HomeMy WebLinkAbout0094 LILLIAN DRIVE �Li Dom ,
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SINE Town of Barnstable *Permit _I�_3�a�
Expires 6 mon hs jrom issue date
Building Department S M
Wee
• snaxszescs, • Brian Florence,CBO .
16 g6 ► Building Commissioner � pv � �0"
Fo met 200 Main Street,Hyannis,MA 02601
www.town.barnstable " Fax:
?1
Office: 508-862-4038 / Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL' �L,Y
L/C�� 21 7 6 Not Valid without Red X-Press Imprint
Map/parcel Number 7 d
Property Address 7 / z/���/l C!
—im z/
50�esidential Value of Work$ ��®� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address AZ4�1.0A- �/JLe-2.
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑�,,�a sole proprietor
�,,�'i am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name Zji &&�.&Z
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
[:] -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:
'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 roperty Owner Letter of Permission.
A copy of the Home I ovement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
QAWPFILESTORMSIbuilding permit forms\EXPRESS.doc
08/16/17
17rs Cownrompeafth of-Waysadrrrsetts .
Department o,f1r &hd Acciderr&
Office a,f�n gadom
600 Wasithloon,S`tr'eet
Boston,41A#2111 ✓
mvmmasxgov1dfa
Workers' Campensat onInsorance Affidavit Bnitders/CorntractursfEIecfticians/Phmbers
Applicant Infth miation. Please Print
Name(Businmamig, afid� �
Address:
Ciwstate1 = &A 4,14 Pharr g-_
Are you an employer?Check the appropriate bow: ' Type of project(required)-
I.❑ I am a employer with ' 4. ❑ I am a general contractor and I 6. ❑New construction
employees(fish andfor part-time)-* have hired the sub-contractors
2.❑ I am a sale proprietor orpartner- listed on the attached sheet y. ❑Remodeling
ship and have no employees These sub-contractors have 8.,❑Demolition
/ang for me irr employees and hate workers'1� 9. �B�uil�addition
Workers,camp.insurance comp.msurance-
5. ❑ We are a corporation and its 10.❑Electrical repairs or ad d tions
3. a homeowner doing all work of have exercised their 1 L❑Plumbing repairs or additions
mysielf[N8 workers'comp- rigR of exemption per MGI.
c.I52, 1 ,�}, and we lrsare aYa 17�hoof repairs •.
insurance reed.]T (4h 13_0 Other
employees-[No wo&s'
comp iusarame required-]
Any appBc=ewtchecUbas#1—sislsofMcatheswd=bet4wshovmgthrswa&as'compenmti(mpokymf rm dm3-
#h omemnem who satmgt this dMAnt mating dzey axe daiog shh vat and&ea bzm aulsi&coahactars oust submit anew affidasit indicating11
fC=MLc1n6 thxt,%eck this boas must aftarhed;sn additimal shag sboiemg then=e of the sub-caWxxctx and sty whether ar not fhose andt eshrm
• eraphoyees.Iftheanb-taahactmsyaveempIoy�s,ESe}�sCgmvid�ih.e'v srork�'tamp•palicFaumise�
I ant art empiay�r iierrl;is prosadir�yvarkets'conrpertsrn�irrrt irrsrtrrttres for rtxy gmpioy�eex $etaty is tJte policy ar�rd job�rte
information.
Insurance Company Name:
Policy-A or Self-ins.Lie.4' Fxpiratioa Date:
Job Site Address: Cify Statel7.rp:
Attach a copy of the workers'compensation policy declaration page(shoving the policy number and expiration date).
Failure to secure coverage as requireduuder Section 25A of MGL a 15�2 can lead to the imposition of criminal penalties of a
fine up to$15OD OD and/or one-yeasimprisonmenk as well as cif penalties in the fog of a STOP WORK ORDER and a fine
of up to$250-Da a day against the violator. BeqAvised that a copy of this statement may be forwarded to the Office of
Investigations of the DI<4 for insurance ca verfcation-
1'rl'o hereby cacti suler the ' s vegu y thatthe in form i-pt mid abmro' bra id correct
Siitntatnre: Date: l
Phoneik
Oiid d use only D'a ttet wrthf in Ellis 4mrea,€a be coinpieted by tiiy artown oficiaL
City or Town: PermibLicense i€
Issuing Authority(circle one):
1.Board of Health 3.Building Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.other
Contact Person Ph-one#:
Information and Instructions
M G
assacj=etfs e7ae rA Lays chaps 152 reggaes all employers to pro�ida wo�ras'cemrpeusafion far their eanpIoyees. .
this sty,an employee is eiefined as."_.everypersoain the service of anafi=vndes any contact ofhire,
express or implied,oral or wuttxn.
