaining wall ❑ Solar Renovation F1 'Pool'; 0 Insulation . Other-Specify, o Section 4 - Work Description ktx vpen ON '20 LkIrc-14EN W A UL5 GE(Lt KY. 4:e one aovo R- c9evj k&Az r70-4 W I 0 W Qe"C.Elvew- ' 6,12- aoerkeo 10SUUAt-r1orJ 6 Vke C7 ED C-V-- Last updated- 11/15/2018 Application Number...........:.............................................. Section 5—Detail Cost of Proposed Construction IS���:"" Square Footage of Project Age of Structure Dig Safe Number # Of Bedrooms Existing 4 .; Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics 1 [ Wiring i i ❑ Oil Tank Storage ❑ Smoke Detectors r ..+ l [Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom Water Supply Public ❑ Private Sewage Disposal Municipal ❑ On Site Historic District Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: opu6cr glgt t- I am using a crane ❑ Yos VNo Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8 Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. i Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yazd Required p Proposed a.+�..3.a >,,,,,7 Rear Yard Required r -:. Proposed k Side Yazd Requ>red Oqsed _ Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/15/2018 Application Number........................................... Section 9- Construction Supervisor Name L09ZN (Y) 4:;S M Telephone Number sp$ G20 ZC(Z k Address Igo CASK6 Li�� City y1/t.M State NIA Zip 6 License NumberC5 1%gIq License Type > Expiration Date Agt'420 Contractors Email �M(oSt bP f oS� Ug hod CMCell# t� 2QZ 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.Attach a copy of your5license. .. Signature U�`V - w ��'i 'Datey r Section 10.1-Home•tmpr'ovement.Contractor'=,J -j >" v n Name �•�. k'tw5`lG1itJ `�'� Telephone Number 5os Address QiAM6 6Z City 5- AaMk l'R State 61k Zip L Registration Number 132.3 79 Expiration Date 21 I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and p documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.LC... a Signature �_ M 9�� Date 1 Z 4 i Section 11 —Home Owners License Exemption Home Owners Name: .; Telephone Number Cell or Work Number E 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 r documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature �,��, �1 .�� Date 14 Iq Print Name 1 ta&,1 M CO5 �bZ- Telephone Number 606 G$0 2-ill s E-mail permit to: 1 m ,ber (05 ram• com Last updated: 11/15/2018 Section 12 —Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Dep_artiieit ,' ❑, '` - !�►' `: Conservatione+' .•) � �� ' } , ❑ zd For commercial work,please take your plans directly to the fire department for a_ppro-4 Y ` Section 13 — Owner's Authorization I, v4aa e 1L 3VD D , as Owner of the subject property hereby authorize f:,0)L- to,act on my be halalf; in all ; matters relative to work authorized by this building permit application for: 25 N012-Ugay 5T- N!4 ftti N is mA ou6a1 (Address of job) Signature of Owner-v 'i'.r •}. ..+p b" k � a a . �r.,.'r �•.'-'l�. ,;� .'y�,...t .✓ ri 1..�..,q�` ;t,.•. �. 6 Print Name r l r a f -M Last updated: 11/15/2018 ® DATE(MM/DDMIYY) ACO L� CERTIFICATE OF LIABILITY INSURANCE 4/12/2019 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 have ADDITIONAL INSURED provisions or 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 CONTACT Rogers&Gray Ins.-Kingston Branch P�HONE FAXA/c 63 Smith Lane 508-746-3311 No):877-816-2156 Kingston MA 02364 ADORess: mail@rogersgray.com INSURERS AFFORDING COVERAGE NAIC If INSURER A:Arbella Indemnity Insurance Company,Inc. 10017 INSURED EFWINSL-01 INSURER B:Arbella Protection Insurance Company,Inc. 41360 E. F.Winslow Plumbing&Heating, Inc. 8 Reardon Circle INSURER C:Arrow Mutual Liability Insurance Company 13374 South Yarmouth MA 02664 INSURERD: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1177535736 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE 1=WVD POLICY NUMBER MM/DD/YYYY) (MM/DDIYYYYl LIMITS A X COMMERCIAL GENERAL LIABILITY 8500069272 12/1/2018 12/l/2019 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTE—D CLAIMS-MADE a OCCUR PREMISES Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY II JEC Fi1 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY 1020078402 12/1/2018 12/l/2019 (CEO,MBl N INGLE LIMIT $1.000,000 acc Ident ANY AUTO BODILY INJURY(Per person) $ OWNED rx SCHEDULED. BODILY INJURY Per accident $ AUTOS ONLY AUTOS ( ) X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A X UMBRELLALIAB X