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HomeMy WebLinkAbout0266 MEGAN ROAD effL,�n-7RCL, W i f f f F 1 `. V f Fire totals RV, damages home CapeCodOnlinexom Page 1 of 1 �g a v fs Wow. / r, Fire totals RV, damages home January 19,2010 2:00 AM HYANNIS—A recreational vehicle on Megan Road was destroyed by fire early yesterday morning,according to a Hyannis Fire Department spokesman. A passing driver called 911 after spotting the vehicle's roof on fire at 12:02 a.m. at 266 Megan Road, according to fire Lt. Richard Knowlton. The burning vehicle was in the driveway within 6 feet of the house, he said. He estimated damage at$30,000 for the vehicle and its contents,plus another$10,000 damage to the house itself.The house is habitable; neither the owner nor her pets were injured. The cause of the fire may be electrical but it is still under investigation by Barnstable police and the Hyannis Fire Department.The cause does not appear to be suspicious, Knowlton said. Copyright©Cape Cod Media Group,a division of Ottaway Newspapers,Inc.All.Rights Reserved. http://www.capecodonline.com/apps/pbcs.dll/article?AID=/20100119/NEWS/1190317&te... 1/19/2010 ' - Parcel �. nia# S 0 Conservation Office(4th floor)(8:30- 9:30/1:00=2:00) Wte Issued Jr 02 9 4, ® Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) . ee Engineering Dept. (3rd_floor) House# T " -i aY 9UST BE Pl . .. ..� LIANCE 19 DE AND '�°'OW 1� 1'104VS TOWN OF BARNST-ABLE Building Permit Application : . Proje ddress 2b� MCC6,06 l ROAD Village `AVANN1S Owner ; rom -MAR0m6 r . Address Zbto MgU I RoRfl Telephone -$y Permit Request First Floor 252 square feet Second Floor -d- square feet Estimated Project Cost $ 2500 Zoning District R5 Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type S Hm Commercial Residential .Y Dwelling Type: Single Family X Two Family Multi-Family Age of Existing Structure 20 VaS Basement Type: Finished Historic House Unfinished X Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel. Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name $Q,AM 1&1A2du2n0N D13A SALT S;PAu Sams Telephone Number '778-e400 H3z-'74c+"2 Address $2 QypEn 20An t 1Atzw�N, nna License# d�2stiS6 Z 0 r Catumpi Pan&, I.IYAN/I,s Home Improvement Contractor# I�S-t —r Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. `" -. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SE►c_r le 1 SIGNATURE , �., DATE zydg§!4 BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. ly D', E ISSUED t M P/PARCEL NO. s, '6 DRESS 3y VILLAGE + ; OWNER DATE OF INSPECTION: FOUNDATION y A$FRAME INSULATION - t FIREPLACE ` ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL - # GAS: ROUGH FINAL r FINAL BUILDINGS Imo` r i 1 DATE CLOSED OUT t 'Z 0 i � ASSOCIATION PLAT Nor, . # rl 4 . i To Date Time WHILE YOU W E OUT M of Phone Area Code Number Extension TELEPHONED PLEASE CALL CALLED TO SEE YOU WILL CALL AGAIN WANTSTO.SEEYOU. URGENT RETURNED YOUR CALL Message Operator AMPAD 23-021-200 SETS 'tit ch EFFICIENCY®. 23-421-400SETS CARBONLESS • �, '~` The Connym l'ealth of Massachusetts -= �•ri: _ �,..i=: Department of Industrial Accidents �; _ • Afee slim WS9929OAS - � 00 !1'`�� :�i•=a 6 asliin;�tun Street < Burton,Mass. 01111 Workers' Compensation insurance.AMdavit �ARnhcant tnformatton• ...._ Pie-A PRiNT'le.• lv - • .;• T name• 912IAr+ WAeL arLrew u,.,.. r location- 67, ftiniw - rxcAQ city 1442W"'1 M A Anne# 4111,:1467 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity - 1 am an emplover providing workers' compensation for my employees working on this job. sotpnnv name• SALT S?ftA SMt address• 2t7 •n 0aMrGN Df2I-i ' citx: lWAA#mS MA nhone#a': '7`7fl••9�1Do "ice co NAn morVAL .NS GO nolie%•# CAe-P a !K4Z I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comnanx name: address, .. ... . .. . :.. ,. . . ..__ . . . •• phone#: - insurnnee co neiier# -- - cimlL� nafne• - _ .- address: - city.. phone#6 inenr..rice cv' .• ttoiicv# . Atiach additional'sheet if tiecem— w%�- ;�+';-,+ "�' ""'^='� •' '" ::%.