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Home My WebLink About0198 LINCOLN ROAD L l C n� 1 J Town of Barnstable *Permit# �56 S ` p p 7.71res 6 months from Issue dare Regulatory Services Fee , 2 Thomas F.Gellerj Director i639' ♦0 �Eo�+►�'�� Building Division Tom Perry, Buflding Commissioner 200 Mafia Street,.Hyannis,MA 02601 Office; 508-862-4038 Fax; 508-790-6230 J U L 1 5 2005 VL EXPRESS PERAM APPLICATION - RESIDENTIAL ONLY PW z 4� - Va1{dwithoutRedXPresslmprint TOWN OF BARNSTABLE iplparcel Number �perty Address 15 iR/ old R/)' /'/Y'l"V�!S A • C a e 0� Residential Value of Work ';t 50 Minimum fee of.$25.00 for work under$6000.00 avner's Name &Address / Ctg L)AJC06V ep. L& 941/ul5 , mw o;zco/ ontractor_s_Name f�0 � ®�t a✓ld�'Q Telephone Number _ ^_` :ome Improvement Contractor License#(if applicable) n onstruction Supervisor's License#(if,applicable) ]Workman'.s Compensation Insurance Check one: (] I am a sole proprietor I amthe Homeowner I have,Worker's Compensation Insurance nsura+ce Company Name Norkman's CdnV.Policy# -opy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof) Re-side [] Replacement Windows. U-Value (maximum.44)- vnere required: Issuance of this permit does not exempt compliance with other tows department regulations,i.e.Historic,Conservation,etc. ***Not Property Owner tff y Owner Letter of Permission. o v�emcease is required. Sigaatur Q:Formsmxpmtr8 Revisc063004 The Commonwealth of Massachusetts = = ' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 - „ www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information <— / Please Print Legibly Name (Business/Organization/Individual): I.i�JU K / C ►/ 1/> Address: - City/State/Zip: Phone#: O G�/ S Are you an employer?Check the appropriate bog: Type of project(required) 1.❑ I am"a employer with 4. ❑ 1 am a general contractor and I . 6.- New construction employees (full and/or part-time).* have hired the sub-contractors P � 7. '❑ Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub-contractors have 8:'.❑ Demolition working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition o workers' comp. insurance 5. El We are a corporation and its [No officers have exercised their 10.❑ Electrical repairs or additions required] - - 1F-ET Plumbing r airs or additions Tight of exemption per MGL g eP 3.� I am a homeowner doing all work _ � � P myself. [No workers' comp. c.-152,§1(4),and we have no - 1oof repairs o workers' insurance required.]:temployees. 1Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.-policy-information. - I am an employer that is providing workers'compensation insurance for my employees. Below is the policy aril job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I doh y certify un r th 'n a alties of pe 'ury that the information provided above is true and correct S' ature: 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'e of another and compensation any contract of hire Pursuant to this statute, an employee is defined as ...every person in the service express or implied,oral or written." - or any two An employer is defined as`.`an individual,partnership,udssnociamtr legal ration 6r other legal deceased e�loyer,or more of the foregoing engaged in a joint enterprise, and including g However the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. 