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HomeMy WebLinkAbout0029 KELLEY ROADr� 9 ,YEd r-�� ., Town of Barnstable BuildingE i tThis�Cad So That it is�Visible From= he Street-A roved Plans Musi be Retained on ob antl th�sard Must be:Ke"t Pos *" 'Posted Until-,Final,Inspection'Ha�Been Madea. z� % � 4639 s ere`a ofOCcu anC s'Re"uiredsuch Buldm �sIl Not`be Occu ied until a:FinalYlns" ection°has?been made^ Permit Whe .u ... ,.. .. M. .: P y:... „q ;��.. 3 a. -- g _ .,.. ...�; p, • ;. e .P q � ._:� � e .... Permit No. B-19-1247 Applicant Name: FRAUSTO, RAUL&PENEVA,YOANA N Approvals Date Issued: 04/26/2019 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 10/26/2019 Foundation: Residential Map/Lot 292-070 Zoning District: RB Sheathing: Location: 29 KELLEY ROAD,HYANNIS ; r C ontractor�Name' Framing: Owner on Record: FRAUSTO, RAUL& PENEVA,YOANA N i Corit�actor'License 2 Address: 29 KELLEY ROAD '~ � EStProject Cost: $5,999.00 Chimney: HYANNIS, MA 02601 0 � = Pe�rmlt Feb: $85.00 Description: BUILD OF BATHROOM ON SECOND FLOOR OF HOUSE(FULL Tee Paid-.' $85.00 Insulation: BATHROOM) ILDate ry 4/26/2019 Final: UPSTAIRS OF RESIDENCE. ON SECOND FLOOR',JN UNFINISHED ROOM, UPSTAIRS SECOND FLOOR HAS TWO ROOMSROOM OW �, ' il �� Plumbing/Gas FT RIGHT IS A FINISHED BEDROOM ROOM ON LE AN UNFINISHED 3 ROOM WHERE BATHROOM IS TO BE BUILD Rough Plumbing: Building Official Project Review Req: Project must meet enery code :� `` � Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authonzed 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 document for which�this permit has been granted. All construction,alterations and changes of use of any building and structures-hall be in compliance with the local zoning by laws and codes. Final Gas: W This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public ,spedtion for the entire duration of the work until the completion of the same. r Electrical The Certificate of Occupancy will not be issued until all applicable signaturesgby�the Building andjFi(6Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing �� z" � � Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT p - ----- ------ -- ----- _ .. r " t �1HE h • U�t`DMIG pEP APR 1 ((� O Application Number...�._....l...... . .. .�.. ............. .� 6 anxrrsrnsr.E, « I 2019 . b[nee $ Tp fV Permit Fee.......................................Other Fee........................ Aim OF BARNS rgBL Total Fee Paid......`......................................................... ...... TOWN OF BARNSTABLE Permit Approval by...C ...............on.t ' `-�. BUILDING PERMIT MV........�...5.2"............Parcel...........Z:7.0:................... APPLICATION Section 1 — Owner's Information and Project Location Project Address L Cflp'y 4\ Village L Owners Name-_ fi F/z �r p Owners Legal Address L6/k E City 1 State tm Zip Owners Cell# E-mail r u --r - PQ+ Section 2 —Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet ❑ Single/Two Family Dwelling Section 3— Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild' - ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar ❑ Renovation ❑ Pool ❑ Insulation Other—Specify. Section 4 - Work Description Z 60 F s r o v� k Last undated: 11/15/2018 1 Application Number...................................................... Section 5—Detail z Cost of Proposed Construction Square Footage of Project__ 6 Age of Structure YES Dig Safe Number . # Of Bedrooms Existing Total#Of Bedrooms (proposed) 3 9 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ 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: I am using a crane ❑ Yes ❑ No 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. Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No .. i Last updated: 11/15/2018 f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations - 600 Washington Street Boston,AM 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LegiRy Name (Business/Organization/Individual): 10 Address: LZ h,e � City/State/Zip: Phone#: �' � Z` '7 heck the appropriate box: Are employer? Type of project(required): I.