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HomeMy WebLinkAbout0089 LEWIS BAY ROAD (11) -- - __ - -- ----------- i �'i Town of Barnstable Building Department - 200 Main Street BAM STAB . * Hyannis, MA 02601 9 MASS $ i6.39. . 1508) 862-4038 Certificate of Occupancyn Application Number: 201006509 CO Number: 20110118 Parcel ID: 32722300E CO Issue Date: 08116/11 Location: 89 LEWIS BAY ROAD 201 Zoning Classification: Proposed Use: CONDOMINIUM Village: HYANNIS Gen Contractor: OCEANSIDE CONSTRUCTION & DEV . Permit Type: CC00 CERTIFICATE OF OCCUPANCY COMM Comments: C.O. FOR UNIT 201 Building Department Signature Date Signed Town of Barnstable Building Department - 200 Main Street BARNSTABLE. = Hyannis, MA 02601 9�A 16.19. , ' (508) 862-4038 Certificate of Occupancy Application Number: 201006509 CO Number: 20110118 Parcel ID: 3272230BA CO Issue Date: 08/16/11 Location: C89`LEWIS 0Y—R-OAD 201 Zoning Classification: MEDICAL SERVICES DISTRICT Proposed Use: Village: HYANNIS Gen Contractor: OCEANSIDE CONSTRUCTION & DEV Permit Type: CC00 . CERTIFICATE OF OCCUPANCY COMM Comments: C.O. FOR UNIT 201 a . Building Department Signature ate Signed SHE , TOWN OF BARNSTABLE ti BU.Uding Application Ref: 201006509 i BLE, Issue Date: 12/13/10 Permt y MASS. �A i639• Applicant: OCEANSIDE CONSTRUCTION&DEV a Permit Number: B 20102696 Proposed Use: Expiration Date: 06/12/11 Location 89 LEWIS BAY ROAD 201 Zoning District MS Permit Type: SPECIAL PROJECT ADD/ALTER COMM Map Parcel 3272230BA Permit Fee$ 308.05 Contractor OCEANSIDE CONSTRUCTION&DEV Village HYANNIS App Fee$ 100.00 License Num Est Construction Cost$ 33,852 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND INTERIOR BUILD OUT AS PER PLANS-UNIT 201 THIS CARD MUST BE KEPT POSTED UNTIL FINAL 12 BED,2 BATH INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: GREENERY DEVELOPMENT LLC BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 52 SHIP'S EAGLE LANE INSPECTION HAS BEEN MADE. OSTERVILLE, MA 02655 Application Entered by: PR Building Permit Issued By: THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLY OR SIDEWALK OR ANY PART THEREOF,EITHER TEMPORARILY:OR,PERMANENTLY. ENCROACHEMENTS ON PUBLIC PROPERTY;NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION. STREET OR ALLY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.; THE ISSUANCE OF THIS PERMIT:DOES NOT RELEASE THEAPPLICANT FROM THE:CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). 5. INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. 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. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). y ,,.Fa. .,,.ir., ', .«,; •:..s. „.,..r �..,. :Y, xg, ,fir BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 2 2 2 • O� 3 r, V 1 Heating Inspection Approvals Engineering Dept Fire Dept ,�.Q 2 Board of Health TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # 1'OC Health`Division Date Issued Z ` (0 Conservation Division Application Fee Planning Dept. Permit Fee. Date Definitive Plan Approved by Planning Board _ Historic - OKH Preservation/ Hyannis Project Street Address e9 LCW S- 13nY R 0M QNJ iT 2- Village t-tyA rN n t S A/�A k Owner 8C(. LJE�l5 12;A y L L L Address Sq 6 tM"`a'N Sts' UN V `Z Telephone ,�_ b _77B SZ©O Permit Request I N+a`o�t- `� o,.s7 As'�'�z- 'PCA-L� Q2oy, P209 �q r-i— Square feet: 1 st floor: existing proposed 2nd floor: existing. proposed Total new ` Zoning District Flood Plain Groundwater Overlay Project Valuation�� �- Construction Type Lot Size Grandfathered: ❑Yes -dfNo If yes, attach supporting documentation. Dwelling Type: Single Family- ,❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes Cho On Old King's Highway: ❑Yes a44o Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing ne 2 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 OtExyr IbmPS Central Air:-67Yes ❑ No Fireplaces: Existing LJWAV Existing wood/coal stove: ❑Yes o-N-5 --a Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: Llexisting o newt 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 cn APPLICANT INFORMATION (BUILDER OR HOMEOWNER) C�G�A MS i f) GIST Die C�P ?t- Name -304t-i JLAC htAjs Telephone Number __7744 Q39 5'q Address�U Mq%N ST UN iT i License # Ogpjl0Z 4�oe)ci`5 cnn o26,ol Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO CASE WASH t' SI ATURE DATE i t I G` FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCELNO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ®CORD,_ IMANS 611/2010 UCER THI CERTIFICATE IS ISSUED TI A MATTER OF INFORMA N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Paul Peters Agency,Inc. HOLDER, THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 680 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Mashpee,MA 02649 MPANIES AFFURD114G COVERAGE COMPANY A Atlantic Charter Insurance Company Compg!jy VDAC INSURED COMPANY Oceanside Construction,Inc, B COMPANY 419 River Road 0 Marstons Mills, MA 02648 COMPANY 1:1 in THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BL6N 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 POLICES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POUCY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MMIPDrYY) DATE(MMIDPIYY) (In Thousanda) GENERAL LIAAII JTM BODILY INJURY OCC 4 CC4APRSHENSIVE FORM _. BODILY INJURY AGG PREMISESIOPERATIONS PROPERTYOAMAGE000 6 PROPERTY DAMAGE AOQ $ UNDERGROUND E7(PLOBION a COLLAPSE HAZARD el a PE)COMBINED COO $ PRODUCTSICOMPLfiTED OPER 916 PD COMBINED AGO S CONTRACTUAL PERSONAL INJURY AGO $ INDEPENDENT CONTRACTORS EIROAD FORM PROPERTY DAMAGE PERSONAL INJURY AUTOMOBILE LIABILITY BODILY INJURY ANY AUTO (Perpamon) 6 ALL,OWNED AUTOS(PRvete Pan) BODILY INJURY ALL OWNED AUTOS (Per aeddent) $ (Olher Then PAvate Pusenpep HIRED AUTOS PROPERTY DAMAGE 6 NON-OWNED AUTOS BODILY INJURY& OARAOE LIABILITY PROPFATY DAMAGE COMBINED S EXCESS LIABILITY EACH OCCURRENCE S UMBRELLA FORM - AGGREGATE M OTHER THAN UMBRELLA FORM $ A FWORKERSRs PKLJAA IA'MNAND WCV00617205 2/3/2010 2/3/2011 X STATUTORYLIMIT5 EACH ACCIDENT $ 1,000;000 DISEASE-POLICY LIMIT s- 1,000,000 DISEASE-EACH EMPLOYEE 9--'11000,000 OTHER DESCRWTION OF OPERATIQN&4ocATION3NANICLR$MPECIALITEM$ Job: 89 Lewis Bay Rd II SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town Of Barnstable EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Attu:Paul Rosa d 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. 