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 deem te �loY�"MGL chaptei,152, §2SC(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 thecommonwealth 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. supply sub-contractors)name(s), addresses)and phone numbers)along with their certificate(s) of e _ necessary, pp Y with no e ' to ees other than th ershi s LP mp .Y insurance. Limited Liability Companies(LLC)or Emoted Liability Partnerships(L ) ation insurance: If an LLC or LLP does have members or partners; are not required to carry workers' compens sed that this affidavit may be submitted to the Department of Industrial employees,a policy is required. Be advi 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 permivlicense 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 homeowner 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 Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia oFz„E,, Town of Barnstable *Permit# k03 a(F _ Expires 6 months from issue date ob ,MAe Regulatory Services Fee Thomas F.Geiler,Director s639• �0 Building Division Elbert C Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 02601w X�PRESS PERMIT 508-862-�t038 , Fax: 508-790-6230 JUN 2. 0 20028 EXPRESS PERMIT APPLICATION Not.Valid without Red X--Press Lnpnt:t TOWN OF BARNSTABLE Map/parcel Number o2�� l g �a�vco�/U �� // GL/ Property Address /vt 5 � Residential OR ❑Commercial Value of Work P t Owner's Name&Address Contractor's Name Telephone Number M41as ' Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box) Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ® Re-side ��?.� V X 3 Y t ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations.i.e.Historic.Conservation.etc. Sisnature expmtrg l 4UZJL n P 1-1.0 i111=E CALL Q A.M. FOR . GI-O4t /�/� DATE v 1 TIME P.M. M �IJ i�➢c A.� L 1 q9 � n PHONOF ETURNEED PHONE 7O 5 7 YOUR CA L AREA CODS� NUMBER EXTENSION /'QM D, d l� /�Q_ - PLEASE CALL MESSAGE ��--��_tT[JT /`t'LXJ RE : l q O , pc6l-� WILL CALL ` `a /�/ AGAIN CAME TO L, SEE YOU WANTS�ZII �CJV t LTA S /JfI MG O SEE YOU SIGNED �11 48003 z 0 m Buddzig Depariment ComplainVInquiry Report Date: �" o Rec'd br. l Assessor's No.: Complaint Name: Location Address: o y g Originator Name: A�Street: State: Zip:__ Telephone:D/E Complaint Q Description: _ Inquiry / Description: t For Offbe Use Only Inspector's l Action/Comments Date. o O Inspector Follow-up p Action s O f i - � • � ./I�/yJ � �-,� Ana/ �i+, r � Additional Info.Attached CoPYDiwibution. White-DeparunenrHe 1'e11oIV-Inspector Pink-Inspector(Return to Olfce:1fWJgVrJ " Pais a "Loeatton'c 198T'INCOLN RD HYANNIS Y _,.. P ft1' . :. . MAP IDi `270%048/%/. Ksion ID: 20020 Other ID: Bldg#: 1 Card 1 of 1 Print Date:08/23/2000 �. g LIT <� i t p a. a 8 \ice??. �,� :. y ;c \ ..-,h .z ._�..; ..� ,.. :.. .. _ ....:.... .,: ,tea..« . ,..a..,.. ..» i �. .�,.., ,., - ,.. Y.s a .. .?. e ;c�tu .. .. .: Y escription (-ode Appraise \a ue ssessea value CBRIDE,SHERRI-LYNN A RES LAND 1010 24,000 /,#,uuu 198 LINCOLN ROAD RESIDNTL 1010 43,400 43,400 801 YANNIS,MA 02601 SIDNTL 1010 4,100 4,100 Barnstable 2000,MA ccount Tax Dist. 400 Land Ct# er.Prop. #SR VISION Life Estate DL 1 LOT 43 Notes: DL 2 GIS ID: lot.11 71,500i , \ u . b,. .,.... .. :� �. u .�,.�c_�: ..�... ti.. ate ,.., a ,.� �. w va , r. Go de ssesse a ue r. o e Assesseda ue r. code Assessed value AMS,RENFORD L& P1529-El 03/15/1992 U 1 1 A 1999 lulu , , AMS,LOUIS R 6835/222 08/15/1989 U I 1 A 1999 1010 434001998 1010 43,400 AMS,LOUIS R&ELLA L P1529-GI 12/15/1988 U I 0 A 1999 1010 3:3001998 1010 3,300 AMS.LOUIS M-792 8319/244 Q 0 Total. Tatal. Total: 63,uuu \ a a n is signature ac now a ges a visit y aData o ector or-----Assessor '�,w ...i:. '? $3'.... :F .,, '�. ear lypelvescription mount Code Description JVum0er Amount Comm.Int. Appraised Bldg.Value(Card) 41,200 Appraised XF(B)Value(Bldg) 2,200 Appraised OB(L)Value(Bldg) 4,100 ota AppraisedValue (Bldg) 24,000 Secial Land Value Total Appraised Card Value 71,500 Total Appraised Parcel Value 71,500 Valuation Method: Cost/Market Valuation Net TotalAppraised Parcel Value , �.<. .� ..r �. ai _ ,ate ..:. .. .,.,:^. ,.�, - �` ..: :.� ...: ., „as•` ,.