An.Moyer is&fa ed as'an in�idnal,partnersb�,assoc�am,corporation or other IC99 e�y;or any two or mare
of the foregoing engaged is a joint else,and including tin Iegal represeMt&&es of a deceased employer,or the
re.eiver or tmstee of as mdividuaI,part=ship,association or other Iegal entity,employing employees. However the
owner of a dwrMag house having not more than threes apartments and who resides therein,or the occupant of the -
dweIIing house of another who employs pemons to do maintmace,consfructron or repair work on such dwelling house
or on the grounds or building appmtm thereto shall not because of sarh employment be deemed to be an employer-"
MGL chapter 152,§25C(6)also states tint'every state izr local licensing agency shall withhold the issuance or
renewal of a license or permit to opeamte a business or to construct buildings is the commonwealth for airy
er
applicant who has notprodnced acceptable evidence of ceimpIra�ace wrth the insurance.coverage e4aked-
"
Additionally,MGL chapter 152,§25C(7)stars'Neither the commonwealth nor a'ay ofits political subdivisions shall
Miter into any contract for the perfunn.aam ofpublio work unbI acceptable evidence of compliance viith the insGrSnDe..
regtmems of this chapter have Been presented in the conLacfmg anihoiity." -
Applicants ,
Please fill out the workers'compensation affidavit completely,by decking tho boxes that apply to your sifnaiioa and,if
necessary,supply sab-contractor(s)name(s), addresses)and phone mmmber(s)along with their certfficatc(s)of
mnzance. Limited Liability Companies(LLC)or Limited Liabi f Partnerships(LLP)withno employe es other than the
members or partners,are not regdired to cant'wmums'compensation iosaianm.If an LLC or LLP does have
employees,a policy is repaired. Be advised that this affidayrt maybe submitted to the Depm1ment of Industrial
Accidents for confnmation of msmmce coverage: Also be sure to sign and date the affidavit. The affidavit should
be retumed to the city or town that the application for the permit or license is being requested,not the Department of
IndastriaT Accidents. Shouldyou have any questions regarding the law or ifyou are required to obtam a workers'
compensation policy,please call fire Department at the number listed below. Self-insredcompanies shouldentertheir
self-ms arance license number on the appropriate line.
City or Town Officials
f
Please be sate that the;affidavit is complete and pried legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant
Pleasee be sure to fill in the pen�it/license number which will b-,used as a reference umber. Ia addition,an applicant
that must sabmit multiple p ennitllicense applications in any giveaiear y ,need only submit one affidavit indicating current
policy infonn.ation Cif necessary)and under"Job Site Address"the applicant should wnte'all locations in (C-ity or
town)-"A copy of the-affidavit that has bey 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 futm 'penits or licenses A new affidavit must be filed.Olt each.
year.Where a home owner or citizen is obtaining a license or peamit not related'to any business or commercial ventane
(Le, a dog license or peunit to bum.leaves etc.)said person is NOT req��d to complete this affidavit
The Of of Investigations would like to thank you m advance for your cooperation and should your have any quesiions,
please do not hesitate to give Ms a call-
The Departmenf s.address,t6lephone and fax number_
CG=,QnWM1*of MashU& tls '
Depad min ah� Aleuts
604 V7Ubh G11�
Tel.4�l�' -49 0 cxt 4D6 car l-�9 MAS AFE
Fax 9 617`27 7M
Re4ised 4-24-07 zaas,5.gav/dia.
