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HomeMy WebLinkAbout0020 LOUIS STREET i l - Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS O T9E1NVIENIT®RY NAME OF BUSINESS: f BUSINESS LOCATION: INVENTORY MAILING ADDRESS: '?,n HWPPN?V(c M9 r?:��_ TOTAL AMOUNT: TELEPHONE NUMBER: ` : CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: 9, !(7 MSDS ON SITE? TYPE OF BUSINESS: ai ;p1 i A,, r, INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following,products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic-fluid-(including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ' ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Rhotochemicals (Developer) lubricants, gear oil 0 NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers,deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers ) 1 (including bleach) Fbti-fir• Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash - -- , WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signa Staff's Initials Town of Barnstable Regulatory Services iNE do Richard V.Stall,Director • Building Division snxxsrnsrt+:. +` _ 9� 1 ,0$ Tom Perry,Building Commissioner QED MA't A 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRA ON Name: t!�jl�b t.5 Y1 �i 1L �t aw Phone#: 2 g 1© Address: 9cJC 3 gT c�AAJ r l'`� MA 0260( Village: Name of Business: lac Gr+/ l Type of Business: TP 1 FU 1 k7!* Map/L ot: ��— ©a IlVTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,haver an ee with the above restrictions for my home occupation I am registering. Applicant- Date- '�T 7` Homeoc.doc Rev.103113 YOU WISH TO OFTEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which you must do by M.G.L.-it does not give you permission to operate.] You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: APPLICANT'S YOUR NAME/S BUSINESS YOUR HOME ADDRESS: -20 a � € s �J yyTELEPHONE # Home Telephone Number 7 Z. C i NAME OF CORPORATION- NAME OF NEW BUSINESS TYPE;OF BUSINESS- Ai I w IS THIS A HOME OCCUPATION? Y S N ADDRESS,OF,BUSINESS' Zi MAP/PARCEL NUMBER (Assessing):- When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner �of rYarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate MU� u iAep r�xo ti DOME OCCUPATION 1. BUILDING COMMIS9IOIVER'S oFF E RULES AND REGULATIONS. FAILURE 1'O This individuals iflf r e any pe mit requir menp is that pertain to this type of business. COMPLY MAY RESULT IN FINES. Aug -.or_iz Si net *. COMMENTS I' �'-- 2. BOARD OF H ALTH MUST COMKY WITH ALL This individual has the permit requirements that pertain to this type of business. HAZRDOW-MATERIALS RECA"T"S Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has e i the licensing requirements that pertain to this type of business. Authorized Si nature* COMMENTS: j a! �oFtRE Ta Town of Barnstable *Permit# 0(�)IN63& Expires 6 months from iss a date 1ARNSfAHLE, Regulatory Services Fee v� M"9 Thomas F.Geiler,Director Building Division ttz-- Tom Perry, Building Commissioner y ����� 200 Main Street, Hyannis,MA 02601 a PERMIT Office: 5087862-4038 AUG - 6 2007 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAKQA4 bf: BARNSTABLE Not Valid without Red%Press Imprint Map/parcel Number 3 Property Address y Lail1S st_TEE E Anr\ Mci C va o [Residential . Value of Work I Igo U d Owner's Name&AddressbUro5tuble- 0Ai-ho� Contractor's Name n lti c V4ov�_A e � I Telephone Number,56,6-7 7 S-' 1 Home Improvement Contractor License#(if applicable) 163 1 S' Construction Supervisor's License#(if applicable) b to U13 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance M Insurance Company Name CA . Ik0i--��1 J_AG �(��-- ` n eaC_LA $� , L p]DO V / Workman's Comp.Policy# v' "1�"► 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) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prope ust sign Property Owner Letter of Permission. rovement Contractors License is required. Signature Q:Forms:expmtrg 1 ne l:omrnorlwealm Of lYluJ'J'aC nuJ'elW' Department of Industrial Accidents. W Office of Investigations 600.Washington Street Boston,MA 02111 'a www-mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plu>i abers Applicant Information Please Print Ledbly Name (Business/Organization/Individual): Address: 1 '�9 r,•rv>i- �SL� c� City/State/Zip: Phone#: SoS 77 s L77_7 F5 Are you an employer?Check the'appropriate box: Type of project(required): 1.01 am a employer with 5 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. [) Demolition working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11-❑ Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.M Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub-contractors aad their workers'comp.policy inforrnatian. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: N-)fl_SS A c A4 Policy#or Self-ins.Lie. #: R.w C Expiration Dat'6 j:13)o-7 ' Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500;00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c"undle ns andpenalties of perjury that the information provided above is true and correct Si ature: . Date: II - G1 Phone#: 5 o 5 ? S— C? 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 e.Electrical Inspector S.Plumbing inspector 6. Other Contact Person: f Phone#• Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration �,1:0.3757 µ h Expiration 7/9/2008 n Type Pr�a4e Corporation } SPRINKLE HOME�IMPR'QUEMENT,'INC. Brad Sprinkle 199 Barnstable Rd. Hyannis, MA 02601 Deputy Administrator " �,�ie �o�ritrjru�uc�� ����1la%�aar�ouael�s BOARD OF BUILDING.REGULATIONS. License: CONSTRUCTION SUPERVISOR Number CS 006643 Bij date 10/08/19.55 J I Expires 10/08/2007 Tr. no: 663a'0 Construction -CS Restricted 00 „ BRAD K SPRINKLE. ` 190 LOTHROPS LANE, W BARNSTABLE, MA 02668 �^ " Commi.ssi.oner r ISSUE DATE 05/21/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND Bryden&Sullivan Ins Agency CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 88 Falmouth Road - -- --- Hyannis,MA 02601 COMPANIES AFFORDING COVERAGE INSURED — --- -_-------------- Sprinkle Home Improvement Inc 199 Barnstable Road""" COMPANY A A.I.M.Mutual Insurance-Co LETTER Hyannis,MA 02601 FIR map {r 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. - CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MMIDD/YY) G ENERAL LIABILITY GENERAL AGGREGATE S r� PRODUCTS-COMP/OP AGG. $ u COMMERCIAL GENERAL LIABILITY PERSONAL&ADV.INJURY $ u=CLAIMS MADE OCCUR EACH OCCURRENCE OWNER'S S CONTRACTOR'S PROT. FIRE DAMAGE(Anyone lire) $ MED.EXPENSE(Anyone person) S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY ALL OWNED AUTOS b (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY Ptr ncc¢enl) _GARAGE LIABILITY PROPERTY DAMAGE --------------------- EXCESS LIABILITY EACH OCCURRENCE 'S —�UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM 2-1; li WORKERS COMPENSATION AND STATUTORY LIMITS OTHER EMPLOYERS LIABILITY X HE PROPRIETOR/ EL EACH ACCIDENT 500,000 A PARNERS\EXECUTIVE OFFICIERS ARE: 7004943012007 05/13/2007 05/13/2008 EL DISEASE--POLICY LIMIT 500,000 nX INCL L�EXCL EL DISEASE--EACH 500,000 EMPLOYEE COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS: - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA1 ION DATL BRAD SPRINKLE HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. 199 BARNSTABLE ROAD HYANNIS,MA 02601 AUTHORIZED REPRESENTATIVE f s 4. Contractor is not responsible for existing conditions of residence. 5. Contractor is not responsible for damage to such items as, but not limited to: sidewalks; driveways; patios; lawns; shrubs; sprinklers; and other such appurtenances. However, reasonable care will be taken. 6. All agreements are contingent upon strikes, accidents, or delays beyond Contractor's control. 7. Homeowner is to carry fire, and other necessary insurance. Contractor's workers are fully covered by Worker's Compensation Insurance. 