+sr Failure to secure coverage as required under Section ZSA of NIGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties is the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement maybe forwarded to the Once of Investigations of the DIA for coverage verilieadoa. I do herehr cenify under the pains and penalties of peryuq•that the inforn mion pyvWded above is True ottd correeL Signatu ate MM-7-4.lgti(. Print natne i mAw 1.1Aam xLnl ` y Phone# 432-74c-7 oRicial use only do not write in this area to be completed by city or tors official _ city or town: permit/lleense# nBuilding Department (3Uccasing Board check if immediate response is required C]Seleetmea's Ottke C31icalth Department contact person: phone#; nUther (rewsed 3•4)5 PJA) > Information and Instructions .� Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employces: As quoted from the"law", an emplgt►ee is defined as every person in the service of another under any contract of hire,express or implied, oral or written. An empli{rer is defined as an individual, partnership,association, corporation or other ;,-,al entity, or any two or more o; the forcgoin,engaged in a joint enterprise,and including the legal representatives of a deceascd�employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing emplovees.. 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 -rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 1.52 section_'5 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 commonvealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally.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 hav g been presented to the contractin authority. ' 77 Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and 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 afGda,% 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. s.w�.Nw�r/OrPfA/.!ti�Rnw .,.o.-.•eR�e*•!+!f: a:.• 7. ...�: s.r.«: 1y.*rrrn•..:•r..:''1''{ �ti .yt'7rCj,+•�".�• �.i _- - �_ � .:rpa:�, ..... .. �- . i -..y-.:iF.-:w�••:Y%'1 �.iw. Y.��raM►n,T.'.4i,�1^jj�io•'�'3�,. +wit',T:.J .s-••1r . City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, Please do not hesitate to give us a call. -..s....,�.�....r- r+v,.r,�.,•....-.,.Y..!�.—!e.ns.�s�. _; •1::-�:: .... ',:.. ..__ ..-•r. - ,C.:e .i_''.:..+r-w ,'.�'•� YtY.• •tom..;: The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 -. phone #: (617) 7274900 ext. 406, 409 or 375 : . The Town of Barnstable KU& ,$ Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Off ce: 508 790.6227 Ralph Ct� F= 508 775-33" Building Commis: 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,.remotiaI, demolition. or construction of an addition to any preedseing owner occupied building containing at least one but not morn than four dwelling units or to structures winch are adjacent, to such residence or building be done by registered Factors,with certain c=ptions,along with vita Type of Work: SHefl —Est.Cost Z&oo Address of Work: ?Arfi MR— WUM Owner.Name• Date of Permit Application: I hereby certify that: Registration is not required for the foIIowing remn(s): Work excluded,by law Job under S1,000 Building not owner-occupied Owner pulling own permit Notice is hereby green that: CONTRACTORS OWNERS PULLING THEIR OWN PERMIT OR DEALING WIT'1;VNREGI51'� FOR APPLICABLE HOME WROVEMENT WORK DO NOT HAVE ACCESS TO TIE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. 0 Contractor name Registration No. OR ' n,,,, Owner's dame _444"3 .t•r afs',t {k}P -litl -S nyy' t�gX JA A c 0 Oft it -44 31 4 J �a1 un"I'ln'N _ 9k= COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY 3•, " ( " OF ONE ASHBORTON PLACES ! y{ MASSACHUSETTS BOSTON,MA 02108 CAUTION XPIRATION DATE FOR PROTECTION AGAINST EFFECTIVE DH 7 LIC-NO. �� 4 IE'STRICTIONS THEFT, PUT RIGHT THUMB I < PRINT IN APPROPRIATE ., BOX ON LICENSE. C, BLASTING OPERATORSt z MUST INCLUDE PHOTO. r �y, PHOTO(BLASTING OPR ONLY) FEE: t• I } F - tx C e alluretopossasa .: Ha )tt y NOT VALID UNTII SIGNED BY LICENSEE AND OFFICIALLY - {r1 r.