Town of Barnstable
Building Department Services
MASIL ` Brian Florence,CBO
�`� Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
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 Job)
**Pool fences and alarms are the responsibility of the applicant Pools.
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q:FORMS:OWNERPERMISSIONPOOIS
Rev:09/16/17
Town of Barnstable
Building Department Services .
Brian Florence,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
s�rsresue,
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXE 11MON
Please Print
DATE:
JOB LOCATION:
number village
� V
xoMEowNER7: O Z//4 � ��' � !/ 7�
nameV home Vp # work phone#
CURRENT MARJNG ADDRESS: �✓ � � 0��`
cityhDWn state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- .
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work yerformed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeo r"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
proce s and and that he/she will comply with said procedures and requirements.
igoatu o
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is .
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in
your community.
Q:\WPFHM\FORMS\building permit krouMTRESS.doc
08/16/17
I '
Town of Barnstable *Permit#
2. n ( 5Ja `� �
� 6 mou 'sup�dfge
Regulatory Services E
xpi
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+ BARNMBLE,
16 9. Richard V.Scali,Director
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Building Division X-PRESS PERMPT
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601 J U N 2 6 2015
www.town.barnstable.ma.us TOWN OF &IRIST
. 501879 Q 6�0Office: 508-862-4038 63 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address
LA [1 1,6, tkow1�
Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address Jim
Contractor's Name r �� It, 3— �� _Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
<h, ck one:
I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name Gjv �1
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑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 co y of the Home Improvement Contractors License&Construction Supervisors License is
q red.
SIGNATURE:
Q:\WPFILES\FORMS\ ' ' permit forms\E doc
Revised 040215
Y�
Dejwwmnt n,f I'nt*aoi l Accad den&
Office o,f Investigations
600 Washinglon Swet
Boston,MA 02111
WMI"alass-g vIdi a
Workers) Compensation Insurance Affidavit:BviMers/ContractordEfechicianslPluinbers
Apphierant 7ufaration Please Print Legibly
A,ddmss: �(A �
Are.you an employer?Check the appropria .boa: Type of project(required):
1.❑ I am a employer with 4- ❑ I am a.genemal contractor and 1 6. ❑New.*conshuckozn
emlrloyQew(fall and/or part-tone).* have hired the wb-com9aaocta13
2. I aim a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
slap amid have no emnployees. These sub-contractors have S. ❑Demolition
weA dng Rw me in any +cif- .ins and.have Svc ess'
9. BuildingEl addition
[No Evor1�' .imsura�nce cowp � ,I
5. ❑ We are a corporati�ou and its 10.E]kcal repairs d or ads
required.] officers have exercised their 11.❑Plumbing repairs or additions
3.❑ 1 am a hazmeov mer doing all work
myself[No wor&ecs'compright of exemption w 12.❑Roof repairs,
i�ao�*+ce d-]T c. 152, �1(4�and we
1ta� e n�
employees.[lwTovaaAeas' 13.0 mer
camp.insurance mquired.]
•laimy spp➢ncamt a hec&s box#1 also fill va the section bdoar shoe z heir woakefs'compensation policy infaauadan.
l Fi�nmaeaa¢obets who submit this affidavet enat3�m=z they axe dating RE wean.said then hiae a�i claw caoanac�ars amnst submit a new affidavit indicating sna h
ZCaatttactars that cbKk then bans mot attacbed an additianA sheet showk9 Sae"EDO of the sub-centrsctm and.stin whether off not erase entities have
maplayem If the sctb<on=ct®s base eaPlagM5.11hey smut provide tEir workers'comp.policy mmiber.
Tarn an emplapsr that is previa workors'compmstadan irasraramce far my aarplajwas. MOW is flltar pan y=diaa+b site
iR�ftra'ma7tiara.
Insm-ante Comm psuyNamve: '� � at/�
Policy#or Self inns.Liic,.;k r r Expintion Date:: a
Job Site Address: 8`? l-G\q I C�ff� CityPState/Zip:
Ae tacla a copy ofthe worlrers'compensatiou polnt y declamation page(showing the polity number and expiration mate).