OCCUR 4600069273 12/1/2018 12/1/2019 EACH OCCURRENCE $2,000,000 EXCESS LIAS CLAIMS-MADE AGGREGATE $2,000,000 DIED I X I RETENTION$ $ C WORKERS COMPENSATION 1909A. 1/1/2019 1/1/2020 X STATUTE ERH AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? tMandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Plumbing&Heating Contractor. Central Vacuum is a division of E F Winslow Plumbing&Heating Inc. Certificate holder is automatically an additional insured with respect to general liability and auto liability when required by a written agreement or contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF DENNIS 465 MAIN STREET A,U_IH=EDREPRESENTATIVE DENNISPORT MA 02639 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ./lr7�iciiarfi Office of Consumer Affairs&Business Regutation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Emkil ion 132379 01/17/2021 E.F.W INSLOW PLUMBING&HEATING CO.,INC ELISHA F.WINSLOW 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02664 Undersecretary Commonwealth 01 Massachusetts Division of Profett'ional Licensure Board of Building Regulations and Standards Can stq �f ` tt �n � 9rvisor CS-106874 E�pires: 08/15/2OZ0 4'Sukt LOREN M FOSTER ^ ° S'u§t4 ' 16 CLAUS WA•Y � , $ MARSTONS MILL MAC S v026484i- � Commissioner 318d1SN8V9 J0 NM01 61OZ 9 J30 '160 9N1.01,1,99 "0 146" \ 47" 8" 51 v W1536 WDC2436L 70 RW3318 DB18 S®0 DISH-IQ6 E, 44 +-� p 12"7 — 38„ 6., 336 _ _ 3 -------------------------------- m Q i w 0o w OD OD (Zl m Proposed Uw- � spBANNED _ ;------------- ------- -- --- --------------- - ---- ------------------------- -- -------------------- -- -- --- - DEC 17 2018 CO00 W C.0 W 0, III, 1311 3 24n Ilk 38" Ilk 8516 A 38n 30,6 n All dimensions_size designations This is an original design and must Designed: 9/27/2019 given are subject to verification on not be released or copied unless Printed: 12/5/2019 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. Judd kitchen.kit I All Drawing#: 1 No Scale. 146" 382" "�L-334" -334 70" W1536 WDC2436L RW3318 O ,_ DB18 SB30 DISH-IQ6 3 12" ---38" V 0" 336 w W w rn 00 r � 00 ----------------------------------------------------------------- M. AS Built ' T 00 03 00 00 X CA) SCANNED s~, DEC17 201 1 1.�; 8 n 38" 30 6" �_24"- 38" 85,6,3 All dimensions_size designations This is an original design and must Designed: 9/27/201 given are subject to verification on " not be released or copied unless Printed: 12/5/2019 ap job site and adjustment to fit job plicable fee has been paid or job conditions. order placed: Judd kitchen kit All Drawing #: I No Scalc r.• E.F. WINSLOW , DESIGN STUDIO . Judd,Darrell Judd,Darrell 2S Harvard St 25 Harvard St Hyannis,MA 02601 September 30,2019 Kitchen Rehab: Demolition: We will provide dust protection and floor protection along walkways. We will remove remaining cabinets, sheetrock behind cabinet area, tide and underlayment. We will remove all material from premises and dispose of. We will,remove sink and faucet and save for reinstall. Carpentry: We will install new insulation, blue board and plaster on wall that the cabinets attach to. We will install new tile underlayment to entire kitchen floor. t Cabinetry: L We will supply and install new Wolf Classic While Dartmouth cabinets in a like for like layout. We will supply and install Postform laminate counter tops from locally available stock. Tile: We will supply and install the on entire kitchen floor and back splash area from locally available stock, not to exceed 1 0.00 per square foot. � z r g Paintin `": We will prime and paint'new piaster to match remaining wail and ceiling paint as nearly as possible. . : Plumbing: We will reinstall existing sink and faucet. IMAIN S-1REFT. Includes: Mass Sales Tax. r:; K�lltl:l ,fir All specifications subject to final design and material specifications, \!rsi 1'aR�i �l�ii AAAmodifications to this,proposal Will affect total proposal. Jobsite ��2�>>3 conditions, anal unknown concealed building conditions may cause delays ®'a ®• and additional cost. Any alterations or deviations involving extra costs ,Fri..:$0s-77r-5630 will be executed only upon written orders,and will become an extra FAx: www.6vInslou 0171 DESIGN STUDIOcharge over and above the estimate.All Workito be completed in a professional manner r according to standard p ractces. Whenever practical,all doorways between work area and adjoining living spaces will be sealed to reduce dust transmission and all finished floors and traffic areas will be protected throughout entire project.All work areas will be left broom clean at the end of each workday.Homeowner should assume that not all construction dust can be contained in the above- described manner and that upon project completion there will be a reasonable cleaning required by others. TOTAL PROPOSAL S151738.00 30% due upon signing $4,731.00 30% upon commencing demolition $4,731.00 30% upon install of tile 54,731.00 10% upon completion S1,538.00 I, Prepared By: Dafe• Z�t Z as 1 ley �•9 M t Accepted By C Date l 61(5 zp Darrell Judd )l3 ;�� # . 