`, < �`• ,.. �,,, r:,,,,,.i, ;� �..�.:�.;- � „ :� .,;, ,:..'. , -,•: ..��\.-c'. - �, ��.� ::ate., a` :'./� :�` .. .\ :.. ;: ',• ', ....tea :. ':::. ermu ssue ate ype escription mount nsp. ate o omp. ate omp. omments ate urpos esu t _ „ .. u , a Use Gode Description Zone D Prontage Depth Units Unit Price 1.Pactor actor Now. Aaj. otes- ,/ pecia racing Adj. Unit Price Land Value 1 1010 ing a am , , o es: ota ar an nit arce ota an rea: ota an a ue , Property Location: 198 LINCOLN RD HYANNIS MAP ID: 270/048/// Vision ID:20020 Other ID: Bldg#: 1 Card 1 of I Print Date: 08/23/2000 Element escnption L mmerciat Data ements Style/Type )I Ranch ----Flement Cd. Ch. Description Model )i Residential Heat&AC Grade --- C- Frame Type BAB 30 Stories 1 Story Baths/Plumbing ccupancy 0 Ceiling/Wall Rooms/Prtns Exterior Wall 1 14 ood Shingle %Common Wall 2 all Height Roof Structure )3 Gable/Hip Roof Cover )3 Asph/F GIs/Cmp 24 �UIVD Interior Wall 1 A Typical X 2 Element Code Description Factor Interior Floor 1 14 Carpet L:omplex 2 Floor Adj Unit Location 3E eating Fuel 02 it Heating Type 05 of Water Number of Units AC Type 01 one Number of Levels 6 %Ownership Bedrooms 3 Bedrooms Bathrooms 1.5 1 1/2 Bathrms �F e:/MOMPTV AVA 11 1 Full+1H unadj.base Kate 8.UU Total Rooms 6 6 Rooms Size Adj.Factor 1.29564 12 Grade(Q)Index .90 ath Type Adj.Base Rate 5.97 Kitchen Style Bldg.Value New 6,418 24 Year Built 1950 Eff.Year Built 1970 NrmI Physcl Dep 27 uncnI Obslnc 0 Econ Obslnc 0 ITT"Specl.Cond.Code 11FT Spec]Cond% Code Description Percentage Single Fam 1UU Overall%Cond. 73 Deprec.Bldg Value 1,200 TV 7, Code Description LIff Units Unit Price Yr. Dp Rt %Cnd Apr. value 1"I'Ll Fireplace ISty -]E[-- I 3,TUU.-M 1979-----T--TOU— FGR2 Garage-Avg L 308 25.00 1950 1 100 4,100 J ffA,1R-JY,--AU Q1 IQ Code Description Living Area (irossArea Eff Area Unit Cost Undeprec. value BAS First floor 1 9UU8 1,M-----T,790 569418 I it. Gross iv ease Area 19008 1,0081 1,00818 dg Val: 56,418 , r .5 j RESIDENTIAL PROPERTY •MAP NO. LOT NO. -FIRE DISTRICT. SUMMARY STREET 198 Lincoln Rd Hyannis ylc/ 270 48 `' H 73 LAND 0 U C G%7 ER OWN SO :. ' TOTAL �O LAND RECORD OF TRANSFER PG I.R:S.` REMARKS: DATE. Lot 43 0.. ;,..• BLDGS. rn ^ TOTAL —96 LAND > ierma >nnr r BLDGS. 4 / .`, G Lt TOTAL F AiqIq LAND Adams, Louis R. �I' El3a, L. ' %5-11-81 �3283- 304 . $44,0 r BLDGS. Cv N TOTAL oabvl LAND BLDGS. Zs'yj TOTAL LAND �. 'BLDGS. TOTAL LAND BLDGS: � TOTAL y r LAND 'INTERIOR INSPECTED: t ' r BLDGS. TOTAL .DATEc �U /71 LAND ACREAGE COMPUTATIO 5 r•+ BLDGS. LAND TYPE ` # OF ACRES PRICE TOTAL 'DEPR VALUE :r TOTAL HOUSE LOT /14% '19 b 0.0 In y y u LAND '.CLEARED FRONT BLDGS. REAR TOTAL WOODS&SPROUT FRONT LAND REAR r BLDGS. OI WASTE FRONT TOTAL REAR LAND BLDGS. TOTAL LAND BLDGS. LOT COMPUTATIONS x,y ar c,. ; LAND FACTORS . TOTAL "FRONT,, DEPTH STREET PRICE DEPTH% FRONT FT.PRICE TOTAL DEPR COR+ INF.`�, Vr?VALUE HILLY TOWN:SEWER LAND ;i-•Phi..:- 'ROUGH. TOWN WATER a) BLDGS. TOTAL HIGH GRAVEL'RD. -LOW DIRT RD.:. '. LAND i :?SWAMPY'. NO RD. BLDGS. ..;.. 1� TOTAL . f' TOWN OF BARNSTAB'LE, MASS. UNITED APPRAISAL CO., EAST HARTFORD.CONN. ` Conc. Slab Bsmt.Garage St. Shower Ex. P _ t Walls � � PORCC PR H.PRICE. Brick Walls Attic F.&Stairs Toilet Room Roof RENT _ Stone Walls. Fin.Attic Two Fixt. Bath Floors Piers INTERIOR FINISH Lavatory Extra o�C---J e Bsmt.! F T 2 3 Sink s/t r/i r/� Attic - Plaster Water CIo. Extra � /�� i, EXTERIOR WALLS Knotty Pine Water Only Double Siding Plywood No Plumbing Bsmt. Fin. , Single Skidding Plasterboard Int.Fin. 3o. Shingles TILING Conc. Blk. G F P Bath FI. Heat �— 83 y• Face Brk.On Int.Layout77 Bath Fl.&Wains. Auto Ht.Unit 3-9 Veneer Int.Cond, Bath FL,&Walls Fireplace 1.1115 J� Com. Brk.On HEATING Toilet Rm.FL G Plumbing Solid Com. Brk. Hot Air Toilet Rm.FI.