Failure to seewe coverage as reT iced under Sectitotb 25A of MGL c-152 can lead to the imposition of criminal penalties of a
fine up to$1,500.0(1 azWor one-year imprisonzaenL as we2 as chit penalties in the form of a STOP WORK ORDER anal a fine
of up to$250.DO a stay against the-violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofthe D1A.for insurance coverage verification-
No a'�irarrad ara3tfi�fyP rdat'the pains anripasn s pat�arry��Mat die in femur an.ptmRi&d above is and a:�arrmt
Signature. Date:
Phone-9:
0,ftiari arse only. Do runt w ite in tiara fireV4 to bar caetpUted bye city or town a�'actat
c
City or Town: PermitiLicense#
L4sming Authority(idrele an,e):
1.Board of Health 2.BwUng Department 3.CiV roan Clerk 4.Electrical Lupec for S.Plumbing fnapector
6.Other'
CoMct Person: Phone 9:
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BA NSTABLEP )IN G DEPT.
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r Town of Barnstable
., r Regulatory 8ervi,ces., ,
M r v Tard V�Scali ":
1639. a DirCcfor � "
Buildilug.Division
TOM
unisgoner
004-u stre"t,'iin x yan„is,MA 02601 w'
www.fown.bs�rnsCa�ble.ma�us
ti .
Officer 508-86.40.38 Ai: 508-790-6230
�y G
Property Owner Must
. Complete and Sign This Section s
If Using A Builder
4
as Owner of the subject property
!+�-• A
hereby authon7z i Or to act on my behalf, 1
j
Hi all matters relative to work authorized by rQ# building permit application for.
_9_
(Address ofrob) J -,
' 'pool.fences and ala.fms are the responsibility of,ihe applicant.Pools
are got to be filled or util d b�;s3re fence is installed.and all"final 4
cf
Taspections are perfo. and cce red.
zgnau.re av a Signature of Applicant R
gig.,
T/r1,C1�x 'dI'r� Print z vu,.+u- �..
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_ Q F1��45.f.T�'4":+'TwRi"k�:•fISS1�+''�?I•S ;
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map` . 1 Parcel Application # � t Y R76(o
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee AE
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address �'7 !��a✓l oli-,
Village -4 / n '
Owner Address
Telephone f
Permit R quest ✓w2 ber)Wq 1,)a.�,� k��c�ev� , Lyl4 a rooK S�or4 l�r�-�/ )�!!Jinee,e.
Remoue ci6hm lvt Zjaud I d'8 wt r avk.e _ u, a IR L awl, f OOcry[ Oo/
a a2idaa E74
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation . D 000 Construction Type
"Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 0 Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes J�Jo On Old King's Highway: ❑Yes Jko
Basement Type: LdIfull ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
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! al stove ❑Yig ❑ No
D.etached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑'OAsting mew lsize_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: ^" I
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 �Ovlv_l CV6,v_%1A Telephone Number 50%' -7 Q
Address 7�I�:l�'_e5��re. oCr. License # 30_1
0 Z5--c 7 Home Improvement Contractor# Tao)74
Email �S C.�C7Vl��/l�_ 014 `06 � Cove Worker's Compensation #
ALL CONST UCTI DEBR RESULTING FROM THIS PROJECT WILL BE TAKEN TO �6aJ_
` 'as�,� �iJ12 � -
�J
SIGNATURE DATE 54 ��
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
9
MAP/PARCEL NO.
I.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
k �
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
,
f DATE.CLOSED OUT
AS,SQION PLAN NO.
r
The Commonwealth of Massachusetts
VJDepartment oflndustrid Accidents
Office of Invesfigations
600 Washington Street
Boston,MA 02111
www.mass gov/ilia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly'
Name(Business/Organization/Individual): Lo I S
Address:
10� Pho e#: 5" Z 7 3 I s`fG
City/State/Zip: S �l?. a, D
Are you-an employer? Check the appropriate box: Type of project(required):
1", a employer with_ 7i 4. I am a general contractor and I
employees(foil 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, E]Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.msurance 9. ❑Building addition
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Oilier
comp.insurance required.]
*Any applicant that checks box#1 mast 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 hue 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'camp,policy number,
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.#: /L.�C V 7 73 Expiration
Job Site Address: f;//�' s I`Iycvys?rS' !/�llc City/State/Zip: D
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 e. 152 can lead to the imposition of criminal penalties of a
fine up to$1,50D.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 c de the pains and penalties ofperjury that the information provided abo ee true and correct.
