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AMPAD 23-021-200 SETS
�J1.] EFFICIENCY®. 23421-400 SETS CARBONLESS
i
Ok G --'3 -13 7P
CAPE COD TOWN O NSTABLE
INSULATION
J�d®®® 2013A11113 AME0- 01
SI5550LASS SLILMLS55 SPRAY FOAM SOSPSNOLD
Wlt OOl}553 INSDlY1ON CSILINOF
1-800-696-6611 —
1'own of Barnstable
Regulatory Services
Building Division
200 Main St
Hyannis, MA 02601
IF,
Date:
Dear Building Inspector
Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed &
completed the insulation and weatherization work at the property listed below. Cape Cod
Insulation did this in accordance to the specifications listed on the building permit
application. All work has been inspected by a certified Building Performance .Institute
'(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements.
Property Owner Property Address Village
dam.-
,L a C v J ,S�f
Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted
Ceilings
Slopes ( ) ( } ( ) ( ) ( )
Floors ( ) ) ) ( ) ( )
Walls r ( ) ( ) ) ( ) ( )
4 iv t r-P! (Vo r
y
Sincerely
H ry E ssi r, President
pe C Ins ation, Inc.
TOWNS OF f ARP ST °LE
CAPE C
INSULAjT"1 "' N'7 AM 8: 57
CVO �
FIBER GLASS SEAMLESS !P¢�IFj ;,,SU.SfHNDHDx
B¢TF! DUTHF¢! INl0FlJ1 �C 11ND7A.
1-800-696-60
6K s 7— (3 PP
Town of Barnstable
Regulatory Services
Building Division
200 Main St
Hyannis, MA 02601
Date:
Dear Building Inspector
Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed &
completed the insulation and weatherization work at the property listed below. Cape Cod
Insulation did this in accordance to the specifications listed on the building permit
application. All work has been inspected by a certified Building Performance Institute
(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements.
Property Owner Property Address Village
[)ONnIGL A444114r- In torvsr S f 144elell /4cc 02 (00
Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted
Ceilings ( ) ( ) ( ) ( ) ( )
Slopes ( ) ( ) ( ) ( ) ( )
Floors ( ) ( ) ( ) ( ) ( )
Walls ( ) ( ) ( ) ( ) ( )
f A)svLm-r P--x— Zivsru,LL�aI
.Sincerely
4eC
, Pr t
sulation, Inc.
L
f
Town of Barnstable *Permit#
CUl20f �G1
Ezpves 6 months from issue date
platory Services Fe
9eb MASS � R 022012 Thomas F.Geiler,Dii-ector
Building Division
Tom Perry, CBO, Building Commissioner,.._
200 Main Street, Hyannis,MA 02601
www.town.'barnstable.ma.us
Office: 508-8 62-403 8 Fax: 508-790-623 0
EXPRESS PERAET APPLICATION - RESIDENTIAL ONLY .
Not Valid without Red X-Press Imprint
Map/parcel Numberp�-
Property Address C 11'I 19�
❑Residential Value of Work J ICX Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address /'2 /7 A—, 7
contractor's Name Telephone Number
•Tome Improvement Contractor License#(if applicable)
:onstruction Supervisor's License#(if applicable)
]Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
(�I am the Homeowner
❑ I have Worker's Compensation Insurance
isurarice Company Name
orkman's Comp. Policy#
opy of Insurance Compliance Certificate must accompany each permit.
:rmit Request(check box) i
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going-over existing layers of roof)
�Re-side
#of doors
❑ Replacement Windows/doors/sliders, U-Value (maximum.44)#of windows
*Where required: Issuance of this permit.does not exempt compliance with other town department regulations,i.e Historic,Conservation,etc,
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy'of the Home Improvement Contractors License& Construction Supervisors License is
required.
;NA TORE: -7
I V7
V
�e
T.
cvinflunmea h-0f Massachuses"is--
Department of Industrial Accidents
Office of Investigations
a
600 Washington Street
Boston,MA 02111
' . www.mass.gov/dia
Workers' Compensation Insurance Affidavit:,Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibI
—.Name(Business/Organizationadivviidual)'
Address: /&�J h O 611Qr Z' Q/ '
City/State/Zip: GI Yj 4/� <; Phone.#: ' 7— 7 7,�- /.�3
Are you an employer?Check the appropriate box: Type of project(required):.
