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HomeMy WebLinkAbout0051 MEGAN ROAD �i � � a CAPECOD TOE ' OF B; ;NST INSULATION 290CEa M-111: 28 PIeflR GLASS SEAMLESS SPRAY FOAM SUSP-090 — YATTS OUTTSRS INSULATION CSILINOS p 1 Sj -- 1-800-696-6611 d! , lo,;N 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 Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) (X) ( 2vl' Slopes ( ) ( ) ( ) ( ) ( ) Floors ( ) ( ) ( ) ( ) ( ) Walls Sincerely PyEs y Jr, President I ulation, Inc. *" TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Y5 Health Division Date Issued Conservation Division >_ Application Fee Planning Dept. nPermit Fee Date Definitive Plan Approved by Planning Board $ -7 l 3 Historic - OKH Preservation / Hyannis Project Street Address Y�/ h".e,zpda Village 66�7J Owner 'fit>1Y) Address Telephone ir J e�n 3/ 7 Permit Request ;F' �� % 2��� ��� / ef4_ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 'Dd nF fJ Construction Typej, 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 ONo On Old King's Highway: ❑Yes )4 No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing \A(((o /coal stg\7e: 05Yes 0 No n" A. . Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barri`❑existing❑ nev size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: =' --r Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ 'h'i Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number mod' Address ,xf zew levy, 45:*V License # /� Home Improvement Contractor# ZL Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 6 ci f SIGNATURE DATE �I�/ri a � c FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. I'J !; ADDRESS VILLAGE OWNER I'4 DATE OF INSPECTION: is at,IF.O.UNDATI.ON!DA±taVML),lah U!VUA—KVL, FRAME -_INSULATION i! a ir�,g;.t_ ?x;g FIREPLACE. ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING f 4 DATE CLOSED OUT k' ASSOCIATION PLAN NO. piy. '„ 1'Irrssaelru ctts - Deparf,ncut of Public Hoar(l of Buil71in" Re"ulatuur., and ")t:u((lards Qonstru,jption Supervisor License f. L(cen�-'-.GSA 100988 HENRY CASSIDY 8 SHED ROW \ t' WEStl 'iARMOUTH, MA 02673 r Exprr tion: 11/11/2013 l ..nuuisiuucr r(#: 7620 cz inlil`z"a)'I'a-zeal6l (I .'CS Office of Consumel• Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 1--tome linprovement Cot itractor Registration Registration: 153567 Type: Private Corporation Expiration. 12/15i2b14 TO 233831 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE SO. YARMOUTH, MA 02664 Update Address and return card. Marts i cason fur change. L� Address Ll Renewal ( .I Employment ( I Lost Gird CREN crrf)ni, ofI r d Rusu ss l2cgul;rtiouLicense or registration valid for individul use only„10ME INT CO TRACTOR before.the expiration date. 1f found return to: eyistr67 Type: Oflice of Consumer Affairs and Business Regulation ,IIIE�yyxpirati014 Private Corporation 10 Part.Plaza-Suite 5170 Boston,MA 02116II`!5(1L 18 RLAROON CIRCLE: RMOOI F1. MA•02664 - ------ Undersecretary - - - .-.. - .-.. of val' with t nat re •'' - The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anlalicant Information / Please Print Legibly Name(Business/Organizationandividual): Address:_/,r /,��:��,�� t/'i/Z City/State/Zip: 41 0.,U Y— Phone#: 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 sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers ! insurance.$ 9• ❑Building addition comp.[No workers' 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 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 / 3a.❑ I am a homeowner acting as a employees. [No workers' 13.10 Other/f/,fra� 'a general contractor(refer to#4) comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensatio0olicy information. t Homeowners who submit this affidavit indicating they are doing all worst and then hire outside contractors must submit a new affidavit indicating such. IContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have j 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: V 4? Policy#or Self-ins. Lic.