Sin attire: Date: t/1
Phone#: 737 /57L
Of 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 0 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(o 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 lime.
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 buns 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 Strut
BastGn,MA 02111
Tel.9 617-727-490-0 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 4-24-07
- www.mass.govfdia
f
The ConttrtomueaUh of Massachuseta
_ D4wrtirmnt of ln&strial Accidence
rIF Off we of Invest gations
600 Washington Street
Boston,MA 02111
N ww,mas&gvv1dia
Workers' Compensation Insurance Affidavit- Builders/ContractarslEiectrkians/Plumbers
Applicant Information 9 Please Print ib
Naive(B,» u&s&Dq nintionvidua0: CR-�'" �.JR(2 WuVk-
Address: L Lfe v
City/Stat&Zip: ��� a.D?AT3 Phone# 5 �`�-3 -7 1 S-Li b
Are you an employer?Check the appropriate boz:_
Type of project(required):
1.El am a employer with 4. � a general contractor and I
employees(full andloryart-time).
* have hired the sub-contractors 6- ❑New construction
2,❑ I am a sole proprietor or partner- listed on the attached sheet. 7- Zl�eawdeling
ship and haine no employees These sub-contractors have g_ ❑Demolition
working for me in any capacity_ employees and have workers'
[No workers'comp.insurance comp-instuance.l ❑Building addition
required.] 5. ❑ We,are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I❑Plumbing'repairs or additions
myself [No workers'comp- right of exemption per MGL 12..❑Roof repairs
insurance rewired.]T c. 152,§1(4},and we have na
employees.[No workers' 13..❑Other
comp.insurance required.]'
'A¢y applicant fat checks box#1 must also fill out the section below showing worlters''Compensation policy infnamation-
#fkmeflwmers who submit this affidavit indicat mg they are doing all want and them hue outside contractors must submit anew affidavit indicating surh
'Contractnis that chew this bolt must attached au additional sheet showing the name of the sub-com motors and state whe&u or.mot those entltkes have
employees. If the sub{.anttaCors have employees,they must provide their workers'comp.policy number.
I am ark emplayer that is providing workers'cougmisation insurance for my employees. Below is thepolicy and job site
informalton.
Insurance Company Name:
Policy#or Self-ins..rLie.#: k)C+ °I�36 C Expiration late: Z t-
Job Site Address: / /-/16Qti1�iA, /74 '76fz A. 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$1,500.00 andlor one-year imprisonment,as well as ci-%nl penalties in the form of a STOP WORK ORDER and a fine
of to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations o€th D for insurance coverage verification.
I dig hereby certify der t pain rt penalties of pedii..►y that the info rm atio I i provided l/ is true and correct
�y - Date: J /
Phone#: / Z51 /6`/-/0
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Toam: PermitUcense#
.Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityl own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
APR-25-2014 10:17 P.02i02
Client#:282463 AMAZONGRAN
DATE(MMIDDrcYYY)
ACORDrM CERTIFICATE OF LIABILITY INSURANCE 4125►2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),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 terns 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 andorsement(s).
PRoouceR None E cT Anne Sanzo
FAX..
HUB International New England (AIC.No,E=t):508-945.7863 auc No; 508-945-9136
265 Orleans Road E-Mal ADDRESS: anne.sanaonhubinternational.com
North Chatham,MA 02660 INSURER($)AFFORDING COVERAGE NAIC i
506 945-0446 INsuaeRA;Safety Insurance Co
INSURED INSURER B:Main St America
Amazon Granite LLC _ INSURERC, _
979 Falmouth Road#A-28 INSURER D. _
Hyannis,MA 02601 IN9UREaE:
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 AFPORDED 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.