� STAMPED-OP, SIGNATURE OF THE COMMISSIONER- rP208S8aChYE ett&State Qy t• -,a HEIGHT: Codoiscausoforrovocer�•: s DOB: I 41 this licenc.r. f �� THIS DOCUMENT MUST BE a S'GN NAME IN FULL ABOVE SIGNATURE LINE CARRIED ON THE PERSON OF SIGNATURE OF LICENSEE - a k tw THE HOLDER WHEN EN- GAGED ( OTHERS-RIGHT THUMB PRINT IN THIS OCCUPATION. a R HOME IMPROVEMENT CON,'RACTORS REGISTRATION Board of Building Rec.�ulations and Standards One Ashburton Place — Room 1301 :Boston; Massachusetts 02108 r HOls1E;-•IMPROVEMENT CONTRACTOR ---- --- - -- --- --- -� r .Registration 12015Z Expiration 10/26/97 � �� �✓ TYPe 0BA. kY HOME IMPROVEMENT CONTRACTOR ` Registration 120157 BRIAN EDWARD WARBURTON Type - DBA rya BRIAN. E . WARBURTON Expiration 10/26/91 RYDER RD r f' R N y HARWIC.H MA 02645 BRIAN EDWARD WARBURTON BRIAN E. WARBURTON 82 RYDER RD -. ADMINISTRATOR HARWICH MA 02645 Y: '3 M " Y. N Y U oN rapw y,. - M r �- a i1 i t N PT IV on Co y"l8`YIL" Soho CA��►Lit�=it ��c� 3 12� 7 t, 1 • • WOO 161 -i4r- • v 1 � Assessor's office(1st Floor): /� ® t Assessor's map and lot number � % _ SEPTIC�� '��` � e�D o� ,^.�IN C®MR : Board of Health(3rd floor): INSTALLEDMTLEE d Sewage Permit number tJ F Engineering Department(3rd floor): ENVIRQ 'A. 4P!@AttR+►nLE S /��� House numberv, � � YQ��� 1639'a�e� Definitive Plan Approved by Planning Board 19 0 MAY APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO Q v i".� e (/ dill/ryj/✓li TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 6 �e C�A�✓ /3 // li �o i✓�� S �� Proposed Use Zoning District Fire,District // V/�/�//✓dS Name of Owne -� s / tlorneos /,�io�d/r/ AddressoZl 2 Al 4� Name of Builderz/�)'(, �a, �d" Address L Name of Architect Address Number of Rooms Foundation Exterior Roofing Floors Interior Heating Plumbing /� Fireplace Approximate Cost �Z. eq-0 Area � Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. N e Construction Supervisor's License O �.� BARONE, THOMAS MR. & MRS. No 33161 Permit For Build Swimming Pool i Accessory to Dwelling i L- Location Lot 54, 266 Megan Road '. Hyannis Owner Mr. & Mrs. Thomas Baror,ca �! Type of Construction Concrete/Vynal f Plot Lot ` Permit Granted August 23 , 19 89 Date.of Inspection 19 `c Date Completed 19 ~ . y � , r3 j .� a f 14 t N. _>c : LoT 43 ?3 30 ` d4 : Y - P . 0 0 lob 1` ,04 b n - - isA`�"i O_N Y:4 rvw/s Mq .c`J out, € € ISt S` � AJ/ Tr N a w.v L 7 0.9 9 A - A.T E .. . # !I > RESY C;EFtTIFY THAT THE - 8".U' I L.D"f.NG FtEG:. LA:;:ND "`SUR.V.EY."O � HCfWN ON THIS "P.L.AN 1. 5 LO"CATED. ON E AR:OUND $ <SHO. WN HEREON AND OOa ' 1# AT t.T CONFORM TO THE" C►NiN:G" St . L''AWS.' :OF .THE TOWN 0F � t11uFMgC` BAFt/YSTABGAv' . W H E N C ONSTR .UCTE D. S-AR STaBLE SURVEY CCN vl SULTANTS, .INC. , _ �� r �� , WEST YARMOJTH,-MASS . ' I _ yo r I n , 91 `73 }� The Town of Barnstable �tHE Permit# Massachusetts •_ Date /6 B�RrrAM • SOLID FUEL STOVE PERMIT 1as¢ ,� o�� Fee 0-2) This constitutes an official stove permit after inspection and approval by the building inspector. Owner�,,,,,, ,:,�c Telephone no. :7-7;- 8 q 4 Cj Address of Property z(o 6 Nip,-tq-rj R e PA D Village ,,,tgt-1 S Location and Stove Type WS,m- � SIM (,. aM) S-MV Date: CX:L -zy, )ctrt6 Building Inspector The solid fuel burning stove at the above location passed: tom.......-- failed: inspection. j Assessor's office(1st Floor): /}� /,r7� Assessor's map and lot number 1P "/ / SOS YNe Toy . Board of Health(3rd floor): i w�Q ♦w Sewage Permit number &4,d t BLUSTABLL 'i Engineering Department(3rd floor): // rasa House number �Lo�yp(j` °o 'a3o• Definitive Plan Approved by Planning Board 19 �Fo Yav d APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION 19 X TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location l l L��P La", /1 -/ ,; /"S '/�� Proposed Use r' i Zoning District /-� Fire District 1T 11_10AIA,11 S Name of Owner:;�l� lei. < fi 1`» S /.- e w E Address, w� Name of Builder �� /�r � Address /J/ 7 G /�✓� .�/.