#: / G� �� � ��1�,;` Expiration Date: Job Site Address: <17 /9,9,g:P? /2/ City/State/Zip: f,2 G e) Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un er the paint and penalties of perjury that the information provided above is true and correct. t Da Phone �-- F l use only. Do not write in this area,to be completed by city or town ofciaL City Town: Permit/License# Authority(circle one): d of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector r t Person: Phone#• Information and Instructions Massachusetts Ckneral Laws chapter 152 requites all employees to provide workers'compensation for then emp)oyees. Pursuant to this statute,an sarpldyet is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An empkw is defined as"an individual,partoership,ssaociatio%corporation or other Ind entity,of any two cc more of the far ping enpged in a Joint edurise,nd inchding the kpl repcaentatiM of s deceased emploM or the receiver or ttnsbee of as individual,prtnash*usockdm or other kpl entity►,employing employees. However the owner of a dwelling home having not mote than three apartments and who resides'I ,or the occupant of the dwelling bouse of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building q urtenaat dw do shall not because of such employment be deemed to be an employes:" ,M3L chapter 152,f 25g6)also states that"Mry stab er 1eea1 IkUW ageney SUN wfddwid the!gasman x renewal d a He="or pKmk to oprate a beds or to eons&ud buddhW iN the esstss Wwalth for say appoem who has ant produced se eptable erideaee of eompllasee with the bm wssm eorersge requ&W Addidaudly,MOIL chapter 152,125q7)states"Neither the commonwealth nor any of its political subdWiskm shall enter into any contract for the paformaoce of public work until accephble evidence of compliance with the insurance mquitemeafs of this chapter have been psaented to the contracting authority." Appileants Please fill out the worker 'compensation affidavit completely,by checking the boxes that apply to your sit nWm and,if necessary,supply sub-caatrac�s)nameW.sd&v*es)and phone numbers)abng with their catifical e(s)of insurance. Limited Liability ompaaiaC)C (LL of Limited Liability Partnership(LLP)with no employees other than the members at prmers,are not required to carry worlmn'compensation insurance. If an LLC at LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Depttmeat of Industrial Accidents for confirmation of hwatance coverages Abe be sere to sip slant date the atyfdaviL The affidavit should be retuned to the city or tows that the application for the permit at license is being requested,not the Deprtmeat of Industrial AccidentL Sbould you have=7 quaesfioos regarding the law or if you are required to obtain a wordoera' compeondoo policy,phase cal!the DepartaiM at the nuambat listed below. Self inured companies should eater their self-InanraaC- license mambas on the apprapdatt liars - i City or Two Offidaie Please be sure that the affidavit is complete and printed legibly. Tie Deparunent 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 arse to fill in the perraWlicense number which will be used as a refaense it m aber. In addition.as applicant that must submit multiple permiacense applications in any gives year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Sits Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stanmped or marked by the city or town may be provided to the applicant r proof that a valid affidavit is on file for fixture permits cc licenses. A new affidavit mud be filled out each yea.where a home owner or citizen is obtaining a license at permit not related to my business or commercial venture (i.e.a dog license or permit to burs leans etc.)said person is NOT required to complete this affidavit The Ofd3cs of Invatiptions would like to thank you in advance for your cooperation sad should you have say question, please do not hesitate to give us a call the pepartment's address.telephone and fax numbs: The Commonwealth of Massachusetts Dep tMent of Industrial Accidents omft err ra atiptlaa 600 Washington Sftd Boston,MA 02111 Tel. Jl 617-727-4900 ext 406 or 1-877-MASSAFE Fax 1#617-727-7749 ! Revised 11-22416 j www.m =.gov/dia ; CAPECOD-27 MYOUNG CERTIFICATE OF LIABILITY INSURANCE oATE1MMIDD IYYIY) 7/8/20/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#PC-514062 CONTACT NAME: Margaret Young Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 A/C No Ext: A/C No): South Dennis,MA 02660 E-MAIL m oun ro ers ra com ADDRESS: Y g@ g g y• INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:PEERLESS INSURANCE COMPANY INSURED INSURER B:COMMERCE INSURANCE COMPANY Cape Cod Insulation,Inc. INSURER C:Evanston Insurance Company 18 Reardon Circle INSURER D:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE D B POLICY EFF POLICY EXP LIMITS LTR I SR WVD POLICY NUMBER MM/DD MM/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CBP8263063 4/1/2013 4/1/2014 DAMAGE EN PREMISES Ea occurrence $ 100,000 