S ADDLSIIBR POLICY F POLIQYEXP LIMITS
TYPE 0> INSURANCE INgR POLICY NUMBER MMIDD (MM/D IYYYYJ
p GENERALLIABILITY BMA000876904 11241201311/24/201 EACH OCCURRENCE $1,000,OQ0
X COMMERCIAL GENERAL LIABILITY
SETOE.Mn.�ne $500 000
CLAIMS-MADE 1'."'OCCUR MED EXP(Any one person) $10 000
PERSONAL A ADV INJURY $1,000 000
GENERAL AGGREGATE s2,000 000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS^COMP/OP AGG s2,000,000
PoucY PRO LOc $
AUTOMOBILE LIABILITY, COMBINED SINGLE UMIT
Ee ecctdonl) $_
BODILY INJURY(Per person) $
ANY AUTO
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS NON�owNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Perm cdent
UMBRELLA LIAR OCCUR +EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
S
_DEo I.RNTION$ _
B WORKER&COMPENSATION WCT9936C 1/24/2013 11/24/201 we Y-LIM OTH.
AND EMPLOYERS'LIABILITY )LLCI R._
ANY PROPRIETORRARTNERIEXECUTIVE YIN
N E,L,EACH ACCIDENT $�OO,000
OFPICERJMEMBER EXCLUDED7 N N I A
(Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $100 000
Use describe untlar E.L.DISEASE-POLICY LIMIT $500 000
Use
Of OPERATIONS bolow
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Aeach ACORD 101,Additional Remarks Schedule,If more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
TOTAL P.02
f
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)
Fo5/13/20144
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 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 UUNIACTPAUL SCHLEGEL
NAME:
Schlegel & Schlegel Insurance Brokers Inc PHONE (508) 771-8381 FAX 508-771-0663
(A/C,No,Ext): (A/C,No).
34 MAIN STREET E-MAIL
ADDRESS: SCHLEGEL INSURANCE @VERIZON.NET
INSURER(S)AFFORDING COVERAGE NAIC p
West Yarmouth, MA 02673 INSURERA:NGM INSURANCE COMPANY 14788
INSURED INSURER B:TRAVELERS
Patrick Cronin
INSURER C
376 Lake Shore Drive
INSURER D
INSURER E:
Sandwich, MA 02563 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 PAID CLAIMS.
INSR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY LIMITS
) (MMIDD/YYYY)
A GENERAL LIABILITY MPT1326G 10/16/201310/16/2014 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 500,000
CLAIMS-MADE rx I OCCUR MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENERALAGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY PRO- LOC $
JECT
AUTOMOBILE LIABILITY COMBINED NGLE LIMIT
(Ea accident) $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS - (Per accident)
$
UMBRELLA LIAB- OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
B WORKERS COMPENSATION X WC STATU
LAM TS ER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCV-52773 05/23/201305/23/2014 E.L.EACH ACCIDENT $ lOO,000
OFFICER/MEMBER EXCLUDED? Y❑ N/A
(Mandatory in NH) �05/23/2014 05/23/2015 E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
PATRICK CRONIN HAS ELECTED NOT TO BE COVERED ON HIS WORKERS COMPENSATION POLICY
CERTIFICATE HOLDER CANCELLATION
KATHLEEN & BOGDAN LUCZYK
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
94 JILLIAN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
HYANNIS, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED R SENTATIVE
8 CORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
l
s of any use group which I
O
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Unrestricted -Building i` n
000 cubic feet(991m3)of I 0 � � 0
contain less than 35, m— o
enclosed space.
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m z rn .s < B
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Failure to possess a current edition of the Massachusetts A z • N
Code is cause for revocation of this license.
state Building n
For DPs Licensing information visit: www.Mass.Gov/DPS -
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License or registration valid for iridividul use only.
Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:
OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
l egistration: •172274 Type'
10 Park Plaza-Suite 5170 }
Expiration -6/6/20 4 DBA Boston,MA 02116
CRONItII.`CONSTRUI,TION
PATRICK CRONIN - 1
376 LAKESHORE DRIVE
SANDWICH, MA 02565 Undersecretary j Not valid out signature
�, of - _ -----------
------ —-
Massachusetts - Department of Public Safety
o Board of Building Regulations and Standards
L�. > Construction Supervisor
LA
o o N License: CS-081321
i. � 3 PATRICK S CRONIN
0 0 3 376 LAi JSHORI DR
c p ° SANDWICH MA-02563
4-1 Is o N 1 -
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0 E J, 07/15/2015
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CUDILO
Q STRUCTURAL
1, No 34774
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MODIFICATIONS to EXIST. MICHELE CUDILO, P.E.