1.❑ I am a employer with .4. ❑ I am a general contractor and I
employees(full and/or part-time).
* have hired the stab-contractors 6. ❑New construction .
2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have_ 8. ❑Demolition
working for me in any capacity, employees and have workers'
9. ❑Building addition
[No workers' comp.insurance comp,insurance.$,
required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions
3t 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.❑Roof repairs
insurance required.]t c. 152, §1(4), and we have no -
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.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.M Expiration Date:
lob 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.ORDEk 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 certi nder the pains penal ies of a 'ury that the information provided abov91 true an correct.
Signafore: Date:
Phone#:
Official use only. Do not write in this area,tb 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#•
A
r
k
a
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-conttactor(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-locatioi s 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 bum 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 Commauwealth of Massar huwtts .
Nparttm.ent of lndnstfial A.coidc� is
Office of InVestigatians
600 Washingtoh Str6et �
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-$77-MASSAFE
Revised 11-22-06 Fax#617-727_7749
www.ma.ss..gov/dia
THE Town of Barnstable
Regulatory Services
rMAIMB' Thomas F.Geiler,Director
Fo ram'` Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038
Property Owner Must `
Complete and Sign This Section
If Using A Builder
as er of the subject property
hereby authorize to act on my behalf,
in all matters relative to.work authorized by this b ' ding pemvt
(Address of J )
Pool fences and alarms are th responsibility of the applic Pools
are not to be filled before fence i installed and pools are not to be
utilized until all final inspections are performed and accepted.' ,
Signature of Owner Signature of Applicant
Print Name Print Name
Date
WORMS:OWNERPERMISSIONPOOI S
4 �r
t Town of Barnstable
Regulatory Services
* snxrtszwsr . # Thomas F.Geiler,Director
Mws9
9`be 1639• `0$ Building Division
rF0 M1A'i�'
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: /
.,JOB LOCATION: /V
nu ber street village e
"HOMEOWNER": 6b Q 1.2 �-
name home phone# work phone#
leCURRENT MAILING ADDRESS:. `/ C C/ �Z
city/town 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 performed 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"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minim inspection procedures and requirements and that he/she will comply with said procedures and
re it ts.
Si ature of Homeowner
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 pernut 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 of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:forms;:homeexempt
w
a
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
10
Map �' Parcel Application # 20 ( OC�(��U
Health Division Date Issued I
Conservation Division Application Fee
Planning Dept. Permit Fee.
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation/Hyannis
Project Street Address LL/2C&5 YC
Village
Owner ���/l//V/cl Address /53 L.D riLSfi -9t_ — Ael'NNY'S
Telephone M— 7-7 /3 Fr 1
Permit Request U1 2 f t 69-. ^ -A tA-errs, 12 S f A-t- del
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation A666 Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, atta pporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (#
Age of Existing Structure Historic House: ❑Yes No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other r? o
. Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.,
Number of Baths: Full: existing new Half: existing new m
Number of Bedrooms: / existing —new ® ,
Total Room Count (not including baths): existing new First Floor Room ount
Heat Type and Fuel: ❑ Oil Electric ❑ Other Zas ❑
Central Air: ❑Yes/ ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached g rage ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached arage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
2 Zdning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
{ (BUILDER OR HOMEOWNER)
Name jr ASd�f Telephone Number SDt —/7j-- /0-
Address 1�i' n yrn /GG1 License # zoo
1;44- d9&0l Home Improvement Contractor# /s 3S67 1.
Worker's Compensation # W 6 4 005 590/
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
Y I
0
SIGNATURE DATE / o
1 t
FOR OFFICIAL USE ONLY
t APPLICATION#
DATE ISSUED
T
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
I1
t DATE OF INSPECTION:
i FOUNDATION:'
FRAME
INSULATION
FIREPLACE
t
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
IC
GAS: ROUGH FINAL
=FINAL BUILDING'! = .