200 Main St BUT FAILURE TO IL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Hyannis,MA 02601 OF ANY KIND Y HE COMPANY,11342 OR REPRESENTATIVES. AUTHORIZED RE I 0; # ril '��4N C4 �iRC . Io► F� ? ►lI'�` r : r ix"'�`� �v� $ rk�,".y; '' ' +�t;r,r �, 1✓ z t F i rJ "a `, ah, s`a t �°f r; Project: Lewis Bay Court- Hyannis, MA In accordance with Section 116.2.1 of the Massachusetts State Building Code, 780 CMR, 7m Edition, I, Wayne J. Jacques, Massachusetts Registered Architect/Engineer #6935 of Jefferson Group Architects, Inc., hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specification concerning: Entire Project Architectural X Structural Mechanical Fire Protection Electrical Other(please specify) For the above named project and to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts Building Code 7rh Edition, all acceptable engineering practices and all applicable laws and ordinances for the proposed use and occupancy. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved of the building permit and shall be responsible for the following as specified in Section 116.2.2: 1. Review, for conformance to the design concept, shop drawings, samples and other submittals, which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials 3. Be present at intervals appropriate to the stage of construction, to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. Pursuant to Section 116.41 1 shall submit periodically, a progress report together with pertinent comments to the town of Hyannis Building commissions. Upon satisfactory completion of the work, I shall submit a final report as the satisfactory completion ad readiness of the,project for occupancy. <r��t �pl"s,U�q�'•4 ' �, C fv � ,9 No.GV135 BCETON MA May 19, 2010 GINAL AND AL DATE Jefferson Group Architects, Inc. Wayne J.Jacques,AIA,NCARB 700 School Street-Unit#2 Pawtucket,RI 02860 T:401-721-2245 F:401-721-2238 Construction Control Affidavit-MA Lewis Bay Court.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �d 600 Washington Street Boston, MA 02111 e www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �15 Address: C] (k'l�N �- y AJ City/State/Zip: ��`I ��Nam'' Phone #: 3 Are 1u an employer?Check the appropriate box: Type of project(required): 11 am a employer with 4. ❑ I am'a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. w ers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. a are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption.per MGL I I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I 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 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.#: V bei ('„ t-7 .Z 05 Expiration Date: Job Site Address: qo City/State/Zip: 6E,�,o( Attach a copy of the workers' compensation pol cy 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 1W D A for insurance coverage verification. I do hereby c rtif n er the pains and penalties of perjury that the information provided above is true and correct. tore: 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 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-contractor(s)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 lnvesti ations has to contact you reg arding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any'given year,need only'submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-77419 www.mass.gov/da `{ N The Commonwealth of Massachusetts 1 1 Department of Industrial Accidents ~x ° 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): Address:64,6 y Ai tT City/State/Zip: imn t Phone #: Are you an employer?Check the appropriate box: Type of project(required): L,Rri—am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. orkers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors 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: f Policy#or Self-ins. Lic. #: W Cal 6�0 11 003 Expiration Date: Job Site Address: ack Lei_jkS J&`° 2(i,Xo 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' de the ains and penalties of perjury that the information provided above is true and correct. �}�-- Si natu e: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town'offecial 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 in the service o_f 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-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy.of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to.any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street = Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617 727-774.9 www.mass,gov/dia e R i Niassachusetts- DepairtmC1t of Puhlic SafetN A, Board of Buildin�o Re�aulations and Standards Construction Supervisor License License: CS 48102 JOHN J HUTCHINS ; ' .419 RIVER.RD ' M ARSTONS MILLS, MA 02648 Expiration: 9/16/2012 ('ununissiuncr Tr#: 3834 . t