8. Fencing, carpentry, painting, plumbing, electrical, dry wells, etc., and all other work necessary that is not contained in this contract, shall be the responsibility of the Homeowner. RIGHTS TO CANCEL The Owner may cancel this Agreement if it has been signed by the Owner at a place other than the address of the Contractor, which may be his main office or branch thereof, provided that the Owner notifies the Contractor in writing at his main office, or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this Agreement. WARRANTIES The.Contractor warrants that the work furnished hereunder shall be free from defects in workmanship for a period of two (2) years following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within two years after completion of any job, including clean-up, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced such damage or such defect in workmanship as long as the owner has paid their agreed contract in full. The foregoing warranties shall survive any inspection performed in connection with the agreed upon work. All warranties for product supplied by the Contractor under this Agreement shall be those given by the manufacturers of such product, which shall be and hereby passed directly to the Owner. Such manufacturer's warranties, the Owner may be required to register or mail in a warranty card or other evidence of ownership, and use of such product in order to activate such warranties. The Owner's failure to send in or register such documentation, which failure voids that manufacturer's warranty, shall not create any responsibility for the Contractor to warranty such product. Note: Any changes in the contract during the duration of the project which results in additional monies due will be paid in full to the contractor at the time of the change. Tauthorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to be performed on this job (i.e. permits, applications etc.) if necessary. Barnstable Hous' Authority Date Brad Sprinkle Date Celebrating 61 years in business a RESS Town of Barnstable *Permit#PERN 4 T Expires 6 months fro 'sue date NOV 0 2 2006Regulatory Services Fee Asa Thomas F.Geiler,Director L E 6 OF'3ARNSTAS ZIerry, ding Division CBO, Building Commissioner �--� 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint vlap/parcel Number ?roperty Address ]Residential Value of Work �( ,(�©Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address \j.-!-"A -ontractor's Name t 1(� ��— Clt'_�K1 S Telephone Number dome Improvement Contractor License#(if applicable).. construction Supervisor's License#(if applicable) 3'*orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance 1 nsurance Company Name Workman's Comp.Policy# '"7 61 1 *0 ®© (p .opy of Insurance Compliance Certificate must be on file. ?ermit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not ex pt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property 0 er must ign Pro wner Letter of Permission. e Imp v nt ontract i se is required. SIGNATURE: ZTonns:expmtrg tevise071405 11 IV CERTIFICATE OF INSURANCE ISSLIE DATE(MOFD/YY) PRODUCER THIS CERTIFICA EIS LS3 AS A MATTER OF INFORMATION ONLY AND Leonard Insurance Ag6cy Inc CONFERS NO RIG$TS UPON TIC C] iTIFICAT'E HOLDER, THIS CERTIFICATE P O Box 494 ' POLICIE6 BELOvV.'EXTEND OR ALTER THg COVERAGE AFFORDED M Y THE . Osterville, MA 0265� COMPANIES AFFORDING COVERAGE 'NSURED i ' Mark'Herbst 35 Peep Toad Road � LETTER COMPANY A A.I.M. Mutual Insurance Co Centerville, MA 021 OVERAGES i TIiIS IS TO CERTIFY TH1AT T11L POI.TCIY:S OF TNSU1tANCE I.LS7ED BELOW HAVE 888N ISSUED TO THir INSURI3D NAMED ABOVE FOR THE POLICY—PERIOD INDICATED,NOTWITH;TANDINGANY REQUIREMENT,TER OR CONDITION OP ANY CONTRACT OR OTHER b CERTIFICATE MAY aE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, OCUMENT WITH RBSPECTTO WHICH THIS -EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIM1Ts SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, D TVI L OF INSI I►C POLICY EFFECTIVE POLICY XXPwATIp !l POLICY NTAIDIiit DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS GENERAL LIARII,IfY COMMLRCIAL(ifNFKAILLIABILITY GENERALAGGRSGATE s CLAIMS MAD lr PRODUCTS-COMP/OF AGG, S _ �JCCUR OWNLR'S do CONrltAq'rolt Is PROT. _ PERSONAL&ADV,INJURY S i EACH OCCURRENCE _ 1 PIRE DAMAGE(Anyone ri,c) S i AUl'OD101111.1,LIABILI'1'I MED.EXPENSE(Mryoneperson) S ANY AUI'O t COMBINEDSINGLE LIMrr S AI,L OWNED AUI'OJ CHEDULEDAUTOS I B06ILYINJUR.Y I liIItGD AUTOS (Per person) S I NQN.UWNCD AUTOS BODILY INJURY GARAGE LIARILIT (Per w6deru) S I' � ROPERTY DAMAGE