65r n 111iV S I Rl"IiT ' ' UTi'T �1�P11 Y\R Iou111,AAA, C,7j3 0 B;gip. "l r1..:503-771=1650 F:3\:5oS-77i-565't R'�VR{2�1NI I15��?la'.ii?itt 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/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �. 11J 1 NS W w 'ut"bl Wo + 0ONT)KICz.' Address: 06. Qe.AO-DW C 4 Q City/State/Zip: .S• 1-',1AP2MVXu � Phone#: 5ce S14 Are yo an employer?Check the appropriate box: Type of project(required): l. I am a employer with lOp 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' t 9. ❑Building addition [No workers'comp.insurance comp.insurance.: red. 5. We are a corporation and its 10.❑Electrical repairs or additions required.] ❑ officers have exercised their 1 L Plumb' repairs or additions 3.❑ I am a homeowner doing all work ❑ � myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t C. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. , I am an emrployer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: A rLa ow M UT"U A L U A&t U 04 Policy#or Self-ins.Lie.#: I?J31-1 Expiration Date: Zo Job Site Address: ZS ��1�QV�Q� ST City/State/Zip: ���I�Il1l5 ,V vUe 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 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. 1 do hereby certify under thepains and penalties ofperjury that the information provided ove' true and correct Si C ieb% - M Date: 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#: 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,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" ersons to do maintenance,consbi:uct on or repair work on such dwelling house or on the grozmds 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 shad witliliold`the'issuance or renewal of ai.ticense or permit to operates business or to constractbull4ingsin 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 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 contad't you'r,egarding 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'mutiple permit/license applications in any given year,need onl}'"submit one affidavit indicating current r 4 -poliey�mformation(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'to'3vn 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 burn leaves etc.)said person is NOT required to complete this affidavit. - J The Office of Investigations would hike 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: Commonwealth of MassachiisetEt's�E - ' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 - Tel.#617-727-4900 ext 446 or 1-877 MASSAM Revised 4-24-07 Fax#617-727-7749 www:maw.gov/dia q ' Town of B *o�D'�S � y 6 �- Barnstable Permit# Expires 6 months from issue Regulatory Services Feed • snaxsznBIAMAM • � 1 ' Richard V:Scali,Director prFD MA'l� Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number Not Valid without Red X-Press Imprint �ry� ` - , 1 A Property Address 1, Hm NwA - �, i'eGT �1yan�� /� N U2601 ❑Residential Value of Work$ 7`1 J(,��� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Datirf j V L,, Zs H V" �GL�,�T,nn(s 6.2G b.\ Contractor's Name �e��-(`i ckc C\1 Telephone Number M 7 952 2 Home Improvement Contractor License#(if applicable) l I ? Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance C�he,c�one: PREU PERMIT FJ'l am a sole proprietor JUN ❑ I am the Homeowner 'tl 3 a �0�5 ❑ I have Worker's Compensation Insurance TOWN OF BA R N S TA B L E Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ (check box) I Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �`rtncsn,}41 1n1/,� ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where.required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improveme t Cont r rs License&Construction Supervisors License is re uired. SIGNATURE: Q:\WPHLESTORMS\b lding permit forms\EXPRESS.doc Revised 040215 C0R_1E_ Y_ &, COREY CONSTRUCTION 1672 FALMOUTH RD #117, CENTERVILLE, MA 02632 77 2,8 4�0, PHONE, , t-t 5,44 CERTAXNTEEP LANDMARK SISTANT L X F E T X K� E-s A L_Q A, E R, 9,' A. R C;, K 1 T 9- C T U.; R A 4 S T Y1,E RE; R 0 0 F IN Q P, Rk 0 P Q S,A,L, June 2, 2015 DARRELLJUDD Tel: 781-408-1567 Cell 25 HARVARD ST EM: dbjudd@verizon.net HYANNIS, MA Tel: 781-769-9750 Ext 4091 COREY & COREY hereby propose to perform the following services in a neat and professional manner and in accordance with the manufacturer's specifications and local building codes. Remove and Haul Away All of the Old 3-Tab Asphalt Roofing Shingles that have Not Been Replaced. Re Nail All Plywood Sheathing as needed. Supply and Install CERTAINTEED LANDMARK : LIFETIME WARRANTY, 10 YEAR SURE START PROTECTION, CLASS A FIRE RATED, COPPER/ CERAMIC STONES for a FULL 10 YEAR WARRANTY AGAINST ALGAE CONTAMINENT,240 POUND, EXTRA HEAVY WEIGHT, 130 MPH WIND WARRANTY, CATEGORY III HURRICANE, STORM[HURICANE NAILED (6 NAILS PER SHINGLE), MULTI-LAYERED, LAMINATED ARCHITECTURAL STYLE, FIBERGLASS BASED ASPHALT SHINGLES. COLOR: BIRCHWOOD Supply and Install 8" WHITE ALUMINUM DRIP EDGE on All of the Eaves. Supply and Install CERTAINTEED WINTER-GUARD (Ice & Water Shield) WATERPROOF UNDERLAYME NT SYSTEM on Roof Eaves,Valleys & Under the Step Flashing on the Chimney and Gable Walls. Supply and Install #15 BLACK SATURATED FELT ROOFING PAPER Supply and Install AIR VENT SHINGLE VENT 11 RIDGE VENT on the Five Main Ridges. Supply and Install ALUMINUM & NEOPRENE SOIL PIPE FLASHINGS Clean and Remove Debris from work area after job is completed. TOTAL INVESTMENT ------------- $ 7450.00 C� OREY* & CORIEY CONSTRUCTION POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards, Plywood Sheathing, Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus Labor at the Rate of$ 80.00 per Hour. PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORK SCHEDULE: All Roof Work is Scheduled for Completion Within 60 Days of Acceptance and Receipt of Deposit providing the Materials are Available. Therefore Deposits Received are Non-Refundable After a Three Day Cooling Off Period from the Date of signing. This Proposal May Be Withdrawn By Us If Not Accepted & Deposited Received Within Thirty Days Or Before The Next Price Increase In Materials Please Make Checks Payable to: PATRICK CLIFFORD COREY & COREY warranties the Shingles and Labor for 10 years. CERTAINTEED Warranties the shingles and labor 100% for the First 10 Years and the Shingles your LIFETIME if the shingles becomes defective. CERTAINTEED Warrants the Shingles up to a CATEGORY III HURRICANE-130 MPH WIND WARRANTY. CERTAINTEED Warrants the Shingles to be Algae Resistant for a Full 10 Years. COREY & COREY carries Workman's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: 20 ACCEPTED BY: SUBMITTED BY: DARRELLSOD CHA RLES 96R�W, CONSULTANT HOMEOWNER CORkY-9 COREY CONSTRUCTION 17se Camaton veah*o,fMassacliusetis Deparwtmt of Industrid Accide7as " = QKwe of.fmwfigations 600 Waskington Street Boston,AIA 02111 nwmmas&gov1dia Workers' Compensation Insurance Affidavit-B leisJGnntractu s/EIecttricians/Phambers Applicant Information f:: t!/ Con n Please Print Let bly Name1�- &r i Wk Cat AAdress_ �� �,� A Are you an employer?Check the appropriate b Type of Project(required): 1.El -I am a employer with 4. I am a general contractor and I 6. ❑New constructirm employees(fill av&orpazt-taw)_* have hired the stab-contractors 2.❑ I am a sole pmprietar orpaztam- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition waziring for me in any capacity employees and have warkers' [No workers'comp.ias mince camp.insurance 1 9. 0 Budding addition. mod_] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work offios have exercised their 11_0 Pl g repairs or additions myself[No workers'comp. t>glit of exemption per MGL 12-ferRoofrepairs insurance required.]T c.152,§1(41 and we have no employees.[No workers' 13.❑Other comp.insurance required.] *fiery applicant tbat cheeks box#I mast also fill out the section below showing their wows'com mmsatimapoliey information_ Hmmoemners who submit this affidaw in&cztWg they are doing all walk and then hire ootdAe contrmcmrs mast submit anew afdarit imdicatiag such. lCoalracmrs that check Ibis bax must attached at odditiamal sheet sharing the—of the and slate whedw ornot those entities base employees. I€tbe suboast=ors bane en s,ffiey—, r mvide thek worker'comp.pony n mow. I am an employer that isprm idong workers'compensation insurance for my enTloyees. Below is the poficp ant job sitt4 informatiotn. Insurance Company Name: Policy A or Self ins.Uc.