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HomeMy WebLinkAbout0500 OCEAN STREET (19) ��y awe ��o TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION '(\ ~ / Map Parcel V Applicatio Health Division Date Issued 117 Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address -506 OCC" 57k U V 1 T 3 —7 Village -l'�/F7V 1>J 15 Owner M IC lw YOMM6 —1 tvS Address ug Telephone . Permit Request 0151- l10 OT do 0 OD t� (Y)O 6-ob ItU 577W P Gv tU_Pr-PC-7Z , ?,tl Y Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District gh Flood Plain Groundwater Overlay Project Valuation Construction Type Z11 Y 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 ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)K1 Number of Baths: Full: existing new Half: existing0 ®, ew Number of Bedrooms: existing _new 201 �T�&, Total Room Count (not including baths): existing new First Floor Fm nt Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other moo'], Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal`stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION _ (BUILDER OR HOMEOWNER) Name �4 Telephone Number Address P/NL <,26 l C N4 uE License # C5 — /6 413 F!rtf W cS 1 Home Improvement Contractor# J(vs1/9 Email Worker's Compensation # i�. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WIL B TAKEN T SU 0 SL E O )4A-2^0-,A L1^rnl� �t LL SIGNATURE DATE UL�I �� FOR OFFICIAL USE ONLY � APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i Yachtsman Condominium:Trust Board of Trustees 500 Ocean Street Hyannis,MA 02601 j DATED 7 �� RE: Unite, Yachtsman Condominium Trust, 500 Ocean Street, Hyannis To the Town of Barnstable Building Commissioner, The Board of Trustees for the Yachtsman Condominium Trust voted-and approved the attached proposal to be erformed as is delineated ' the request we received from the Unit Owners. Contractor, contracted by the Unit Owner to perform the work as efined in the proposal. This letter serves as notice of the Board's vote to approve the proposal,which has been noted in the Minutes of the Board Meeting. Signed Under the Pains and Penalties of Perjury this VdayofAaloi , 20 -z7 CT Trustee - oard of .rustees f chts an Condominium Trust 500 Ocean Street(c/o Manager's Office) Hyannis, MA 02601 Enc./File F 27m fsowntompad&qfMffssadmvet& ,.� ��c�fr�erzt c���tskiai�$ccideFrts we-ofhn-wxd9ntiaxrs. 600 WarlraWon met • k4'F(jliZ�11t7ST,�AP�l�ill • Warkers' Campens.afienlusuimice fd�-13.uildeis[Contracf.Gr&finechiciaIIs(Flmmbers ypUcaut lufarmatign • -I`�a�e.(Hasiaess��iga�4ienf�nal� ����� �e�'�l��� . Address: gti/statd J u N C>X93 one 6'0k Are you an e=EpIoyer?check the appr grWe bor: Type of project-(regosed)c L❑ I am a craploye-r with 4_ ❑I ant a general carfrsctar inc€I • empToyees(full andf'oz•gad-fi me). ��* Iravelvredfhe sub-coflr �- El New rnnsiracfiasr 2 I am a sale Fupudtar arparInw- 1is d OIL the attached Sheet 7_ e D&U—ng s and have no I r. Thme sub-c�radaim have � ffip mlrlod have x��cers' 8. �Demolifiog woiiatzg for M—any sty e a Inez ane$ 9. B.uMng adziific'm o wodcerg'camp_am=e comp. repaired-] S. We are a cmporafian.and ifs 10-❑Electrical repairs ar adcRiom In Iam.ahameovm rdoinga3wodc offceas have exercisedthek 1 LEI FlumbingrepairsoradcRfions rr fsm-,£[No WCA-fn•gip_ right of exempSou per MGL lY-❑Roafrepairs jn, a regMaect]i c.152,§IM andwe have no employees.