� n P P/"j f �K Name of Architect Address Number of Rooms Foundation Exterior Roofing Floors Interior Heating Plumbing Fireplace Approximate Cost Area 4-27 ,&4a `/ i Diagram of Lot and Building with Dimensions Fee r I , I 1 i OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name`s 4 Construction Supervisor's License s BARONE, THOMAS MR. & MRS. A=291-273 _ 71 �- 7 No 33161 Permit For Build Swimming Pool Accessory to Dwelling Location Lot 54, 266 Megan Road Hyannis Owner Thomas Barone Type of Construction Concrete/Vynal Plot Lot Permit Granted August 23 , 19 8 9 Date of Inspection 19 Date Completed 19 c � ? /.....-;.�.,( SEPTIC SYSTEM MUST BE / Assessor's map and lot number/. ............. INSTALLED IN COMPLIANCE ` — WITH ARTICLE II� � STATE Sewage Permit number ... ...........r................................... SANITARY CODE AND TOWN AEGUTATION,% F7MEt 'TOWN OF BA1� NSTA r BARNSTABLE. i 9� D�Y�.e� BUILDING INSPECTOR 1 � .... APPLICATION FOR PERMIT TO r4O'Y'140_�� .. ............. TYPE OF CONSTRUCTION ......Z-�� .................................. ..............: °:.................... ......... ....��.......................197 TO THE INSPECTOR OF BUILDINGS: The undersiigne_cd hereby applies for a permit according to the following information: Location .` � ............ .. .G�/. �........ (-�� !_�.... .......:........:... Y' � r ProposedUse ........ �,.. .' ..: .................................................................................................................. ZoningDistrict ......................................................................._.Fire District ..... :. .. .......................................... Name of Ownerr.U... .....� C'� -... .........Address .1r.j.... ... tr Nameof Builder .......... .......................................................Address ..................................................................................... d/ Nameof Architect ......................../.......................................Address .................................................................................... Numberof Rooms .............6......................I.........................Foundation ......&...r..... .. . ............................... 4��.. �-x-�C ......................Roofing ..............� � -�..................................... Exterior ....... . ... .... ................ . g :��• • Ca• Floors �c� .Interior ..........�............ � h ..................... ............... /.a Rl ....................................... ff`/ Heating ......... ...... ./T..AI/.........................Plumbing ......... :. -- 1......d......../................................ Fireplace ................................................Approximate Cost ........r. °. ..4!..4..b............................. Definitive Plan App rvedbyPlanning Board -------------------_-----------19________. Area ....7 Diagram of Lot and Building with Dimensions Fee '... . SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ......... ....... J. I. J. Realty --~~~%���� / . . i ' | �No S, one—�����.�— Permit for .................................... ' vsingle family dwelling / —`----------~------=------' ^ ` ^" — Road \ ----'— -- '''~-------^--------' Hyanni { ' ........................ ......................................... . 1 } Owner ...........��..��_�x.. . __.. - Type ofConstruction ------- ......... — ` ~ ----.—^--------------------.. ^ ^ ��� � Plot �� x°�� ---------. ---. ----- . . l ]�. ` . Permit Granted --..Sep���tembe����� �9 �---.-lg ^~ ' v -�Date-of Inspection . Dote Completed ��� ' ^ " PERMIT �����B� � ________—_-----------.. lV '------------------~------- �-----.—...---..--------.-----.— . \ ^ ' { —.—.. ---'-----------..—.---.—.. � ' 7 `—._--.�--.---------..--.---.. . , Approv- ................................................. lg ^ ----------------.,---------. . --------------------..--..~.... � . . �, _ - -�� �� ' i •. � , �'} I'M bra}'' ..L•.a,,t- .3 _ _ 5 T.s%-- "��- t; '_ j% ^I 't _ - .:t` =+ - n s t z .' - .° t ' ' .� - .. e:_ m z , Y - _, -. .- - . _ - r - =- �0 _:�F_ - l70 v 'e��' ,'!t i:- an �i V _ - _i � -. - _1% '�+- --.. - 1. _� Y - '_ '' _f- �Al 71�___'�_____�_�_ - tom,-�"h 'z _ d.. � B_� �o 'y_ Y:._ _ �#7. _ � Q d 1­1 i * - �- '- .