#: Expiration Date: Job Site Address: ? n ri f✓of J 5�" Rt ann f&, ,1141f- City/Stawzip: 02401 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 up to$1,500.00 andfor 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-6olatcr. Be advised that a copy of this statement may be fx nded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerhfj,raider the pal ns Mnd pen 's ofpet l toothat the information provided above is true and correct Sitrftattire: - Date: 10— Phone 4- Z Z "Z 2 Official ztse only. Do not write in this area,to be completed by city or town ofciat City or Tonrn: Permitll icense 9 Issuing Authority(tdrele one): 1.Board of Health 2.Building Department 3.Catyfrown Clerk 4.Electrical Inspector S.Plumbic Inspector 6.Other Contact Person: Phone 9: ---- 6 AC D® CERTIFICATE DATE(MM/DD/YYYY) OF LIABILITY INSURANCE 5/19/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS :F 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,(les) 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 cFCape tifie holder In lieu of such endorsement(s). CONTACT NAME: Christian Barber, CIC anside Insurance. Group PH°NE (508)775-0500 F 0:(508)790-7955 ia E-MAIL Main Street ADDRESS, INSURERS AFFORDING COVERAGE NAIC l MA 02601 INSURERAMain.Street America Protection 3026 INSURER B Associated Em to ers Ins CO e Home Improvement LLC INSURER C: re RoadINSURER D: INSURER E: mouth MA 02664 INSURER F COVERAGES CERTIFICATE NUMBER:CL14111303545 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 TOR OTHER DOCUMENT WITH CERTIFICATE MAY H RESPECT ALL BE ISSUED WHICH THIS OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMrTS SHOWN MAY HAVE BEEN REDUCED BY PAI D AID CLAIMS. TYPE OF INSURANCE B POLICY NUMBER POLICY EFF MPOLILICCY EXP LIMITS LIABILITY ID EACH OCCURRENCE $ 1,000,000 ERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500,000 LAIMS-MADE FO OCCUR X T4406Q 1/12/2014 1/12/2015 MED PREXP MISES one arson $ 00,000 PERSONAL&ADV INJURY $ 1,000,000 - GENERAL AGGREGATE $ 2,000,000 REGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 Y PROJFQT lOC Is ILE LIABILITY COMBINED SINGLE LIMIT UTO Ea accident BODILY INJURY(Per person) $ WNED SCHEDULEDS AUTOSBODILY INJURY(Per ecciden:) $ AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ d nD UMBREUJIUAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ B WORKERS COMPENSATION $ AND EMPLOYERS'LUIBILITY FR ffE.L STATU- OTH- ANYPROPRIETOR/PARTNER/D(ECUTIVE Y/N tln OFFICER/MEMBER EXCLUDED? N/A E.L. ACCIDENT $ 500 000 (Mandatory in NH) CC-500-5014057-2014A 1/12/2014 If yes,describe under E.L. SE-EA EMPLOYE $ 500,000 DESCRIPTION OF OPERATIONS below SE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Old Cape Exterior and Remodeling dba Corey & Corey Construction listed as additional insured CERTIFICATE HOLDER CANCELLATION saf—armen@hotmail.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BF CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All Cape Exterior and Remodeling dba Corey & Corey Construction 67 Sea St AUTHORIZED REPRESENTATIVE Hyannis, MA 02601 C -Murray CIC/MC I cay&, 0, ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. IN1,17195 r?nimo m Ti,a Af`f1CIl Ai f1Rr1 BSaxd ova ullcf"no 32egwatio+,s ana Stanch i`trtsrrrantsrin Sul�>r�trz cr+lt:s P Ltce.nse r: CS4SL 105$5:'f, P r r s-' GarrVrtla rt>ifer OSf0 2,1 Office of onsumer Affairs S Busines9 Regulation License or registration 4 alid for indiN idui use only FrfOME IMPROVEMENT CONTRACTOR before the expiration date, If found return to: , r}registration: 173192 Type: Office of(:'onsurner Affairs and Business Regulation ;expiration: 9/1112016 1 10 Park Plaza-Suite 5170 Boston.:*v1.A 02116 COREY AND COREY CONSTRUCTION 12 BALD IN RDORD C+�i��� t2 SA�DWIN RD DENNIS,MA 02638 Undersecretary \ot.vnIid without nature Town of Barnstable R Regulatory Services t Thomas F.Geiler,Director . Building Division T€ 9�AMASS. g Tom Perry,Building Commissioner l PH a: 1659. r 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us zz� Office: 508-862-4038 DI IS g Cn,4 Fax: 508-790-6230 Approved: Fee: d--O Permit#: -Dc) HOME OCCUPATION REGISTRATION Date: Name: / a sAet4cloa