S EXCESS MAIJILITY MRRCLLA FORM tI _ _ — — — AC11 GCCURPENCE S I,111 K TIIAN UMIIHELLA l7ORM - - - - - - - - - - - - - ' A� - - - - - - -S- - - - - - WORRAk S C'OMITNSATII IN AND EMPLOYIi115'UARILI'I'Y I x WCSTATU_ OTH- j 7016215012006 IM TNF PROPRIITOIt� 07 $ 10 PAR'PNERS/EX11CUTIvE tNCL 01/10/2006 01/10/20 ORICERS Akb! ; X .X C L DIS6AStl.PO ICY LIMIT $ 500.000 UI'liLlt BLD Srr6A EMW YEE S 100 000 i i 1 I Ittl'rIUSOPOPLAA IONS/T,gCAI'IONS1VI;IIICLQ1SPGCIALITEm i IiT1R1CA'i'L 110LUI'R CANCELLATION SHOULD ANY OF TIIB,yBpV$D)rSCRM91)POLICIES BE CANCELLED BEpORE THE EXPIRATION DATE THEREOF;.ThE ISSUING COMPANY WILL, ENDEAVOR TO I MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LF.n,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR DWn Of Barnstable Bldg Dept. LIABILrrY OF ANY KIND UPON THE COMPANY, ITS' AGENTS OR Irvin St REPRESENTATIVES. yalltlis, MA 02601i AUTHORI ZED REPIIESENTATtv11 ✓�ze-�o�nzoowiea�o���iacQel�d',' Board of Building Regulations and Standards License or registration valid for individul use only HOME IM before the expiration date. If found return to: Prp CEMENT CONTRACTOR P �` Board of Building Regulations and Standards Registratt 6480 One Ashburton Place Rm 1301 08 Boston,Ma.02108 - s dual MARK HERBST MARK HERBST ,c 35 PEEP TOAD D. .v 5 �3r^'"a'""'�- Not valid wrtho t nature CENTERALLE,MA 02632 Deputy Administrator r .. The Commonwealth of Massachusetts I Department of Industrial Accidents :, Office of Investigations 600 Washington Street Boston, MA 02111 «`!� www.mass. ov/dia t r � g Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): \L Address: 9- ?e e�, City/State/Zip: Qevit MA Phone #: �� �1 �� (oo`11 (o Are�ou an employer? Check the appropriate box: Type of project(required): 1.CJ I am a employer with 1 _ 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the'sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 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 and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12. oof repairs insurance required.]t employees. [No workers' 13.0 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. \\ \ Insurance Company Name: -%( \ ' P\ Policy#or Self-ins.Lic.#: 1 6 c,1 R0 9 D b lo Expiration Date: —( `d'- 5\ 5� ' Job Site Address: c�Y1 \S _ City/State/Zip: � 1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurant coverago verification. I do hereby certify under t pain and p a of perjury that the information provided above is true and correct Signature: Date: I L 3 "b 10 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#: pAA ��1 77 77 RBST HERBS 1 3 Peep Toad Rd. Centerville NlA 02632 (508) 420-6216 Cell phone 774-238-29�8 PROPOSAL SUBMITTED TO: WORK PERFORMED AT: Barnstable Housing AuthoriO 20 Louis Sheet Att: David Hart Hyannis MA 146 South Street Hyannis MA 02601 Cell hone 508-280-5702 ` P r We herby propose to furnish the materials and perform the labor necessary for the Completion of the following; e� Roo : N �. Remove I laver of existing shingles Install 8" drip edge Install ice &water shield at edge & in valley areas Install 151b felt paper Install Certainteed Wo dscype 30vr. Algae Resistant shingles Co1o�( )*Please fill in Thank You Cut ridge & install cobra vent Storm nail all shingles All debris cleaned daill Price includes material labor &dump fees ia All material is guaranteed to be as specified, and above work to performed in accordance with specifications submitted for above, and completed in.a substantial j workmanlike manner for the sum of, Three-Thousand Nine Hundred&Nineo;-Five Dollars( $3,995.00)with paym is as fo�ow;full amount due upon completion Any alterations) from, Lboy inv vi ' extra costs will be added under written n tra a�' a over and above signed estimate/agreement agreement, and beco RESPECTFU- B T F; nature ,�� 5-22-06 Signature ACCEPTANCE OF PROPOSAL r The above prices specification & conditions are satisfactory, we herby accept You are authorized to do the work, and payments will be as specified above. g Si natures( ) -_ Date: e 6 `� This proposal may be withdrawn by said company if not accepted within 30 days