[Nowokcrs' 13-D'other • cow_ins�ace mcluired-� •.4ay aggFr�ttSac cbe�sTioz�1 nm;t also fi7lo�the seciioabrlawshmdag�ea•a+arkea'eomisessaSnupo&tgi�unaago� #Hamevvm�stcha submit das¢ ths=y amed=_-alf wa l and 6leahae aubu&e r,.,,+,• ,.t _tSt cnF.+..ih B nEW S�t�TYlt 1D�Dn Si1CTL rCaaixacinszTzztd�eaihsbmcma 7ftr1T •9a,a;fl Isheetshnnzagthen—ofthesa7i-c ssndstdevrhelhecarnatffinseentitiesl�a� emplv}ees.Ifthesn5-c=kzamsIx7e �rmaviderhesrsro�'t�p.gaitapses lam art ertipxrr ffta�is prmzdirfg fvarkets'coatperlscrliar�ursrcraricaar�c}�earpfvJtees: SeTn�v is�Ics patiry acrd jaFi side irL�armafrnrL Insum c:CcmipanyXI2=: 761ky 4-cr Self--ins-I.ic-*. �piaatiauDafe: Job TifaAddles= Ciig/StafeE p: Atf2ch a copy afthe workers'cvmpensatiaapoUcy decEaration page(showing the policy number and expiration d'ate). Fail=to secure coverage as requiredunder 5ec6osF 25A of MGL m 157 can lead to the imposi i of criminal penalties of a free up $L 4�p(}asdFar one-}�earimpnsonmeut�as we31 as civsl pe^alfi�c is fbe fans of a STOP WORK ORDERand affne of up to$?f&Da a day agpind the violafnr_ Pe.advised ffid a cagy of this sWement maybe forwarded to the Office of Investigations of the DIA for insu=-e cavemp vedfica#ialL Jri`rr Fietw y c&vjy rurdgr tits pe!lUizy gerdW7 tJraMa inform.a€iauprm drd abmrg is bus and carrect Siz Date phMe lk d7, ial use t a£�. Ina ncrt Crete in tFas=eaa fa be ar1r rFeted by car artotr-ri mat City or Toga: ,iceFxse;9 Is313ing Auffim-ity(lade one): L Board of$caI BTamg Department 3.#aj-irown Clerk 4 nectried IuipwAur 5.Ptumbmg Insge� $ 6.Other Con act Person: Phone#: information and lxs ct,01s all may=m P � �' e on for f EUNr 7"��cc�r-3„ice#ts G nezalLa s I�Z � esQnin$re sesvi.ce of � ny e2 a cmtcac t ofhrre, g -Ibis sue, Inye�is defined as=�veaYP dress or finplisd,oral or vritmf _ arcp�iafioa,ccaporafion ar other IegaI enemy, aaY flvn aI mare An Moyer is defined as an m parfne Iegal represerlFajiv�s of a deceased=pIoYet,or the andinc7nHg ees. Howev of&b:forego a3ai association or o$iexIegal e�itY,e�plaY MIOY esElie recoiYear or frastee of an indrvidnal,p or the occt offhe- o�enea of a.d�]�g 7mSe�g lot M=f m t�apa dmm s aadwho resrdes ffi=�A e dFaU�nghouse of ands vrho errrpIaps p=S=to do cc,consdxv cn.orlepaicwo&onsuch dtveI1mg or on file grounds or b�mg fiiw:b shan=tbeca=of sock�Ioy==t be d==cdin bean emploYer. sf a nr local spy agmcY shall wiffihold•Bie issaance EX 7�GL GT�aptPr I�Z,§2$C(�also stains that"everp the carsmun ealfdi for any renewal cf a)cerzse or permitfo opesafe a T��smess or to mr�sii ark bmZd� „ apPIic=-6WTio has aofpr-odu4 aacepfable e4idence of contpP��wlfh i ce coverage avlsion t 152,§25CM sales ffeith=fbe c 3hh ntsr jY ofifs po t subd'ivi lions sha11 