Phone# � 9z— 75+edokC AA Address: 1 - ` Village: Name of Business: -iZ3lnp Cm,e 1C c Type of Business: Map/Lot: 36 7I4 p�b �,p� 20 b-1 INTF.N'I': It is the intent of this section to allow die residents of the To«mn of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discenible from outside the dwelling: there shall be no increase in noise or odor;no usual alteration to the premises which would suggest anything other tlall a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration Kati tie Building Inspector,a customary home occupation shall be permitted as of right subject to the folloraang conditions: • The activity is carved on by die permanent resident of a single family residential dwelling unit,located 11athii that dwelling unit. • Such use occupies no more dian 400 square feet of space. • There are no external alterations to tie dwelling which are not customary ii residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offernsive noise,`ablation,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • Tlnere is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to tie Customary Home Occupation,other than one vane or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on die same lot cont•ailiug the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed ui tie Customary Home Occupation who is not a permanent resident of the dwelling unit. 1,the undersigned have read and< ee with die above restrictions for my home occupation I am registering. Applicant: Date: G Homeoc.doc Rev.01/3/08 +y YOU WISH TO OPEN A BUSINESS? � For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: 141171,261 a Fill in please: APPLICANT'S YOUR NAME/S: ��1r�� �7;rHle•-lc�r��+ r BUSINESS YOUR HOME ADDRESS: Z 5 HCor-,ie arck s-f- . b_ I-I Clan n 1 S H A r'�. 1 C:)Z TELEPHONE # Home Telephone Number 5 O 2 7 77.5 4 NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATION? i:::� YES NO GZLa i 7/y7 %o i e^7 -A ADDRESS OF BUSINESS Y i -A MAP/PARCEL NUMBER 0�1 Le•4-12) (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may.need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has en i or ed of y ermit requirements that pertain to this type of business. Authorized Sign e** UST COMPLY WITH HOME OCCUPATION COMMENTS: RULES AND REGULATIONS. UUMPLY MAY 2. BOARD OF HEALTH This individual has L bee or ed of the permit requirements that pertain to this type of business.r�(�n Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSIN AUTHORITY) This individual has b info r t e licensing requirements that pertain to this type of business. �I Aut�prita Signatur COMMENTS: !x IC�, �C 0 Town of Barnstable *Permit# 7 Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 X=PRESS3 F!"ERR7;.� Www-town.bamstable.ma.us 11Z E—P Office: 508-862-4038 Fax: 508-790-6230 LWOt&O F B N S 3 L EXPRESS PERMIT APPLICATION - RESIDENTITAO LYA R Not Valid without Red X-Press Imprint Map/parcel Number :7 7 Property Address 74& [Residential Value of Work 0 Minimum fee of$25.00 for work nder$6000.00 ` 139 Owner's Name&Address rc. veV ci Contractor's Name 14q Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance C9ck one: I am a sole proprietor I am the Homeowner 1 have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. ?ermit 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 C) Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sip Property Owner Letter of Permission. Home Improvp*nt Contra c Ors License is required. ;IGNATURE: ?:Forms:expmtrg 17 Levise071405 The Commonwealth of Massachusetts Department of 1`ridustrial Accidents Office.of Investigations- + 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/Organization/Indivi . .sdress• _�/! f 6� Phone#: .City/State/Z,ip:... `? .f D . Are you as employer?Check the appropriate box:. Type of project(required):• 1.[1 I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (fu1T and/or part-time).* have hired the snb-contractors listed' the attached sheet ❑ Remodeling . 2.❑ I am a sole proprietor or parEner- . ship and have no employees These sub-contractors have 8. .❑ Demolition working for me in any capacity. workers' comp.insurance. 9• ❑ Building addition o workers' comp.insurance 5. ❑ we are a corporation and its officers have exercised their 10.❑ Electrical repairs or.additions � �] ll.❑ Plumbin repairs or additions 3. I am a homeowner doing all work right of exemption per MGL g eP myself.