-r b -t i _ Ir. _ e _ `+ '� �, _ _ J �- �a "'-� '- r:_,yam " -7•f, ` - .,,r '43 0��1., 'k- _- �;,.� __,�� � .i..! _.I E s ? -h- .t - _ i-� ash _ _ _ .sy. S_ 4 - 4 �R i _ �.. _ _ _ - r - - - - - _ � ' �� �. . P ��s WA T , wE!mac 4_ r. �'_ .�.�_.rko wN c - _ - # �. �..� -.. - A i E. ht r , N `tE$ Y CERTIFY Tt .AT :TH 8Ut" Ld , I 6 RAG LANs. U it � YO lbw- N .. flW" iit5 PL. N tS L0:_DATED . () N- - - T dsA0ttN0 AS SHOaNN HIE EON AtVD - �' $ 174E.t CaNF0RM TO THE I f E-M $Y - SAW:S QE._TH.E T0'W �t OE ; �`� � :r x = f r4'RI1F.S Tii 6.E'' WHEN 0'N S T R v C T E O. <.. '� i . '� S A L - S ( RV.sY'`C0NSVL-TANr im k w - _ � _ _ _ — I I. 9. _g T Y A R fA O J.t Ft, Wt A _ -4�` � tY - - - _ m� _ y o . Assessor's office(1st Floor): Assessor's map and lot nu r C>)9/ 3 � of IN It>o ? SEPTIC SYSTEM MUST' Conservation(ath Floor INSTALLED IN COMPLI Board of Health(3rd I ' r (�•. "" Sewage Permit numbe � WITH TITLE s spar'rant Engineering Department(3rd floor):� � ENVIRONMENTAL CODE `630. a�,r►�� House number i/f�c to to G'�- lr TOWN.RECUUTIONS Definitive Plan Approved by Planning Board 19 , APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1 W-2:00 P.M.only TOWN OF BARNSTABLE BUILDING ~, INSPECTOR 1 s APPLICATION FOR PERMIT TO CCt ng-Zq- A G ,Q ��i" j e f C L C t2 Nil F TYPE OF CONSTRUCTION ��I 1 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 1 rI Location %,? i�r G'�4 t�► �c/I �J V�d ✓)✓A► C 1 _ Proposed Use /t ("11!f 2 a c3 w o b 1z ch Zoning District Fire District t`4 Name of Owner %0 W W204V Address' Name of Builder (� �� ` TJI� 1 Address -At 01Cj CAI I I R CA d�k D) Name of Architect Address Number of Rooms ` Foundation r Exterior V E �V C SCI&4- 5 h�ylc ti z:C Roofing A-S Qh 0, Floors bn Interior ba-V W Heating r N A Plumbing Ir1Cl tn1L9 Fireplace iR041VIL Approximate Cost 2'�'500 i4lrrt f 6'�azC Area � �• Y OO Diagram of Lot and Building with Dimensions FeeS� � yS` off `--- - --- r= Xts�%Vj OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name >M62n, Construction Si ipervisor's License y 9 9 aZ 3 BARONE, TOM 266 MEGAN ROA , ;HYANNIS 37045 z No Permit For Location - Owner - Type of Construction - i -%j Plot Lot Permit Granted Sept. 20, 19 ' 94 Date of Irispection: . Frame "t o -/ ?— 19 4 Insulation 10 t2- 2� 19 Fireplace 19, Date Computed 19 , TOWN OF BARNSTABLE BUILDING. PERMIT ` COMMONWEALTH OF S ACIMSJ � =AI�Tf 'T OF L�DUSTR2'A--►ACCIDENTS0. ' 600 WASHINGTON STREET games Ganaoei; BOSTON, MASSACHUSEM 02111 or.:n ssrone: WOBICERS'.COWENSAnON UZURANCEAFFMAVIT . aieensedpermittec) with a principal place of busincssfresidenee do hereby eer*,under the pains and peaslties of perjury, j J I am an employer providing the following workers'compensation coverage for my employees worlciag on job. Insurance Company Policy Number am a sole proprietor and have no one working for me- I am a sole proprietor.gener.0 contrnaor or homeowner(circle one)and have hired the eontrac Tors listed below who have the following workers'compensation insurance policies: Name of Contractor Insurance Company/Poliey Number Name of Contraor Insurance Company/Poliey Number Frame of ContractOr Insumnce Companv/Poliey Number Q l :m: homeowner performing aJl the wort:myself. 1'-'0TF-.PJcasc be aware t::at While boMCo•wacr1 woo empJoy peraoas to eta caiateaanee.construction or tepairwer>;oa d.•Yliint o(not r�orc L^a> L^rcc r r iu is waieo tie bor_co_Mcr also resica or oa Cc Erouacs appurtenant thereto arc not ren<ralh consiccrc2 to be emclovcn v^icr 6<'T--'o&-en'Cor ocsatioO f e:(CL C 152.scc- 1(5)).applieztioe by a bomcowoer for a license or permit m�v e.icecee tie lc=aJ rotor o{aa employer uader the 1�:'orIcrs'Cotzpensation Act. } o�lnsur-ncz for mwr%=c lnc :c scce:c cc�c—se recci:CC L:cc Scene:_ .'u l: _car,iced to t:.c i reposition orc r=L'1-J CC.^.;15::-.t Cl : l:nc C: C�l tG c:cr.G.GG :, C_�O:1. ^rL:o...---t O: C" to C.0 VC:_ ;Cna'6cs in Lc rorr i of L Stop"-7Ork OrOC: fin"Of S 100.00 a day a ::ns:Tic. Sicncc this 9 d;v of SE-y7�cM >` . 