&Wains. -- Tiling 1 2 Steam Toilet Rm.F1.&Wel ls Blanket Ins. Hot Water ,, j{1 St. Shower a / Roof Ins, Air Cond. Tub Area Total Floor Furn. ROOFING COMPUTATIONS Asph.'Shingle Pipeless Furn. L-2 O S.F. Wood Shingle No Heat 52oZ 0 S.F. e 9O / Asbs. Shingle Oil Burner S.F. Slate Coal Stoker S.F. Tile Gas S.F. OUTBUILDINGS ROOF TYPE Electric S.F. 1 213 4 5 6 7 8 91101 1 2 3 4 5161 7 8 9 10 MEASURED Gable Flat .Hip Mansard FIREPLACES S.F. Pier Found. Floor L 1. Gambrel N Fireplace Stack Wall Found. 0.H.Door LISTED FLOi0RS Fireplace Sgle.Sdg. Roll Roofing Conc. LIGHTING Dble.Sdg.' Shingle Roof Earth No Elect: DATE Shingle Walls Plumbing Pine t Cement Blk. Electric �� b/7 Hardwood ROOMS. r/ Asph.Tile Bsmt. 1st,, TOTAL J.,A lo; Brick Int Finish PRC�1C Single 2nd. 3rd A FACTOR REPLACEMENT 'a OCCUPANCY CONSTRUCTION SIZE AREA, CLASS AGE. REMOD; COND. REPL.,VAL. Phy.Dep. PHYS, tVALUE. Funct.Dep. ACTUAL VAL. D W.LG. _ 2 9 .. q - ,. ... .s +t 7 9 .. 1 p . �0 - TOTAL PERMIT PAYMENT RECEIPT TOWN OF BARNSTABLE BUILDING DEPARTMENT 200 MAIN STREET HYANNIS, MA 02601 DATE: 09/06/06 TIME: 12:15 -----------------TOTALS----------------- PERMIT $ PAID 25.00 AMT TENDERED: 25.00 AMT APPLIED: 25.00 CHANGE: .00 APPLICATION NUMBER: 20063013 PAYMENT METH: CHECK PAYMENT REF: 194 Town of Barnstable *Permit# tOcs� �o Expires 6 monihs from issue date . X-PRESS PERMIT Regulatory Services Fee 0S. 00 Thomas F.Geiler,Director SEP O s 2006 Building Division TOWN OF BARNSTABLE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us fL Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ! o Y O Property Address ! L//V co D Z-/y/9/ /1// S 10 Residential Value of Work =/ S-d Minimum fee of$25.00 for'work under$6000.00 Owner's Name&Address "7'�R(f i-D x / FI ,C 1 NCO ZN i�. /�c,.17ivAL/l S. Contractor's Name ��a/!%Z) C. !'/ Telephone Number 5 06� F6a'09S NomejImprovement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor RrI am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will betaken to ❑Re-roof(not stripping. Going over existing layers of roof) ["Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. copy of the Home rovement Contractors License is required. SIGNATURE: G Q:Fomms:expmtrg Revise061306 Department of bndustiial Accidents t Office.of Investigations: 600 Washington Street y� Boston,MA 0211T. °,� S�• www mas&gov/dia Workers' Compensation Insuranze Affidavit: Builders/Contractors/Electridans/Plumbers kpplicant Information Please Print Legibly 1Tame(Business/orgamzatiowTmdividual):�/4 _ K • / t 1 kddress: 9 F 4 lie�. amity/State/Zip: J�Slq A)/U i S Oc260 J Phone#: �®� . (EV ,-0 V.3.S ►re you an employer?Check the-appropriate box:. Type of project(required):• ❑ I am a employer with' . 4. ❑ I am a general contractor and I 6 employees(fu and/or part-time).* have hired the sub-contractors ❑New co traction r<s ll .❑ I am a sole proprietor or partner listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance: 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We'are.a corporation audits . required.] officers have exercised their 10.❑ Electrical repairs or.additions I an ahomeowner doing all work right of exemption per MGL ILEI 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' Other S 1 ti'ct camp.;n�„arce required.] ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information `e iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such )ntractors thatcheck this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. . !m an employer that is providing workers'compensation insurance for my employees'Below is the policy and job site Formation. Durance•Company Name: licy-#or Self-ins.Lic.