-[No workers' cow. c. 152,§1(4), and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers-eq ] k . 13:0 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 ead then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the nerve of the sub-contrabtors and their workers'comp:;policy information. 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.Lic.#: Expiration Dater Job Site Address: City/State/Zip: 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 up to$.1,500•.00 and/or one-year imprisonment, as well as,civil penalties in the form of a STOPVORK ORDER and a Ame of .p to$250.00 a day against the violator. Be advised that a copy of this statement may fie forwarded to.the Office of . Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenaldes of perjury that the information provided above is true and correct. _)PSi ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city,or town official City or Town: PermitMcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department I City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: j Information and Instructions. K Massachusetts General Laws chapter 152 requires all employers to provide n the service of an�th�er under any contract oi^hire� Pursuant to this statute, an employee is defined as"...every person express or implied,oral or written." association, Wrporation or other legal entity,or any two or more An employer is defined aa.'=. mdivi¢ua1,.:P to er,or the' the foregoing•engaged m a joint enterprise, and including the legal representatives to a deceas .Hov�teYer:the of ciation or other legal entity, employing employees. divide artuership,also tee of an individual,P t f the receiver or trustee resides there' or.the occapan o thre e apartments and who m, owner of a dwelling house having not more than ap dwelling house of another who employs persons to do maintenance,construction or repair worktin such dweIliag house ant thereto shall not because of such employment be deemed to be an employer." or on the grounds or building appurten ce MGL chapter 152, §25 C(6)also states that"every.Seas or to cstruct buildings in the commonwealth wtealth four any r f a license or pew to operate a busiti wired." al o ere ew coverage Ten insurance co q applicant who has not produced acceptable evidence of compliance with the ins ag . . 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 con pliance with the insurance requirements of-this chapter have been presented to the contracting authority. 77 Applicants Please fill out the workers' compensation affidavit-completely,by checking the boxes that apply to your situation and,if. necessary,supply sub-contractors)uame(s),address(es)and phone numbers) along with their certificates)of d Liability Partnerships(LLP)with no employees other than-the. insurance. Limited Liability Companies(LLC)or Limite members or par•mers; are not required to carry workers' compensation Dep or LLP artment of Industrial does have employees, a policy is required. Be advised that this affidavitY be submitted to the D 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 being requested,ed too the Department of Industrial Accidents. Should you have any questions regarding the la you compensationpolicy,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 Departmentohas providedou regarding the aPPlicanm of the affidavit for you to fill out is the event the Office of Investigations Y applicant Please be sure to fill in the permitlicense number which will be used as a reference number. In addition, an 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 s ed or mazked by the city or town may be provided to the been officially tamp . town).' A copy of the affidavit that has beenout applicant as proof that-a valid affidavit is-on file for;future permits•or licenses..A new affidavitmi�st be filled 1.vut r 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 bun leaves etc.)said person is NOT required to complete this affidavit 'Like to you in advance for your cooperation and should you have any questions, The Office of Investigations would 1 please do not hesitate to give us a call. The Department's address,telephone and.fax number: The Commonwealth of Massachusetts . Department of Industrial-Accidents Office o;�Investigations 600 Washington Street . `r. �1; Boston,MA 02.111.. Tel.#617-727-4900 ext 406 or-1-877-MASSAFE Fax#617-7274749 Revised 5-26-05 vAmmass.gov/4ia