DATE CLOSED OUT
ASSOCIATION PLAN NO.
y The Commonwealth of Massachusetts
,Department of Industrial Accidents
T1 r' Office of Investigations
600 Washington Street
1 Boston, MA 02111
y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians(Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual):� ,rN,�1� ( a f Ct� _1�u 1�,--
Address: ✓�
City/State/Zip: UCC Phone #: 5-0 -7 7 Y-, 1
Are you an employer? Check th appropriate box: Type of project(required):
1. I am a employer with�, 4• ❑ I am a general contractor and 1 6. ❑New construction
eiripldyees'(full and/or'part-time).* have hired the sub-contractors.. .
2.El am a sole proprietor.or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, (� Demolition
employees and have workers'
working for me to any capacity. 9. ❑ Building
addition
No workers' comp. insurance comp. insurance.$
e
5. [] W are a corporation and its 10.❑ Electrical repairs or additions
required.] "
3.❑ 1 am a homeowner.doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers
right of exemption per MGL
comp. 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. Otber fy ,g� i
comp,insurance required.]
*Any applicant that checks box#1 must also'ill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
f am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 4+L A4l'rl n 0 .
Policy#or Self-ins, Lic.#: �Q �d�Zs 0 Expiration Date:
Job Site Address: ( /,6Q6TST City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy nu nber 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.
Ldo hereby certify it e pa' and penalties of perjury that the information provided above is true and correct.
Si nature: Date;
Phone#: S � �S Zit
[F�ff,cia l use only. Do not write in this area, to be completed by city or town officiaL
r Town: Permit/License#
g 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#:
a1 Rogers s Cray Ins. Page, 002
P Client, : 4597
CCINSUL
ACORD,,. CERTIFICATE OF LIABILITY INSURANCE DATE(1vwvoD,YYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER?HOISO
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.
Itu1PORTANT If fha cerificata holder is an ADDITIONAL INSURED,the policy-i must be endorsed,If SUBROGATION IS WAIVED,subject to
rile farms acid conditions of the policy, Certain policies may require an endorsement.A statement on this certificate does not confer F•ighls to the
ceriiticate holder in lieu of Such endorsemant(s).
PROpUCER
Rogers S,Gray In,.,. -So. Dennis coNracT
rIAME: Margaret Young
PHONE,—.------ -------'_.--
434 Route 134 508 760-4602
P.0.Boy,1601 ADDRESS:
A/C,Nu):
-FR
South Dannis, NIA 02660-1601 CUSTOME S __-- _ — --
INER ID B:
INSURER(S)AFFORDING COVERAGE NAIC H
Cape Cod Insulation Inc wsuRERA:Peerless Insurance
INSURERS.Ohio Casualt Insurance Con'1 �n - --
455 Yarmouth Road y -' --•-
p` Y
Hyannis., MA 02601 INSURER C;Atlantic Charter Insurance -
INSURER D:Commerce Insurance Company 34754
INSURER E: --
COVERAGES INSURER F:
CERTIFICATE NUMBER: REVISION I HIS 1. TO CERTIFY THAT 1'MIE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AB(VE FOR THE POLICY PERIOL)
WDIi;ATEO N014VI'f HSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHEk DOCUMENT WITH RESPECT TO WHICH 1'FIIS
Ek1 iFiC; fE MAY BC ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSION•`;AND CONDITIONS OF SUCI•I r OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
d5'
I TR7'jGENERALLIA8ILI
TYPE OF INSURANCE NSR VO POLICY NUMBER OLICY EFF POLICY EXP
A . fY MIN/DOtYYYY /YYYY LIINITS
CBP8263063 0410112010 0410112011 EACHOCCURRENCE $1 000000
(iPd61C Hi;li\I.(A Nl.hAI.I JAUILI'IY DAMAGti OR- C'Lt71 LI '—
rrr-natsra L=:: ,,�,,
Q AINIS hAUF pi;CUR
MED EXP(Any wa parso(j) $5,000
- - _—___--- - - PERSONAL MADVINJURY $1,000,000
GENERAL AGGREGATE $2 QQQ QQO
iii-;NI Al l(;N1 i1/11r 111011 APIIIJ i;PIiR — —•----• ---t--=.--_..__.—._..
rol IcY F PH(1 — PRODUCTS-COMP/OP AGG $2,000,000 `
r LUC
D AUTOMOBILE LIABIL I rY $
10MMBCKVMK 04101/2010 04101/2011 COMBINED SINGLE I.INUT
AN',Au Iv (Eaaeddenl) $1,000,000
i
,U I OWN[1)AlII OS 130DILY INJURY(1'urpersun) $
:;i:Ni-UUI IrI)AU I U:; BODILY INJURY(Pnr ar;t:ulanl) $
X NN OAUIC)5 PROPERTYDAMAGE
' (Puraccillanq $
--��_ ------ .....