❑ I am a employer with * 4. I am a general contractor and 1 6. ❑New constru ction employees(full and/or part-time). have hired the sub-contractors . listed on the attached sheet. 7. 0 Remodeling 2.El I am a sole proprietor or partner- ship and have no employees . . These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance., 9. El Building addition required.] 5. We are a corporation and its 10.0 Electrical repairs or additions. 3X I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs c. 152, 4 ,and we have no ;insurance required.]t §iO 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, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for iq employees. Below is thepolicy and job site information: Insurance Company Name: Policy'#or Self-ins.Lie.#: Expiration Date: 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 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 u er the pains andpenalties of perjury that the information provided above is true and correct Si afore: I'tn, �y 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#: - - - .l Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to tbis 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 shall withhold the issuance or 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 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 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 licenseor permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would lice 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: , The Commonwealth of Massachusetts DqW nient of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAM Fax#617-727-7749 Revised 4-24-07 wwc►,rnass.gov/dia , Application Number........................................... Section 9- Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell # 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 your license. Signature Date w' Section 10—Home Im rovement Contractor P Name Telephone Number Address City State Zip Registration Number Expiration Date 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 documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section 11 Home Owners License Exemption Home Owners Name:� � � /�71p Telephone Number 5_6 2 y(o? Cell or Work Number. ;? `7 l 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 documentatioZredd by 780 CMR and the Town of Barnstable. Signature Date t s a cAPPLICANT SIGNATURE a I � Signature ( Date Print Name Telephone Number s C E' 2y� E-mail permit to: ct-J 22CC/1� Last updated. 11/15/2018 Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval, Section 13— Owner's Authorization i i I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of j ob) Signature of Owner date Print Name - • � r 1• r• t ' 1 1 Last updated:11/15/2018 CAPE COD TOWN OF ARNsTA tp INSULATION 110tR OEASS 0lp MlFSS FP0.AT FOAM 9YSPENDED 0Aii5 OURERE NSUWfON GfILINOF YEffi. 1-800-696-6611 QIV!�f� , Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: .7/f.)-/j -3 Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village ZG Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( Y- ( Z(, ( ) ( ) C-6L, nIj Cx C (iz) �x) Slopes ( ) ( ) ( ) ( ) ( } Floors Walls Sincerely He y E Cas y Jr, President Cie Cod I 1 ulation, Inc. ,a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma Parcel l� lication # p pp Health Division Date Issued 5 . Conservation Division Application Fee Planning Dept. Permit Fee - Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/'Hyannis Project Street Address o19 /LleIlcy Gam' Village Owner _G/�fo,�/ ff , 14Yf ei �Address , Jr Telephone `Permit Request Jr.S A ..fie oeT�,�1Ce �A Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type 14t/ Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.,_ Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) k=4' o. w Age of Existing Structure Historic House: ❑Yes J4 No On Old King's i i hway: 3Yeslloo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ry _ :n. Basement Finished Area(sq.ft.) Basement Unfinished Area (sq. Pa -� cn Number of Baths: Full: existing new Half: existing new cs� Number of Bedrooms: existing _new Total Room Count (not including bate,,): 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 e �/���, i 0� Telephone Number s,32 TT j Address ,/e Z1*° , ,:v"e_7 License#�/y,o Home Improvement Contractor Worker's Compensation #4A%��6;7 l ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE dAZ DATE S FOR OFFICIAL USE ONLY r ` APPLICATION# r E DATE ISSUED i, MAP/PARCEL NO. ' ;k ADDRESS VILLAGE ` OWNER ' F 4 r DATE OF INSPECTION: - ,FOUNDATION ` FRAME INSULATION 'r s FIREPLACE f ELECTRICAL: ROUGH FINAL f s PLUMBING: ROUGH FINAL 'z GAS: ROUGH FINAL t FINAL BUILDING 'F DATE CLOSED OUT ASSOCIATION PLAN NO. i r " Massachusetts - Department of Puhlic Safco Board of Buil(lin., Regulations and stalidards % Construction Supervisor License a 6• - LicenA`.r CS 100988 . HENRY CASSIDY r 8 SHED ROW WESfjT 1*ARMOUTH, MA 02673 ? Expiration: 11/11/2013 ( uuuisiuncr Tr#: 7620 Of ice of Consumer Affairs and Business Regulation ' 10 Park Plaza -Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2"b14 Tr# 233831 CAPE COD INSULATION, INC HENRY CASSIDY 1.8 REARDON CIRCLE SO. YARMOUTH, MA 02664 Update Address and return card. Mark reason for change. Address L_I Renewal I._-I Employment Lost Card ,,� ��.r �l`(nrrrrrrr rrroc:rr.lr� n>%C�I�rJJrrCf[tG;IC�C ', zv\ ,Office of Cousumer Affairs S Business Regulation License or registration valid for individul use only s. vim. p OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: e istration: Office of Consumer Affairs and Business Regulation 9 � 153567 Type: i; Expiration: 12/15/2014 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULATION,;IN'Q., Hr:.NkY CASSIDY 18 REARDON CIRCLE SO YIARMOUTH, MA 02664. A —ilidersecretary wi[ho t re i CAPECOD-27 _SPURDY ACORU" CERTIFICATE OF LIABILITY INSURANCE °A4/24/2013 013 I 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 j REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. - --- ---- ---- ----- - ----- ------------------.__ -_ .. _---- IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsem_ent(s). (PRODUCER CONTACT NAME:- -Cape Cod_Commercial _ Rogers&Gray Ins.-Dennis Branch PHONE : 508 398-7980 r lay,Nol__ 877 816-2156 l i434 Rte 134 _(Alc,No ExtL(-) -- — ---------__I_- - --� ,South Dennis,MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE _ _ I NAIC p INSURER A:PEERLESS INSURANCE COMPANY_ -I - IINSURED INSURER B:COMMERCE INSURANCE COMPANY I I Cape Cod Insulation Inc I_INSURER_C:Evanston Insurance Company 18 Reardon Circle INSURER D;Atiantic Charter Insurance Company - I South Yarmouth,MA 02664 INSURER E INSURER F: I 1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i 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. INSRI - - - ------ ---------IAODL SUBR - — POLICY EFF POLICY LIMITS LTR.I - TYPE OF INSURANCE - _ INS,�WVD POLICY NUMBER __ _ j[MMIDDIYYYY) LNIMIDDA0 YY) LIMI r --- F.- _I----_--.- GENERAL LIABILITY EACH OCCURRENCE __ $ _ 1,000,0001 I A I X COMMERCIAL GENERAL LIABILITY ICBP8263063 4/112013 4/1/2014 _DAM_A-GE TO-RENTED- pREMISES_(Ea occurrence 100,000I j CLAIMS-MADE [X j OCCUR i I i MED EXP(Any one person) $ 5,000� ` ___ PERSONAL&ADV INJURY $ 1,000,0001 i GENERAL AGGREGATE I$ 2,000,0001 ----- ---- ----- --- .-__.. --- -- GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000 0.0 - - POLICY I�I EC Y TLOC AUTOMOBILE LIABILIT, l COMBINED SINGLE LIMIT 1 000,006 I I Ea accident B ' ANY AUTO I 12MMBCKVMK 4/1/2013 I 4/1/2014 BODILY INJURY(Per person) $ { ALL OWNED X SCHEDULED I AUTOS --- AUTOS ( $ -- BODILY INJURY Per accident) NON-OWNED FROPERTY DAMAGE X {HIRED AUTOS f X AUTOS _(PE I R __ T) $ EACH OCCURRENCE $ 1 OOO,OOOI X OCCUR --- -__- - . ExcessuAB XONJ453512 4/1/2013 4/1/2014 AGGREGATE C$ 1,000,OOOI I C I CLAIMS-MADE I a UMBRELLA LIAR _._. - --- -- I _ ..._.. 1 J DED �L� RETENTION$ 10,000 I _ $ - - -- - - ----- ---- --- TH- j WORKERS COMPENSATION I J X I TpRY L M T$ OER AND EMPLOYERS'LIABILITY YIN iI I 1,000,000 D I ANY PROPRIETOR/PARTNER/EXECUTIVE��� � N/A WCA00525903 6/30/2012 6/30/2013 E.L.EACH AC_C_IDEN_T $ l OFFICERIMEMBER EXCLUDE D? I N - j ;(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ 1,000 0001 i If yes,describe under DESCRIPTION OF OPERATIONS below_-_ ______. _- __ E L.DISEASE-.POLICY LIMIT $ _- 1,0001000. �- -----___ ------ - ----- -....