19 c1 y 1 nsor,Fcrrri— - T •--vim.. 1 ♦�V• HOME IMPROVEMENT CONTRACTORS REGISTRATION I ' Board of Building Regulations and Standards ! One Ashburton Place - Room 1301 j Boston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 117293 Expiration 09/18/96 i -- f - - -f- -- ^----- "---- Type - INDIVIDUAL i �,. i HOME IMPROVEMENT CONTRACTOR Registration 117293 DENIS J COLBATH Type - INDIVIDUAL DENIS J . COLBATH Expiration 09/18/96 282 OLD MILL RD •• OSTERVILLE MA 02655 DENIS J COLBATH DENIS J. COLBATH G� Q o 0��OLD MILL RD ADMINISTRATOR OSTERVILLE MA 02655 i I COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY 3 c OF ONE ASHBORTON PLACE �aifa/1 e Midirb j' MASSACHUSETTS BOSTON,MA02108 �fA¢RoeAozg4£8"� t eQ1lidi ) ' OodoJ�cuc+� ��rrhreowtloa L I CENSE of tAlr 6"bN EXPIRATION DATE 02/ 10/ 1995 ! CONSTR. SUPERVISOR EFFECTIVE DATE LIC-NO. FOR PROTECTION AGAINST RESTRICTIONS THEFT, PUT RIGHT THUMB 90 1 PRINT IN APPROPRIATE tt� 00 12/3t/1993 049923 8 1 DENIS J COL13ATH 6 ING OP ATO a M S INGL-UD I H SS 11 032—46-2546 28:� OLLD .MILL RE) M ""F 1 PHOTO(BLASTING O RONLY) FEE: OSTERVILLE MA 02655 AR. � �! 19�a 1 00. 00 NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY j HEIGHT: STAMPED-OR-SIGNATURE OF THE COMMISSIONER a DOB: 02/ 10/ 1958 Ir ®,P, , THIS DOCUMENT MUST BEE ` « IN FULL ABOVE SIGN CARRIEDON THE PERSONOF; SEE j I THE.HOLDER WHEN EN-, 15 1 OTHERS-RIGHT THUMB PRINT GAGEDIN THIS OCCUPATION.i, - COMMISSIONER e. Fc t E b Ise 4 n5 �R — � •{.' ..r f `_ III r-_�"Ll-�-1-1 i Tg''c�,no'Nbt i aLf rno5 ,t I I r I I tit L / v�ntt9 I I iT r I I_IJ -I I L! 1rL I II �L� ]_ir rt�i t_II._I ..IrE ,1.i 7i LL. J I T I`a YV - - bb it£e�� �ttl't„�ov�o l r\ 5� vi 3 - - s a 1nq n'2 I1 .1._r�-T71 I' I-I-r- r I_ I ! I I I fit I f . �.� .I ,' (r_ 1 t_.I I l__L,I ! ! t 11 R r r t ! �l l� f 1 I r ' r I T1 ! .!{. t. I-_.' •_ r t�R2 SVt�rn�lf r r -� 1 11 r! i t r l I T I ! I I t i i 1 I- �. �. 8 So I f P rIIt1lll!ff f.li'1T1ITIT1j- --1T7l1-fil_Il-IitiTiii i -IT, l—T -r >% �tzoy�ost:d I i trL ,.._ _ c r r I ,_ , t -•, .� r _i - r T r_, SEE T r-i'i i—(—i i I'T- ?� _ tom- T }—r r_ �\ /• — 1 .. tt II �'I'iT r r'r r )00 I 1 1 1 t 1 ON S,C P L r 011 C) °4w� ems. The Town of Barnstable BAR\SrABi,E. MA8& Department of Health Safety and Environmental Services i63g. �0 Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-775-3344 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME U"ROVEMENT 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. � J_� � e Type of Work:_ Y f foN Est. Cost Address of Work: b� 9g �► �d Owner Name:--1'-6 Q dLft o✓li c� Date of Permit Application: Ce Y I hereby certifv that: Registration is not required for the following reason(s): Work excluded by law Job under S 1,000 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 IMPROVEMMENi' 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 of the owner: ©' rIf Y k Date `�tontracto name Registration No. OR Date Owner's name i DAIS J. 282 Old Hill Road Osterville, Na. 02655 (508)-420-3538 Ma. lic. No.049923 July 20,1994 Tour & Mary Barone 266 Megan Road Hywinis, Ma. 02601 We hereby propose to furnish all the materials and perform all the labor necessary for the completion of; 12 x 16 dining room with cathedral ceilirig,Roof-windows,Eft. sliders on a full foundation. 53 x 8 ft. scrap around porch enclosed for three seasons use. .See plans for 'further details. Al material .is guaranteed to be as specified., and the above work to be performed in accordance with the drawings :and specifications submitted for above .work.. And completed in a substantial: workmanlike manner for the sum of;. $274 4.50.00. With payments to be made as follows: $ 9,150.00.upon..start $ 9,150.00 upon weather tight frame. $ 4,575.00 upon completion of drywall $ `,375.00 Upon completion of job. Respectfully submitted � Y Acceptance of P mal The above pr ees,spec f cations and conditions are satisfactory and are hereby .accepted You are authorized to do the work as specified Payment be made as .outllined above1. Accepted. Signature , :Date 'Signature L O T. .5-3 o tv: s Y:. tow 77 J r. f s C A-_L E' so r s- 7 0 A T_E.. L o T�.f"y A_r .r'wo yv v ,A:T E:. Y THAT T H t �- $.HCSWtN .::. E 8U LDING REG. . LA-ND SU.R:VEYO ON .. TH`tS . PLAN . IS LOCATED ON x' KE' G R,_0UNO : AS .S H 0 W N HEREON AND f!T A Tu r e�00s CONFORm r o . THE ZONIN .