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HomeMy WebLinkAbout0003 KEATING ROAD ��� ,( 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map C 6 {U Parcel 0 05 Application # �d Health Division Date Issued —'-O' S Conservation Division 5c, Application Fee 11� Planning Dept. Permit Fee � 00 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address y Village Owner_ �� �{ ��elfl/C-�n/ Address Telephone �U 5 Permit Request er t- ec-Ac I Q F c q i(" _ f9w rfasw Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District e Flood Plain Groundwater Overlay Project Valuation �etu Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes, attach s,pporting docume)ltation. Dwelling Type: Single Family .❑ Two Family ❑ Multi-Family (# units) 6 _.'J D Age of Existing Structure Historic House: ❑Yes ❑ No On Old King' ighway:L❑Y03 ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.f) "9 Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 73fuk Imo'Oy Telephone Number Address ev License # OS9< Home Improvement Contractor# Email J cw- o STNt 1(td qo -a'► vorker's Compensation # V ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT.WILL BE TAKEN TOtd('NE SIGNATURE DATE r C FOR OFFICIAL USE ONLY ,} APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE 4 OWNER { DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL o' FINAL BUILDING } DATE CLOSED OUT ASSOCIATION PLAN NO. T7ie Comrnomivealth o,f assadiusetts ., Department gf1rdi s&id Accidents Offi-ce of1m.wtigatiom 600 Washington Street Boston, 4 O2II1 Wc-kers' Cuinpensafian Insurance Affidavit:Bu ldens/ContractursJEIec r cianslPlu nbers Applicant Iufm-mafruu Please Mint f,eeffily Name SI Address: ra( ` 13 City/StateiZip- Are . u an employer?Check the appropriate box: I. a Type of project(requaretl): I am a general contractor and I I m a employer with. ❑employees(full anVor part-fine).* have]sired the sub-contractors 6. 0 New consfrucfion. 2.❑ I am a sole proprietor or partner listed oati.e attached sheet. I'- ❑Remodeling ship and haze no employees Thy sub-contractors have g_,❑Demolition working for run in any capacity. employees and have workers" [No w?rke-m' comp.astir„ca comp-immranml 9- ❑Building addition required_] 5- ❑ We.are a corporation and its 11D❑Electrical repairs or additions 3.❑ Iamahomeoumerdoing all work offscen have emmised their 1L❑Plumbingrepairs oraddifinn¢ rays f-[No workers'comp_ right of exemption per MGL 1 mc�rcance required-]i c.152,§1(4),and we havena ❑Roofrepairs employees-[No workers' Other comp-insurance required-] `eLay applicanttbatchedmbox R um alsa fiR out the section beiaarshm¢ing then vmaere eompmsatiaupoRU inormsaan I3nmeowuvrc who submit ifzis zfBdz,.qr]nacating they are dniag au S4cl sari then himaatside contractors matt s.mit a new affidavit indicating-sz+r'h iCoatractors that rhorY this bmc mast sttarkxT,as addiHanal sheet showing the name of the rnlrcontscto-m and state whether or not those entitiesha e e inees.Ifthesuh caatsctoeshaceemployees,they3in Cprui.-ide-their workers'comp.polivaumber. I111IL Qrt P11tpLo}`RI t�1 rrtisprer�7tlirrg 71�Qr1FRrSa COrrr�3eresrrtiall 2n371rt�lfcB jor m}�elrrpl�y�es. Below is IfflePolicy curd jab site informadom v Insurance Company Name: 7 64 Policy or Self-i>zs.Lio_ �f�1 I`�.7��.1 — cS Exp -nDate: lob Rellddrem k�gfit civstateltzip: Attach a ropy of the workers compensationpolicy declaration page(showing the policy cumber and expu-ation date). Failure to secure coverage as required.under Section 25A of MOIL c. I572 can lead to the imposition of crimrflal penalties of a fine up to$UOQ00 anVor one-year iumprismunenf,as well as civil penalties in the fora of a STOP WORK ORDERand a fine of up to WO-00 a day against the violator. Be adsased that a copy of this.statement may be forwarded to the Office of Imvest gahoons of the DL4 for insurance covera a— verification-Ida lferaby esrhfi�arrdcer 'is and per:atoms of per,j`uj y that trio in ormatiarrpm ded ahmr a is ft-e acid correct Sitmatnre: Date: phone ik 1S t3Racial use aril}. Da teat tvrrte in tlris area;to be crrinpteted by city orton-t affitaal Cry or Town.: PernritUcense f€ Tming? uthority(drde one): L Board of Health 2.Building Departnnent 3.[ity1Town.Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: r ormatiaz, and lastructions Massachusetts Geheaal Laws chapter 152 reqa:irrs aU employees in provide workers'compensation for their employees. pnrsTom„ this sty,an er,�7IDyee is dtfined as.-..every person m.the service of another ender,any cortra.ct of hire, . ex:press or finpliecL oral or " Aa errs raver is defined as Iran jaTwidm-4 parfnersb�,ass�ciafion,corporation or other Iegal entity,or any two or more of the foregoing engaged in a Joint cntz�.and including thO Iegal representatives of a deceased employer,or the receiver or trwtee of an mdividnal,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having-not more t hm three apartments and who resides therein,or tie oceapant of the - dweIling house of another who employson pe3ss to do mai� e fxu anc ,consetiou or repay want on such dwtIL house or on tie grounds or building appu�thereto shall not because of such employment be deemed to be-an employes." MGL chapter 152,§25C(6)also staffs fiat"every state or local Iicen is ageneg shall withhold fheissuznce or renewal of a license or permit to operate a business or to construct buildings is the commonwealth for any appticantwho has not produced acceptable evidence of complianm with the imsnrance coverageregaired." Addition-Hy,MGL cbapinr 152,§25C 7)states`fileither file commanw-ealth.nor aIIy of i is poIitical subdivisions shall ent�r into any contract for tht,perfounaace ofpublic work until acc c-pfable evidence of complianc(_-witi the inmm- ce-. regret emus of this chapter have been presented.to th-e mntiactiD g anfhouty"Applicants ' Ph �Phase fill o the workers'compensation affidavit completely,by checl®g$e boxes that apply to your sitnaiion and,if necessary,supply sub-contractors)miners), addresses)and phontnumber(s) along witllthDir certracate(s) of Torrance. LimitE Liability Companies(LLC) or Limited LiabRity-Partnerships(LLP)with no employees other than the members or partners,are not regained to carry workers' compensation=arance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidayitmaybe snbmitir:d to thD Department of Industrial Accidents for confnmation of insurance coverage. Also he sure to sign and date the affidavit. The affidavit should be ret=ed to the,city or trwa chat tie application for the permit or license is being requested not the Department of A_ccide�s. nouldyou have any questions regarding the law or ifyou are required to obtain a workers' comps-wa'dou policy,please caIl that Department at the number listed below Self-mmned companies shovId enter their s elf-in stance license number on the appropriate line. City or Town Offidals f _ Please be sure that tie affidavit is complete and pri ded.Iegibly. The Department has provided a space at the bottom of the affidavit for you to fll out in tn.e event the Office ofInvesfigations has to coidact youregarding the applicant. Please,b e store to fill in the p ermitflic=e;number which will.be used as a reference nomb es. In addition,an applicant that must submt mult�ple pe=ltuc.fmse applications is any given yc a,need only submit one affidavit mdiratiag cmyPnt policy filfb nation(if necessary)and under"Job bite a_d&ress"tie applicant should rite"all locations in (city or town)-"A copy of the affidavit that has been officially stamped or ma6ced by the city or town may be provided to the applicant as proof that a valid affidavit is on fiat for fat=e.pam. or licenses_ A new affidavit must be filled DiIt each year.Where a home owner or citizen is obtaining a license or permit not related to any business or comme venioie a dog license or permit to burn leaves etc-)said person is NOT rcqabmd to complete this affidavit The Office of Investigations would like to thank you in advance for your cooper ion and should von have any quss-tions, Lease=dfl not�.esii�#e� --a=call=----------:-------------------= - -------- ---- -� --- ---- -- TheDepartment's addreps,telephone and fax CaMMM- tbE of Nfassach ' lupazfine nt cif ladusirial Aacid�t~ Office d Itvedikatio--= 1504 wash Gil st=t ��o-�I�fA Elul l l TeIL 4 617- -4900 i�xt 4.06 W 1-977-MASSAM FaxI617 727'74 revised 4-24-07 ,m3sgQgfc�'d Rightfa:x N3-1 8/25/2015 7 :32: 19 AM PAGE 2/002 Fax Server DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE T. IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME: MURRAY&MACDONALD INS PHONE FAX 550 MACARTHUR BLVD (A/C,No,Ext): (A/C,No): E-MAIL BOURNE,MA 02532 r ADDRESS: 75NHN INSURER(S)AFFORDING COVERAGE NAIL# INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA KADY,STEVEN DBA STEVEN KADY&SON MASONRY INSURER B: CONSTRUCTION INSURER C: INSURER D: P.O.BOX 493 INSURER E: FALMOUTH,MA 025410493 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 PAD CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE. - LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MMDD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT❑LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR El CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY ;OTHER EMPLOYER'S LIABILITY Y/N UB-931X7321-15 08/29/2015 08t29/2016 LIMITS ANY PROPERITOR/PARTNER/EXECLMVE OFFICERIMEMBER EXCLUDED? WA E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS TFITS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING PORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR KADY,STEVEN. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 200 MAIN ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT{. .1/E P HYANNIS,MA 02601 ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. Steven Kady Phone: 508-563-2515 Ma. Licensed Construction Supervisor#059847 Toll free: 800-567-9787 P.O.Box 493 Falmouth. Ma 02541 Cell:508-566-5087 Fax:508-563-2616 Email:skzxl2rD-aol.com www.SteveKadyMasonry.com PROPOSAL August 14,2015 Peter Kunen �3 Keating Rd. Hyannis, Ma. 503-442-5897 odkor(@-msn.com WORK TO BE PERFORMED: • Construct ground staging • Construct roof staging • Remove center chimney,down to roofline • Panflash • Re-construct with Boston Colonial brick o With detailed crown Labor,material,disposalG&building permit: *$4,800,00 Peter Kunen Y4- L�� ©ate:____ *50%to schedule, balance due.upon completion i Offi ce of Consumer Affairs&Business Regulation onj t IN OME IMPROVEMENT CONTRACTOR egistration 126014 Type: xpiration `d/8/2016. Individual, 1 1 STEVEN KADY j j STEVEN KADY 10 ROCKLEDGE DR. N. FALMOUTH,MA 02555 I I Undersecretary ( ., J i Massachusetts =Department of Public Safety Board of Buif-ding regulations and.Standar ds Co strucfion Supen-isor Specialty ` License: CSSL-059847 STEVEN L KADY= t. PO BOX 493 a� FALMOUTH Mk- 02a''9 may— Expiration C Commissioner 10/03/2016 - k Al { License or.registration Valid for individul use only t j be#or'e the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Pa-rk Plaza ;.Suite 5170 Boston;MA 02116 f !� i� Novalid,' -ithoutsignature 1 f ^ F s i Restricted To: CSSL-MA-Masonry 21 Failure to possess a current edition of the Massachusetts State Building Cade is cause for revocation of this license. For DPS-Licensing information visit: www.Mass.Gov/DPS Message Page 1 of 1 Anderson, Robin From: O'Connell, Timothy Sent: Tuesday, July 05, 2011 8:44 AM To: 'Milton Berglund' Cc: Anderson, Robin Subject: RE: Rogue Houses Mr:. Berglund, I have looked up both properties and both are registered with Barnstable Health Div. Rental Ordinance Although, the occupants may have NOT followed Chap#59 as you have indicated. I will look into this matter further. We may put properties on night time inspection list. Timothy B O'Connell, R.S Health Inspector Town of Barnstable 200 Main Street Hyannis, MA 02601 (508)862-4646 Email: timothy.oconnell@town.barnstable.ma.us -----Original Message----- From: Milton Berglund [mailto:m.berglund@att.net] Sent: Sunday, July 03, 2011 6:20 PM To: O'Connell,Timothy Subject: Rogue Houses Tim...you may want to check out#16 Studley Rd where on the nights of July 2 and 3,I suspect excess occupancy. About 8 cars were parked on July 2 and 3. Over-occupancy suspected also at#3 Keating Road (house on the SE cornor of Keating and Ocean Ave). No number on the house anymore. About 5 cars parked about, 3 regularly on a longer term rental. I would also look up to see if thathouse is registered for rental. Owners are the Kunen family members of which one lives in Brooklyn NY and is rarely here...he may not even know there is an ordance about rentals. Thanks for looking into it. Regards, Milt Berglund 7/5/2011 Engineering Dept. (3rd floor) Map Q Parcel a S ermit# House# +� �' Date Iss �d Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) - = Fee. Conservation Office(4th floor)(8:30-9:30/1:00-2:00)' Planning Dept. (1st floor/School Admin. Bldg.) _ o,t►+E►o, " Definitive Plan Approved by Planning Board 19 - , • RN ABLE, _ M9. ASS TOWN OF"BARNSTABLLE Building Permit Application ' Project St Address Village ,�� Owner 1xv J &ix,aLz Address .Telephone ! a Permit Request First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ _w,0A Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) E Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No f Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) _. Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Op Jj�_ . /", Cam J Telephone Number 71S " 77b,3 Address _ .41 ;�—// License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ` ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE Tf I BUILDIaNG PERMIT DENIED FO A72 OLLOWING R ASON(S) J. t ' r l FOR OFFICIAL USE ONLY _ PERMIT NO. �� DATE ISSUED MAP%PARCEL NO. ADDRESS VILLAGE - OWNER ' DATE OF INSPECTION: , '» FOUNDATION FRAME INSULATION _ f • 1 FIREPLACE ' t i ELECTRICAL: ROUGH FINAL•; PLUMBING: ROUGH A FINAL t GAS: ROUGH 1 FINAL FINAL.BUILDING DATE CLOSED OUT - t ASSOCIATION PLAN NO. ., The Town of Barnstable Department of Health Safety and Environmental Services Building D*Won 367 Main Suvok Hyuzkb MA a=, Office: 509.790-6227 F Ralph Crosses: a+ 503-79o-coo Building Commiuio1 For office use only Permit na Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alteraUons, renovation, repair, modernimtion, 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 exesptlons,along withh other requirements. Type of Work: s T/^s,o f R� - Q�;� Est.Cost Address of Work: Owner's Name Date of Permit Application: /h T9.7 I bereby certify that: Registration is not required for the following reasou(s): Work rscluded by law __Job under 51.M Budding ant owner-occupied waer puWag 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 busby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR 1 It HOM5 IMPRROVEMENT CONTRACTORS REGISTRATION Boar of Bui ing egu atxons an dd Standards One Ashburton Place - Room 1301 Boston , Massachusetts 02108 9 HOME IMPROVEMENT CONTRACTOR ! Registration 108918 Expiration 08/27/98 Type - D B A i HOME IMPROVEMENT CONTRACTOR Registration 108918 THEODORE L . HITCHCOCK Type DBA THEODORE L. . HITCHCOCK. Expiration 08/27/98 PO BOX 211/SS LISA LN W BF-+RNSTABLE MA O2668 THEODORE L. HITCHCOCK THEODORE L. HITCHCOCK i pMQ„$OX 211/55 LISA LN ADMINISTRATOR -BARNSTABLE MA 02668 i T11c• Cu111111u1111'clthll of mas%ack"scttt -. 12 Deparmic•rrt of 111.cltcstrial.4ccidclrts ON=flllnyesllgat1VVS 600 l f-u.vhht;run Street Briton. Alas (j2111 _ Workers' Compensation Insurance Affidavit • vi t -.....�.�._..�. inf rm in �.. a n• Plc:►te I'RI1V'T•le ►i,lv natnc. Incation 3 &d'n/tj Ao44D I►honc. 0I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity Q I am an employer providing workers' compensation for my employees working on this job. rnmnanv name: �D/i�0/� �7/ 7 Gam•% address citv- /11. 1g �✓r J` 5/ rhnne# 77S- -7 insurance co. �/"'�1L���-S noiic� # ��7/1- IN9 -el 7 _ [J I am a sole proprietor, general contractor, or homeowner(clicle ogre) and have hired the contractors listed below who hav, the following workers compensation polices: cmmMrrn• nnmc• adriresc• 1►hnne# incurincc rn. nnlicv# cmmnnn.• nnrrrc.. addresc•" rin•. q ohnnc#• insurance co. _ noiic� # Attach additional sheet ifneccsiaty` ..� ..�::.-. --+: •W.:' :'_:_' �`+`�Z+.. -v- �y�,,._��'a"_.....•�.�77 Failure to secure coverage as required under Section:SA of A1GL 152 can lead to the imposition of criminal penalties of a line up to S1.500.00 andiur une N cars' imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a dad•against me. 1 understand that n cope of this statement ma% be forwarded to the Orrice of Investigations of the D1A for coverage verification. 1 do hereby cc, ifl•under the pains nerd penalties of perjure•that the information provided above is true and correct. Signature _ Date / /19�Q7 Print name — Phone# 7 7s- 7 Zle� w oRciai use unly do not write is this area to be completed by city or town official w `. citi or trove; permit/liccnsc it r1lluitding Department tC3Licensing hoard 0 check if immediate response is required (:IScicetmcn's Wee i contact person: Phone!!: C311calth Department r t-tUther�_ "r r. t