Consulting Structural Engineer
Centerville, Massachusetts 02632-1979 5081771-7601
Drawn By: MC Date: 04/18/14 Drawing
94 LILLIAN DR.
Sc.ale: AS NOTED Rev. 0
HYANNIS, MAS K— 3
File Name:SY Project No.2014-72
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MODIFICATIONS to EXIST. MICHELE CUDILO, P.E.
Consulting Structural En ineer
Centerville, Massachusetts 02632-1979 508 771-7601
Drawn By: MC Date: 04/17/14 Drawing
94 LILLIAN DR.
HYANNIS, MA Scale: AS NOTED Rev. 0 S K— 2
File Name:SY Project No.2014-72
i
M
'I' u of
ow Barnstable
Regulatory Services
Richard V._Seali,Director
Building Division
Thomas Perry. (".Bq
.Building; Cwmnis�ioner
:'I;U,44in Street, Fly3nnis, \1A 0_'601
+rn•►v.to►rrt,b>z rn sf�b l�.m;i.u s '
Prix: 508-790-6230
PropCrty IN111st
C;oMplete land Sign `.F'i:is Se.,tio,.,
If Using A Builder
c
hereby 7,
t�� acL r;�rt. rt2t bah f,
in all 171[►.tC��_ rE'.]tl'd�( C1 C',`rj!'n r � by th'�s )lL[11dhir lil la i
(Ad(7r(. c c7f ob,
Dave
1f 1'rUf+ert) U►,•ner is applyirll" for pel•ntlt, please Complete lbe License 1"Xe:mpt'ion n.iY(tt lilt [he
rE\'4r'SE''sldi',
:�.c\'lscd 0061;1 _
TO'd 9ZOZ-699-£Tt, 27ao02�) aTesaTOXTA 2-90 NVU, 0T VT/3Z/60
?lie Commomirealth of-Vassachusetts
Deparionent of Industrial Accidents
O, re of Investigations
Investigations
600 Washington Street
_ Baston,4 02111
wivtu mass;gvv/dia
'"corkers' Campensation Insurance "Affidavit:B.uilders/ContractarsfEIectricians/Phunbers
Applicant Infarmatian Please Print
Address: R4-'V
C ity/Statel ip: dL o c<<4 Phone
Are you an employer?Check the appropriate box: ' Type of project(required}:
1.❑ I am a employes with 4_ ❑I am a general contractor and I T e of project
ject(required):
loyees(full and/or part-timed* liar*e hired flee sub-contractors
6.2.U? am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees. These sub-contractors hafie g.,❑Demolition
worlr ng for roe in any capacity_ employees and hate wa¢lcers' g. ❑Building addition.
[No workers' camp.insurance comp.msurarice.1
required-] 5- ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am.a homeoum-er doing all work officers have exercised their 11-gtiumbingrepairs or additions.
mysel€[No workers'comp- right of exemption per MGL 12-❑Roofrgmirs
insurance required.]i c.152,§1(4X and we have no
employees.[No workers' 13.El Other
comp-inset-once required-]
OAnyappficza diatchecksbox9lrmnstalsofaloatthesectionbelowstowing&eirwu&eWcompwocnfi r,�rpor1iepinformari=
m 1 Hme n.arho submit ifiis sf5dan�indicating they are dGmg ail Wa t sad&m lm¢e ouw&cons=tars mast submit a new affidavit indicatm.-sorb
=canhamn-&It,baa ibis box must attached sn additional sheet showing the name:of the sub-caa ftv Uws and state whether at not those eaddeshare
employees.Ifthesnb-cont a=shave emplayms,titeymnstpmvide their workers'•ramp.policy number.,
I am art erltplg,er tliat is proWdirig ivorkers'compmsadvii irrsrirauce,f br my entpla wet Below is the policy and yob site
information.
Insurance Company Name:
Policy or Self-ins..Lic. ExpirationDate:
Job Site Address: City;/State/2 p:
Attach a copy of the workers'compensation policy declaration page(shoWing the policy number and expiration date).