#: Expiration Date: b Site Address: CO z dv �, ' City/State/Zip: 14 V13 fU ry l S II A 0 02�o l tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). tlure to.secure coverage as required under Section 25A of MGL c. 152 cari lead to the imposition ofcriminal penalties of a ,e up to$.1,500,.06 and/or one-year imprisonment; as well as,civil penalties in the form of a STOPVORK ORDER and a fine up to$250.00 a day against the violator. Be advised that a copy of this statemenf maybe forwarded to the Office of restigations of the DIA for insurance coverage verification. Where certify unde the ' and enaltie of perjury that the information provided abo a is true and correct: maturef Date: one#: Official use only. Do not write in this area,to be completed by city,or town official City or Town: Permit/License# . Issuing Authority(circle one): 1.Board of Health !..Building Department 3.City/Town Clerk 4.Electrical Inspector'5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and. Instr ' ctions r m lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. . r an contract of hire, '��e of another under. person in the servrc Y arsuant to this statute, an employee is defined as .• every press or implied,oral or written. . :. - • 0a employer is defined a$•:'ari mdividAal,.Pa;ingtiP,:association,corporation or other legal eutity,.or any two or more f the foregoing-engaged in a joint enterprise, and'including the legal representatives of a deceased employer,of the eceiver or trustee of an individual,Partnership;association or other legal entity,employing employees. Howev..er:the .weer of a dwelling house having not more than three apartments and who resides therein;or.the occupant of the c employs persons to do maintenance, construction or repair woik•on such dwelling house welling house of anotherwho mp Ys P , )r on the grounds or building appurtenant thereto shall not because of such-employment be deemed to be an employer. . vIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or •enewal of a license or.permit to operate a business or to construct buildings in the commonwealth for any ►pplicant who has not produced acceptable evidence-of compliance with the insurance coverage required." kdditionally,MGL chapter 152, §25C(7)states"Neither the commonwealth noz any of its-political subdivisions shall Mter into any contract for the performance of public work until acceptable'evidence.of compliance with the insurance -equirements of-this chapter have been presented to the contracting authority. °,pplicants. 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 nirmber(s)along with their certif eate(s) of insurance. Limited Liability Companies (I.LC)or Limited Liability Partnerships(UP)with no employees other than the members orpart aers; 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 fire permit or license is being requested,not the Departnneat of Industrial Accidents. Shouid 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 permitllicense applications in any given year,need only submit one affidavit indicating current -policy information(if necessary)and under"Job Site Address"llie applicant should write"all locations m •• (city or town.),"A copy-of the-affdavit 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 onlile for:future permits•or-lkenses..A new affidavitmust 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 (ie. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office'of Investigations would like in 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.faz number: ' The Commonwealth of Massachusetts . . : DepFtrment of IndUsttiaLAccidents ..Office gf Investigations . ..600-Washington Street . 4 Boston,lVlA 02111. Tel.#617-727-4900 ext 406 or-1-877-MASSAFE Fax#617-727r7749 wised 5-26-05 www,mass.gov/din