� BY - LAWS- OF THE TOWN OF RRR/YSTABGE WHEN C O'NSTRUGTE D. BARNSTABLE SURVEY CONSULTANTS 1N s C. WEST YARmo'tjrH�.,MASS . J�aj F aZ e .33AC. .�ro 99 Zib .43 `os •Zqa� arc Q zoo _ o► 2 a -33AC. _ �5 O �+ rIQ 0 g 61 ly A, N ' 2 .33AC. �9 fro o tc N sv .;3zAc 60 1 '2�►At tp ►Ac 0 .33AC. , U o z "l2 *AC F- 59 8 1'i8 0 $ 3.1 At ,35AC. .39AC. g� fq too 3� 2 j -131 Z� Q` S.KATNG ts� FAAll AC d sl 3ACc - . s INV goo Application number. ..........t........'.................... Fee ..................... ... .............................................. BARiv3TA8t�. Building Inspectors Initials.. ....................... &6 RCS APR 0 3 ZOg� Date Issued..............." 4< � �y. ® nntt � 1 �j t3A" 1`_'kBL� Map/Parcel... ...1. ...... .�.3.................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 2 G (a X004 , 5 NUMBER STREET 11 VILLAGE Owner's Name: Phone Number VV Email Address: Cell Phone Number Project cost$ �,�c�V Check one Residential I/ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authoriz to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ® Siding 0 Windows (no header change)# ® Insulation/Weatherization Q Doors(no header change)# Commercial Doors require an inspector's review ED'koof(not applying more than I layer of shingles) Construction Debris will be going to _ �z CONTRACTOR'S INFORMATION Contractor's name 0,6, Home Improvement Contractors Registration(if applicable)# 3 1 (attach copy) Construction Supervisor's License# (2J!j (�L) (attach copy) Email of Contractor ° J Ghone number G,� 7 7( S j 0 ALL PROPERT►ES TH HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. Town of Barnstable Building Post This Card So;That it is Visible From the Street Approved Plans:Must be Retained on lob and;this Card"MustbeKep; BAJUWABL4 ", i ��° • M Posted Until"'Final Inspection Has Been Made. `` "� `" 'y ''"ied until a"Final Insects n ha`s°been made' Whe e afCert ficat of0 cupancy�s Required,such Bu�ldmg shall Not be Occupy p o i .r._ . a met Permit No. B-19-1082 Applicant Name: CAPE& ISLAND CONSTRUCTION CO INC. Approvals Date Issued: 04/03/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 10/03/2019 Foundation: Location: 266 MEGAN ROAD,HYANNIS Map/Lot: 291-273 Zoning District: RB Sheathing: Owner on Record: BARONE,THOMAS F&MARY A o a x Contractor Name CAPE& ISLAND CONSTRUCTION Framing: 1 Address: 266 MEGAN RD � �CO INC. z - 2 HYANNIS, MA 02601 `d Contractor L cense ,.165936 f Chimney: fst Project Cost: $6,500.00 Description: roofing • ` Permit Fee: $35.00 Insulation: Project Review Req: Roof onlyE :Fee Paid: $35.00 Final: � x Date: 4/3/2019 Plumbing/Gas r Rough Plumbing: ;Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authoraedg"by this permit is commenced within six>rnonths after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application anthe approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by lawsand codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or:"road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. - Electrical i Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are=provided on this permit. Minimum of Five Call Inspections Required for All Construction Work K, a Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: t 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Application number................................................ FeeQa ....................................:......................................... Building Inspectors Initials....................................... 16 DateIssued................................................................. Map/Parcel.............:................................................