X NUN:Iv'ctvl:U All I i)5 .._.___..
$
- a
B EXCL UMBRELLA LIACi x c,ccurc MEYAPP397725 06/1712010 0410112011 EACH OCCURRENCE $1 UUUL000 EXCESS LIAR CLAINIti•NWDI' —
_. AGGREGATE $1 UQU ODU
ur:ut,c I I r
X HrIrNII(114 i;
(✓ WORKERS COMPENSATION $
ANO EMPLOYERS'LIABILrrY WCA00525901 6/3012010 06/30/2011 X I WC,STAYU nTH-
ANY PHOI'HIF.I OHIPARI NL-Ril_XECl1l'IVE YIN Y .IL,' —._L't3_._..._..__.___....,-_.—...__..__._..._.
i)rPICCat�A9C'Mi11-H I-::(CLUDED'I a Nhl) N/A E.L.EACIIACCIDINr $500,000 -
(Mamimiu y w
II Yu�.Udarllb,i tlat E.L.DISEASt-FA GMPI.OI'EE $500,000
nl-5CRn'I igIV ui T'(Pt RA I IQN 5 below __._.....,._.
e L.OlsfAsr:•POLICY uMrr .500,000
Ld
DESCIiIP'FION OF UP[RAI'IUNS r LOCATIONS I V EHICLE5(AIIUCll ACORD lUl,Additional Romatks 5clwdule,it more space is roquaatl)
"Workers Comp Inforrnation "
Included Officers or Proprietors
(See Attached Descriptions)
_CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Housing Assistance Corp. ACCORDANCE WITH THE POLICY PROVISIONS.
484 West Main Street
Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE
01988-2009 ACORD CORPORATION.All rights reserved.
ACORD 25(2009/09) 1 of 2 The ACORD name and logo are registered marks of ACORD
4S548141M53353 MEY
Massachusetts- Department of Public safety
Board ofBuildin�- Re�„ulations and Standards
`. Construction Supervisor License
License.` CS 100988
Rest icted to:. 00
HENRY CASSIDY
8'SHED ROW '
WEST YARMOUTH, MA 02673 � µ
Expiration: 11/11/2011
( uuiuisiun<r Tr#: 100988
JeiM
-- _ B i y e ula`/"ons�aneahAars
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Registration: 153567
Type: Private Corporation
Expiration: 12/15/2010_ Tr# 278247
CAPE COD INSULATION, INC
HENRY CASSIDY
455 YARMOUTH RD.
HYANNIS, MA 02601 ---- _.._.__.._. , _. _- __._.__.._.-_.....
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
-CAI 0 5OM-07/07-PC8490 "p ,/a
Bo&t1(2 ?CttYf'F(K+fifii�i�iotl�ft/A 'g License or registration valid for individul use only
== -HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration: 153567 One Ashburton Place Rm 1301
-, = Expiration:`12/15/2010 Tr# 278247 Boston,Ma.02108
Type: Private Corporation .
CAPE COD INSULATION;INC,
HENRY CASSIDY t'
455,YARMOUTH RD. of id wi ' gut ignature
HYANNIS,MA 02601 Administrator
1 .
Town of Barnstable
o
i
Regulatory Services
' st�x6TABLE,
r MAB& g Thomas F. Geiler,Director
i6SP- 11�
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.Eown.b arnstable.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
P rtY
hereby authorize CIAfJ-2_ jCQ to act ou my behalf,
in all matters relative to work authorized by this building permit application for.
��� LOGGGS� �S7t: l� �/vf'►�fS
(Address of rob)
lgnature of Owner ate
Print Name
If Property Owner is applying for permit please complete.the
Homeowners License Exemption Form;on the reverse -side.