Failure to serum coverage as required under Section 25A of MGL c_ 15'2 can lead to the imposition of criminal penalties of a
fine up to$150D 00 andror me-year imprisonmentas well as civil penalties u the form of a STIOP WORK ORDER and a one
of up to$250.D0 a day against the violator. Be advised that a copy of this statement maybe f awarded to the Office of
Investigations of the DIA for insurance coverage Lerffication.
I do hereby calify itder the pains andpenabies ofpedmy that the iir,/ar ration protzded abmv is true and correct
Sitmature_ Date: 711 / J
- hone ik o c/'7 0 3 N
Official we only. Do not write in this area,to be-completed by city or town offidat
City or Town: PernritUcense#
Issuing Anthority(circle one):
1.Board of Health 2.Building Department 3.Cityffown tr'lerk 4.Electrical Inspector S.Plumbing Inspectoor
6.Other
Contact Person: Phone#:
Information and Instructions
Mzccar_husetts Geiimal Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Per umtfo this statah%an employee is defined as."_.every person in the service of another hider airy contact of hire,
express or iaipliecL oral or wiiitim.."
An ern player is defined as"au individual,partnership,association;corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
ec
owner of a dwelling house having not more than tbree apartments and who resides therein,or the occupant of tie .
dwelling house of another who employs persons to do maintenance,contraction or repair work on such dwelling house
or oa th5 grooms or bolding appurtcnant thereto shall not because of sash employment be deemed to be an employer."
MGL chapter 152,,§25C(t7 also states that"every state or local licensing agency shall withhold$re issuance ar
renewal of a licmise or permit to operate a business or to construct buildings k the commonwealth for any
applicant who has not produced acceptable evidence of cdmpfianm with the.a sur.-ap.ce.coverage required."
Additionally.MGL chapter 152,§25CM states`Neither the commoriwCalth nor any of itS political subdivisions shall
enter info any contract for the performance,ofpublic work until acceptable evidence of compliance with the insetn a cA..
req m--e entS of this chapter have been presented to the contractng authority_".:;
Applicants
Please fill out the woi3mrs'compensation affidavit completely,by Cher�me boxes that apply to your sitnation and,.if
s
necessary,supply sub-contcactor(s)name(s), address numbers)
address(es)and phone along vrith their cm ifi cam()of
insrTrance. LimitedLiability Companies(LLC)or LimitedLiabr7ityPartnerships(LLP)with no employees other than thr,
members or partners,are not rbqudmd to carry workers' compensation insurance. If an LLC or LLP does have
Be advisedthatthis affida "Yt m be sub i�d to the Department of Industrial
Employees,z policy is r�reZa3'
Accidents for confirmation of insurance coverage. Also he sure to sign and date the affidavit The affidavit should
be retvmed to the city or town that the application for the permit or license is being requested,not the Department of
lndn al A ccidents. Should you have any question regarding the law or if you are requ:ired 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
t _
eta d rued.I . The De artment has provided a ace at the bottom
e that the affidavit is co 1 an Iy pr sP
Please b sore mp p �' P
of theffi affidavit for you to fill out in the event tie Office of Investigation has to contact you regarding the applicant
Please be sure in fill in the permitllieense number which will be used as a reference number. In addition, an applicant ,
that must submit multiple pexmrlUcense applications in any given year,need only submit one affidavit iadirat;,,g cm-rent
policy information(if necessary)and under"Job Site Address"tie applicant should write"all locations nz (city or
town)--A copy of the-affidavit that has been officially stamped or mmced by the city or town maybe provided to the
applicant as proof that a valid affidavit is on file for future pezin#s or licenses. A new affidavit must be filed 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 bum leaves ern.)said person is NOT=quircd 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.
Tht CaMD1ag *of M.R�ahusil-tfs- '
ti De min of 1nd�ial Aunts
1�
7tCe of fveAkalio.= '
Bagk U2111
Tf,-L 4 617 727-4900 cxt 4-06 or 1-977-MASSAFE
Fax#617-727-7M
Revised424-07 -Mae gQg/dia