CLAIMS-MADE 1_x_1 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COEaMa ccidBINEDentS INGLE LIMIT $ 1,000,000 B ANY AUTO 13MMBCKVMK 4/1/2013 4/1/2014 BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED BODILY INJURY(Per accident) $ AUTOAUTOS J H REDSAUTOS NOWOWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE XONJ453512 4/1/2013 4/1/2014 AGGREGATE $ 1,000,000 DEC) I X I RETENTION$ 10,000 $ WORKERS COMPENSATION N WC TO Y LA ITS OER AND EMPLOYERS'LIABILITY YIN - ` D ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A WCA00526904 6/30/ 013 6/30/2014 E. .EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED9 (Mandatory in NH) L.DISEASE-EA EMPLOYE $ 1,000>000 If yyes,describe under DESCRIPTIONOF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Compensation includes Officers or Proprietors. Addtional Insured status is provided under the General Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. - AUTHORIZED REPRESENTATIVE I r f�wtun 0/11!!988-20010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD r OWNER AUTHORIZATION FORM (Owes Name) owner of the property located at (Pr perty Address) z6Gl (Pr perty Address) hereb authorize Ci -- Q y (Subcontract an authorized subcontractor for RISE Engineering,to act on my behalf,to obtain a building permit and to perform w o;OeVs operty. Signitbre— Date - I Assessor's map and lot number � `!..... ✓ � SEPTIC �-1 / INSTALLED MUST SE Sewage Permit number ....... I, ................................. WITH ARID IN COMPLIANCE: SANITARY E II STATE �PyOFTHE rp�o TOWN OF BA ��A'8'EEWN iid „ • t i BARNSTABLE. i % 9 'EGppt BUILDING I SPECTORe �p 1639. 90 a` APPLICATIONFOR PERMIT TO .. ......... ............................................................................................... TYPE OF CONSTRUCTION ...... .....A ........ / % f .............................................................. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies forr/a permit according to the following information: Location ........ .../ :�/..........` ...... .. ......:.........: ....... �' .�1 ?�e!L........................ ProposedUse ..c /? / ................................................................. r Zoning District ..I.flelll . ................. ................................Fire District ............ G`✓f Gflf..��.lf��� G .. .... <.� .. .Address .0 � &I edl 0+ /✓/!//,� Name of Owner . ......... .. .. er <,.......................Y Name of Builder ie ........... ................................Address .................................................................................... Nameof Architect ..................................................................Address ............................................................................ :...... Number of Rooms Z .....Foundation ............r.................................... � ............... ... �1 ................ Exterior .. �'"' .� ............................ .............................Roofing .......... ......... ... Floors F .' .� �� �P..' .......................... . .... f%4 . vvo Heating ......../....w"..y.��°...... ...........................:...........Plumbing ...........!...................................................................... Fireplace ............ .................................................................Approximate Cost ....... .. .. F > ............................... Definitive Plan Approved by Planning Board _____ _ l� 'S ------19 Area 00 Diagram of Lot and Building with Dimensions Fee4/0 SUBJECT TO APPROVAL OF BOARD OF HEALTH V� low� x /a so I hereby agree to conform to all the Rules and Regulations of theaoregardin e above construction. Name ...... .. .. _ �:..... Dacey, William E. Jr. �'�2.... Permit-for one story No ............. ...... single family dwelling .........1............................................................ Location ` Megan Road ........ .......................................... ........................ yanni .................................. Owner ..........William E. Dacey, Jr. ............................. Type of Construction .....frame ................................................................................ Plot ............................ Lot ........#128............... { I /CJ I Permit Granted ....7..2.16........:.....19 Date of Inspection Date Completed ......S/xlt ft3....19 PERMIT REFUSED f ................................................................ 