Q:FORMS:O WNERP ERM ISSION
t
TOWN OF BARNSTABLE BUILDING PERMIT.,APPLICATION,
a 0r3
Map Parcel :.Application # (Poo
Health Division bate Issued
Conservation Division Application Fee
Planning.Dept. Permit Fee °
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation /Hyannis
Project Street Address
Village Y G+ 17,,/ S
Owner t� /,! / 7`�`(. � Address
Telephone — 7 7�4
Permit Request /
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District A Flood Plain Groundwater Overlay
IWroject Valuatior� Construction Type
..
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family , Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes XNo On Old Kin§R s Highway: ❑ s )(No
Basement Type: XFull ❑ Crawl ❑Walkout ❑Other °'r': 4 C>
Basement Finished Areas ft. . Basement Unfinished Area s-' 'ft '
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing _new co
w
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas *il ❑ Electric
LJ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing I New Existing wood/coal stove: ❑Yes Ao
Detached garage: xisting ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage:(existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
.Name\ 0 /7•/7 ,k Telephone Number — 7
Address �V�i 6 G C/Cr T �/ License #
/'I 17/�J_ Home Improvement Contractor#
Worker's Compensation #
I
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE AZ41DATE
FOR OFFICIAL USE ONLY
4
APPLICATION#
1
DATE ISSUED
s MAP/PARCEL NO.
A
ADDRESS VILLAGE
OWNER
:x
DATE OF INSPECTION:
FOUNDATION
` FRAME
INSULATION
k FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
f
DATE CLOSED OUT
` ASSOCIATION PLAN NO.
:µ
S
` 1
The Commonwealth ofMassachusetts
,Department of Industrial Accidents
Office oflnvestigations*
600 Washington Street
Boston, MA 021I1
i. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumberg
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 0 O '09
Address: /�,5`2 Q GC/ �� G
/ hone.#:
City/State/Zip: �%` 9' 4 / .c
Are you an employer? Check the appropriate b - Type of project(required):
I.❑ I am a employer with 4. I am a general contractor and I
6. ❑New construction
employees (full and/or pat-tim.e).* have hired the sub-contractors
2.0 I am a soleproprietor or'partW-'
listed onthe'attached sheet. T. []Remodeling
ship and have no employees These sub-contractors have g, 'E]Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers'.comp.•i:nsurauce comp• insurance.#
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 l I.❑Plumbing repairs or additions
self. [No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.❑ Other
employees. [No workers'
comp.insurance required.]
*Any applicant.that checks box#1 must also fill out the section below showing their workers'eompcnsation 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.
XContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and 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 io secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimiri4l penalties of a
fine tip 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 ofthe DIA for insurance coverage verification.
I do hereby certify nder the pains-and penalties ofperjurythat the information provided above is true and correct.
j Z�
Data: aZ 6F
Si afore: q ` s
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.Pl71n3pector
6. Other
Phone#:
Informationr�
and � st�rcti® s
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 on 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 buster,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
appurtenant there
to shal
l not because of such employment be deemed to be an employer."
or on the grounds or boildin g
MGL chapter 152, §25C(6)also states that"every state or local liceusing 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 .
ublic work until acceptable evidence of compliance vzth the ins uran
enter into any contract for.the performance of p co
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-.conti actor(s)name(s),address(es)and.phone numbers)) along with their certificates)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 aurgber 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 Address"
"Job Site (he.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 maybe 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 borne owner or citizen is obtaining a license or permit not related Eo any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would at 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 Ittyestigati ans.
600 Washington Street
Boston, MA 02111
Tel. #617-727-490.0 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 11-22-06 www.mass.gov/dia
r
Town of Barnstable
le ram,
Regulatory Services
Thomas F. Geiler,Director
� 2ArW6TABI.E,
MASS.
Building Division
lfD 'y Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street zvillage
,•HOMEOWNER":C2�0'?9 1 /l`.
name ` a home,
phone# work phone#
CURRENT MAILING ADDRESS: �V V y/G`e ( /
ity/town 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 performed 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"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
require nts. .
Si tore of Homeowner
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."
I 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 helshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form./certification for use in your community.
Q:\WPFILES\FO RM S\homeex empt.DOC
THE Town of Barnstable
Regulatory Services
YAMSTABLE, Thomas F. Geiler,Director
TiA8.9.
39- Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis, MA 02601
ynm.town.b arnstable.ma..us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using.A Builder
I
r of the subjectproperty as Owner J
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for
(Address of Job)
Signature of Owner Date
Print Name
If Propedy Owner is applying for permit please complete the .
Homeowners License Exemption Form on the reverse side.
Q:FORMS:OWNERPERMISSION
,(IC Engineering Dept.(3rd floor) Map 310 Parcel �/�j' Permit# Q_q ct cl �
" House# Date Issue $
Board of Health'(3rd floor)(8:15 -9:30/1:00-4:30) Fee
Conservation Office(4th floor)(8:30-9:30/1:00-2:00)
Pl g Ow 419& 05chaa6Mmiu_B1dg-
DefinitiV44--pill. 19
UMSTAOL&
MA 9.86 p
�
�f0 MKt `
TOWN OF BARNSTABLE mac 0e'M a SMR
BuildingApplication COlMtEottop Pgl�ut Est.
`���3� � / Permit �/1 � �raMaRMa omswa M>nuos'ro
Project Street Address /�:J�r L-- ��� V T/ �J� SON
Village A
Owner.�0/7 /I OJ . I 0 /Q t// -e/C, Address �v�13 �G G� C��� e7` Alita
Telephone S(15- *? 715--/& 9/ 0.;4'a01
Permit Request /01 ga t.41_5 3CC& 00-7b
r
First Floor �' // square feet Second Floor square feet
Construction Type bide iD E eS l/Ftg 'T/4ris�1�d
Estimated Project Cost $ o c)5 ,o o o
Zoning District 2.a Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure V'r7 VA Historic House ❑Yes No On Old King's Highway ❑Yes NLNo
Basement Type: pull ❑Crawl ❑Walkout ❑Other /
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing�_ New Half: Existing New
No.of Bedrooms: Existing c7Z- New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas @(Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces:Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) /1111Y/f
ttached(size) /� Jt' o� 0��'' El Barn(size) ✓t/f/i+
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes,site plan review# -
Current Use Proposed Use
Builder Information
Name_42.&� Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE r DATE
BUILDING PERMI DENIED FOR FOL WING REASON(S)
n4,!4A"q
FOR OFFICIAL USE ONLY
PERMIT NO. �/�TJ
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
F�
ASSOCIATION PLAN NO.
f.„ova
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o ' war
ST
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TOWN OF BARNSTABLE
BUILDING DEPARTMENT '
HOMEOWNER LICENSE EXEMPTION
Please print. .
DATE 9 9
JOB LOCATION
Number Street address Se ion of town
"HOMEOWNER" _ _
3
Name ome phone Work phone
PRESENT MAILING ADDRESS
City town State Zip codE
The current exemption for "homeowners" was extended to include owner-occuvi
dwellings of six units or less and to allow such homeowners to engage an it
dividual for hire who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER:
Person (sj who owns a parcel of land on which he/she resides or intends to r
side, on which there is, or is intended to be, a one or two family dwellinc
attached or detached structures accessory to such use and/or farm structure
-
A person who constructs more than one home in a two-year period shall not b
considered a homeowner. Such "homeowner" shall submit to the Building Offi
on a form acceptable to the Building Official, that he/she shall be resnons
for all such work performed under the building permit. (Section 109. 1. 1)
The undersigned "homeowner" assumes . responsibility for compliance with the 1
Building Code and other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Department minimum inspection procedures and requirement
and that he/she will comply th said ocedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35 , 000 cubic feet, or larger, will be required
to comply with State Building Code Section 127. 0, Construction Control.
�THE
O
The Town of Bafnstable
1'. Department of Health Safety and Environmental Services
Eo ► Building Division
367 Main Street;Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissior
For office use only
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
Type of Work: 9 X / Est. Cost J56 a.0
Address of Work: V�
Owner's Name V G,17-0 740
Date of Permit Application:
1 hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent f the owner.
� �' k;1
Date Registration No.
OR
�- File t1111111011HIC J U QSSQC 111SC1t.S•
• ''�, ;; ;-- i�r Department of Industrial Acridelnts
- ..� 1- 1� OflfcPallayestlgallans
\ A" ,. i 6011 11 aching tun Street
4.
em
Workers' Compensation Insurance Affidavit
� Please PRI —M tmlica_ntinformatirin= --• 1VT•1er�jv
VT am a homeowner performing all work mvself.