__ ....I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate Holder is an additional insured under General Liability when required by written Contracts or agreements. i i I II i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN i EVIDENCE OF INSURANCE i ACCORDANCE WITH THE POLICY PROVISIONS. . --- AUTHORIZED REPRESENTATIVE -- ' ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The C'otnntonwealth of'Massachusetts Nnnthorm Depurtment of Industrial Accidents ;k �. r Office of'Investigations .�. 1 Congress Street, Suite 100 Boston, MA 02114-2017 w ww.trlass.gov/din W011-kern' Cori,ipensation Insurance Affidavit: Builders/Contractors/Electricial►s/Plutubers Aj)illicaut Please Print Lcgj! Namt: (13LISilless/01'gUnization/individual): _ �I(� Vet a,h 4m� c it,rtil,ttc/%i `J V v� �I/I Phone #: �0 - ' 14 P� 71 9rc. ou an employer? Check t e appropriate box: Type of project(required): ;utr a employer with 2-0 -- `l. ❑ I am a general contractor and I ...... _� 6. ❑ New corish•uctiort �ntplu�eeti (Cull ,:uui/qr part-time).* have hired the sub-contractors I ;uu .I sole prupric lfirr or partner- listed on the attached sheet. 7. n Remodeling 'whiir <utd have: no employees These sub-contractors have a. ❑ Demolition rtorkin� for me in Gtny capacity. employees and have workers' lNo 'workers' corny. insurance comp. insurance. # 9. ❑ BUildinl addition r0yuircd.j S. ❑ We are a corporation and its l0.❑ Ilec[ric�il 'chairs or additions U I aun a honicowner doing all work otticers have exercised their I L❑ Plurr►bing repairs or additions ntyscl l'. I No workers' cone right of exemption per MGL p. 12.❑ .Roots re all s insurane:c reduircd.] .t c. 152, `I(4), and we have no �j ���t(��I� /p � employees. [No workers' 13.� Other W t tt __. ra✓ bq comp. insurance;required.] 'An} ,q)lilicauit that checks box it I must also iill out the section below showing their workers'compensation policy information. I I,nucs e teas who subutit iltis ufl-ldavit indicating they are doing all-work:utd then hire outside contractors must submit it new affidavit indicating such. lC n lia,,ons that chuck this box must attached an additional sheet showing the uwne of die sub-contructons and stute whether or not those cntitics huvc 11 the soh-contractors have;employees,they must provide their workers'comp.policy number. 1 am an emplover that is providing workers'compensation insurance fur arty employees. .Below is Me policy and joh site ru/urmu�iurr. rA , I iiranau��.•l.'ontp�ttty Name:---- l�V! �C� �l/1GLVt`� I�GyGi�Gt�l G-�i ------•— I'nli�ti r tu-S'cll ins. Laic. #: (QQ 2� 01 Expiration Date: Joh�ilc :�tlefress: _ — City/State/Zip: ---------..._.._ Attach it copy of the Workers' coinpensatiou policy declaration page(showing the policy number and expiration date). F;tilure ter secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition or criminal penalties ofa 1,500.00 and/or one-year irtiprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine „I tti,it)$2%.00 it clay against the violator. Be advised that a copy of this statement may be forwarded to the OCtice of Invc'Su aeons ofthe DIA for insurance coverage veriticatioli. 1 Ju hrrcbV c'ertifp,i♦nller the ,tins-inyl penalties o/ erjury that the inlbrmatiun provltled above is true and correct. �1 Il.11llrl; Date: r^ Official awe only. Do not write in trtis area, to be completed by city or town official. l ity t,r'1'uwu: _ Permit/License# lssuilig Authority (circle Otic): I. Board of I lealth 2. Building Department 3. City/Towu Clerk 4.1lectrical Inspector 5. Plumbing Inspector 6.0Cher t'ottucl Person: Phone#: OWNER AUTHORIZATION FORM , I, (Owner's Name) owner of the property located at ffe j J (Property ddress) Jl Gi , � z6Gl (Property Address) hereby authorize__ re-T X9 P (:::�J T N�) 0 [Ck 0 A, (Subcontr or) an authorized subcontractor for ISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. 4/ Owner Signature Date