19 �t ............................................................................... i ............................................................................... Approved ................................................ 19 I ............................................................................... ............................................................................... E4gineering Dept. (3rd floor) Map ,50 Parcel c �'�[�/ ax Permit# House# ��� Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee LY,2.5 a� L Conservation Office.(4th floor)(8:30- 9:30/1:00-2:00) Planning Dept: (1st floor/School.Admin. Bldg.) oFIHE rqi DefinitiFs PIoved'by-Plaiuiing Board � 19 ; •- BARNSTABLE, MAWk 019. TOWN OF BARNSTABLE Building Permit Application Project S/ ,, u &f}Q Village .20 Owner Address Telephone Permit Request a First Floor square feet Second Floor, square feet Construction Type Estimated Project Cost $ a,DDD.D6 Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family :�o Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑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 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) ❑Attached(size) ❑Barn(size) ❑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 / _ 11� �j�2 / Telephone Number �,5'Q9) 7 7,5 -7 76 3 Address P. License# Home Improvement Contractor# Worker's Compensation# 7 41 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[_ Zj1eZ&,6i7JJ DATE ILL& B L P I OLLO ING REASON(S) `t FOR OFFICIAL USE ONLY _ PERMIT NO. DATE ISSUED F .� MAP/PARCEL NO. ADDRESS 1 ' VILLAGE t OWNER DATE OF INSPECTION: FOUNDATION ✓ ` FRAME INSULATION FIREPLACE 'r - ELECTRICAL: ROUGH -' FINAL _ PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. '? '. N r��qy •wy i �'� _ .. �.. {Y. $, L Y '4 t�rr.x� �.'.Y.� -t.�'S,J"-''1� �{�A 1'"J :Sf�• o'' :r�' �•4-� ''s �e d t + �.i `,'J.•` _:y.'r>' �, .ay ?�.:* 1 +,.sfx+��,:J^. Ey?�* ;,, cam+.-z. ^a,:_m'� 'A '?°::t« •�-. ..,_ __„'k <, r S: - .r*'z 4' r.' ,;, M G ,.,r'd^�: •.;.y ,.... �'..., ...:r.•: -.{;_ - Y- '','.. ~. ;1t., - Y:-• t tYr � j :, t :'k': 1''a�� ,v. 'ram` :.r ::-,w1 .�xa•-� M .v`?,.�"Yl�:d R. m• .r�` G� _..,.... �.Y" °C;P'. . :,5 t ,�<G .,,,,�� Y' "a. �+d'`>"":. 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'T' -''�wf - �3.;.��i.� ,ls :�r,Y��',y4 n� ;�� �,C,. f,�rh- The Town of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Stmet,Hyannis MA 0=1 Office:.508.790-6227 r Ftuc: 508-790.6230 Building Commissior For oWn 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-Costing 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: - Est.Coat Address of Work: A 1,y Owner's Namc Date of Permit Application: � fi4,, 7. ,. : . I hereby certify that: Registration is not required for the following reasoa(s): _Work culuded by law _Job under SIAM _Building not owner-occupied wner 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 IJN®ER PM"17EtS OF PERJURY I hereby apply for a permit as the agent of the owner: g a 9� Date Contractor Name Registrad n No.. OR k• The Commonwealth of Massachusetts Department of Industrial Accidents 011Jceo1/eresllosal 600 Washington Street Boston,Mass. o2111 Workers' Compensation Insurance Affidavit e ❑ I am omeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ❑ I am an employer pro%iding workers' compensation for my employees working on this job. address: phoneu -7215 7/�ri: insurance co. /A M7,o®'� policy# gnil gel D4Z ❑ I am a sole proprietor. ;eneral contractor. or homeowner(circle one) and have hired the contractors listed below ho have the follo%%ing workers ;ompensation polices: comoanv name• address: IN: phone 8• insurance co. polity p „ company name: address• city: phone!!. insurance co. potiey M � a Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of erimiaal penalties of a fiat rip to S1,500.00 aawor one years'imprisonment as well as civil peoaldes in the form of a STOP WORK ORDER and a floe of S100.00 a day against am 1 ande stand that a copy of this statement may be forwarded to the Once of Investigations of the DU for coverage verifieadon. I do hereby c rtify under the pains and penalties ojperjury that the information provided above is trite and coasts signature Print name_v ed&,,O� Phone N -7 7.S 7 7 x 3 official:usedo.no,0*rite in this area to be completed by city or Iowa official city orpermiUhccose fl mBuilding Departmeot pUcensiag Board chee rspnse is required (3seleetmeo's Office contac phone p;_ :_'� _ *= �Otberh Department (revised 3,95 P3A(