I am a sole proprietor and have no one work-in_• in any capacity
[! lam an emplover providing workers' compensation for my emplovees working on this job.
enrnnanv mime-
add rccc-
CHI-- nhnnc#•
incurance cp. Holier•#
[j I am a soic proprietor. sencral contractor, or homeowner(circle otte)and have hired the contractors listed below who nay
the following workers!,
polices.
emmrianv n:ttne-
:ttlrirrcc-
cin phone#!
incnranrr rn _ _ Holier•!!
cmmnnnv nime-
atltirccc-
-ire nhnne#!
ncurance co Wolin•#
Machadditia_nalsheetifneces_iat;%" .:•.!•: �_. • - fit':V..•tI �• •• N•..rr..•..I�. '.......•i.:,�.�:r.• r.....7+s u
» y.a..,w. -ra+iirl•��1MMS:Y .._.��..���—w.� ., ri�...�._1�f•w.. ..,•Y.fawLA.
allure to secure coverage:ts required under Section 3A of AIGL 152 can lead to the imposition of crimtnai penalties of a tine up to SIS00.00 andiur
ne.cars' imprisonment ax swell:ts civil penalties in the form of a STOP WORK ORDER and a fine ofs100.00 a day against me. I understand that a
opt Iof this statentrnt may be forwarded to the OMcc of Investigations of the DIA for coverage verification.
rtv hercht•ccrT0,j tool• /te paitrs attd prtta/tics ojperjurr t/at the information prosided above is tme and correct
^^atur. a�&�
- � � Date
'Tint nameACP G�%✓ .�C� Phone#
aflicial [INC univ do not write in this area to be completed by city or tO"'n official '
city or town: permit/license it ►'tlluilding Department
❑Licensing hoard .
check if iminediate response it required QSeteetmen's Office
Dtleaith Department ,
contact prmnn: phone#• Other�_
Information and Instructions
Massachusetts General Laws chapter 152 section '_5 requires all employers to provide workers• can1pcnsatiettt f
employees. As quoted from the "taw".an empluree is defined as every person in the service of� iuther under z
contract of hire. express or implied. orni or wrinen. '
An c mplurer is defined as an individual. partnership, association. corporation or other lcgnl entire or anv two a
the foreaoin�g enaaacd in a joint enterprise.and including the legal representatives of a deceased employer. or t1
reccirer or trustee of an individual , partnership. association or other legal entity, employing employees. Howe,
owner of a dwelling, loose having not more than three apartments and who resides therein. or the occupant of th
dwclling house of another who employs persons to do maintenance, construction or repair work on such dwcllil
or o» the __rounds or building appurtenant thereto shall not because of such employment be deemed to be an em
MGL chapter 152 section :5 also states'that every state or local licensing agency shall witltlruld the issuance
rette»•:tl of a license or permit to operate a business or to construct buildings in the commonwealth for an,
applicant who Itas not produced acceptable Lwidence of compliance with the insurance coverage required.
r am• of its political subdivisions shall enter into any contract for the
Additionally. neither the commonwealth no
performance of public work until acceptable evidence of compliance with the insurance requirements of this clta:
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation
supplying company names. address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tate
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 rec
to obtain a workers* compensation polic}•. please call the Department at the number listed below.
City or ,towns
Plewrze be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottc
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
be sure to fill in the permitilicense number which will be used as a reference number. The affidavits may be retur.
the Department by mail or FAX unless other arrangements have been made.
The Office of Invest i cations would like to thank you in advance for you cooperation and should you have any que
please do not hesitate to ;,give us a ;,:11•
1 �
r"av�.w.._ ..._.�•.�rw—. ....ro��..'r-.,rwwn'��.�..�w.�-.r« ..ern. w+.a•r•r .. ..t+w_ •'�.�i_ .. .S.•. r.
The Department's address. telephone and fax number.
The Commonwealth Of Massachusetts "
Department of Industrial Accidents _..
Office of lm►eSI Morena
600 Washington Street
Boston,Ma. 02111
fax #: (G 17) 727-7749