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET VILLAGE Owner's Name: Phone Number Email Address: Cell Phone Number Project cost$ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK © Siding ED Windows (no header change)# 0 Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review Q Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY.IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each-tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or>Yes No , if yes, a gas permit is required. Natural Gas Yes I No , if yes,a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT'S SIGNATURE ; f Signature ;f Date l All permit licati ns L"O;Lject to a building official's approval prior to issuance. `r �°►�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)5/15/Do1s 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 have ADDITIONAL INSURED provisions or 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 FRANK L HORGAN INSURANCE AGENCY INC NAME cr 44 BARNSTABLE ROAD PHONE I FAX PO BOX 250 E--MAIL AIC No HYANNIS, MA 02601 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation 33600 INSURED INSURER B: CAPE& ISLANDS CONSTRUCTION COMPANY INC PO BOX 210 INSURER C: CENTERVILLE MA 02632 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 41936319 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 ADDLISUBR.TYPE OF INSURANCE INSD WVD POLICY NUMBER MMI POLICY DfYYY1 LTR MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ To CLAIMS-MADE OCCUR PREM SES Ea occu ence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JE CT PRO El PRODUCTS-COMP/OP AGG $ OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-377540-018 5M2018 5/7/2019 �/ SPER TATUTE TH- �RH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N N EL EACH ACCIDENT $100000 OFFICERIMEMBEREXCLUDED7 ❑N /A - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS MA 02601 AUTHORIZED REPRESENTATIVE Jon Smith ! ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 41936319 1 1-377540 1 18-19 WC 1 n0270258 1 5/15/2018.11:32:51 PM (PDT) I Page 1 of 1 i x, Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE�Corporation _Registration Expiration ?65936= _04/08/2020 CAPE&ISLAND CONST UCTIQN,CO INC. -- JOSHUA KOURI r 55 ELM AVE. HYANNIS,MA 02601 Undersecretary Commonwealth of Massachusetts ty� Division of Professional Licensure Board of Building Regulations and Standards Const\p�tf'L�riqS$perviso r j. CS-074660 ,pires 02/12/2021 JOSHUA X KOURf; 90'� iPO BOX 210 i `ti� CENTERVILLE NFA0263 E. �C ��pISS=i3O�S o- Commissioner l!^ r The Commonwealth of Massachusetts ,l 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 Applicant Information Please Print Legibly Name(Business/Organizadon/Individual): C `� L9 Address:_ E 611 Lg�t4 /o City/State/Zip: ` hone#: Are you an employer?Check the appropriate box: Type of project(required): 1.L'y'I am a Y emP to er with 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 g. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.# 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 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.#: I_9�1-'— �i�G —2 —r�r Expiration Date: Job Site Address: H - City/State/Zip: / ` '-1 0 PI/c S 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 �e violato Be advised that a copy of this statement may be forwarded to the Office of Investigations of the for`' ance c verage verification. I do hereby ce fy un th airs a penalties of perjury that the information provided ab ve ' true and correct. Si mature: Date: Phone#: LJ�3 d Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' 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-contractor(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 locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington.Street Boston,MA 42111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 wwvv.mass.gov/dia ti Co _ _. ----_ 'O:r)ef'cad P66x4 _ INrt)►��,035..'' - jPalt198 EgTIONS i . 7—f _ , j i — 1 tell Oil - i'"-►...+.. af---'?""`t---- �..�i�x�a-..-.:� -.`-''�'' :1W�, .. J,.�ts.�-2".R.�t•w."�'.. "}sS-+r.�-' .,. $� - -y- -- - -�-,. - _ - ._ -�- ----. - _._� _ ___.. _ _ _ .. ___ -. h. I 1 _ C S JJI :._.- il 3?�P'f��=1 � =t �NC7� :CIF "G'C7C�1� �t�:�.�._fi�.�+�: �tld�° • (1NC_.._ PSi. cu cap i l , t - tc OF �� j`✓r�J m�s �'�iGndr� P G i