AddionsIly.Md h mtj table eviden ce of complia =Wn th a iDs�anre.. entez mtD any coatma f tb.D p �olio Wo� acceP meets of this chapt=have been•prescxt�d tD fie canft cffi29 anfboutY:'_ App�caafs - . b ch=Tda9 ih.e boxes mat apply to Yo or.sitakion•a if Plzase fill.o� the wo>l='ccomapmsatcon affidavit comple#�Iy, Y s)name(s).addresses)�dpbonen�bber(s)alangvPitTiijieir ce��-(S)of n Y.supplys, )ono �pDYees I D&Cr than.th-e insnx'�ce. Lirni€�d Liability Companies(LLC)or I inrii�-��Y'Parfn�slshiF (IMP . are not fa caay�oxh�s'cau�=Saf=fi2sm nm If an L LC or LLT does hate McQ). s or pmta be snbmi dfn fiieDepa-tnent of In IIsfaal =pToyees,a policy is req - B e advised that furs a$daYrt may h affidayit should Accidenfs mr common ofia uraace covemgm AIsa be sure to siga.and da[Eam a-daYn be reformed to fiie edY or fnvvn that tha application for tiie pew or license is being not•fiie DcparMenf of ' the law or$ u are r to obtaim a vtozlks' LT steal Asci �+� S ouldyou have anY q�� g Yo awes sh onld ems` r t3ieir compensaiianpoHcnPleasecaUthdDepartmeutatibe�berlisfadbeIo Leif-msvred�P . self-fiLsm- zmber onfhe�PrI - Cby ar Town Officials f - Iefa and IegRb y. The Dcpartmenthas Provided a space of 1bc botirnn Please be sore f at f m a�davif is Pam• has to cant tYon g am applicant of the a$davitfor Youfo fill out iathe event the Office ofI addition, av Pimscbo mn-cin flLiaflicpma hI c;easemmnber7hichvn�Ibc scdas arefeseace�bQ Tn' �an P�cif Ie tense applieafrons at any given Ycaz',n�only wit�c affidavit i' . that mIIst submii m P a ( Y or p olicy mfomatioxr (If ncr�s°mY)and ndra`Tob �t� ss f'-e applica+ rhoTsd aII Ion provided to flit " '•A co ofthe•affidavitfl athas bey.officiBnY stamped c�madCedbYtlie nt: ort�nmay P town)_ PY P be filled oi±earh appIir�t as groat that a valid affidavit is on fle far fire. e�ity or ficrnses_ A neFY a�s or COMMM1 v� year.Where a.home owner or citi=is obtaiag aIia®se orpeam>tnoflelafEdfn any ' permit to boor Ieaves eft. said ers®.is MOT��to co�Iet O— affidavit (ic.a dog li.cMISe or ,) P TlieOf =oflu woIIIdl�cin fhankponm-a&Mcm f�Yovr cooperafian and sboBldyoubav� please do not hesBMf m to gi7c us a call Ibe pep�I�czlfs addte5s,telephone and faxMnbc:- ` of Dej afaAd . s dill Fax9 7 � R Tised4-24-Q7. maser ��c THE Town of Barnstable Regulatory Services KAMRichard V.Scab,Director 1659.Efl5+� Building Division. Paul Roma,Building Commissioner 200 Main street,Hyannis,MA 02601 www.town.barnstable.maxs Office: 508-862403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �1�.�.(�s"z.. �Z�i ,as Owner of the subject property hereby authorize �✓'�—UG� �` '1Z-='t� to act on my behalf, in all matters relative to work authorized by this building pert it application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. ignature tf Owner Signature of Applicant ` Print Name Print Name Date I Q:FOR Z:0VR4=ERMIs3I0NP0oLs ----�-"' �/10, r�ll/-u ulatiou `� office of Consumer Affairs&Bus`CTOR _ 1OME IMPROVEMENT CONTRA Type:. t rEegistration 165119 Individual xp►rat'on 1(112018 yTcVEN HETZEL STEVEN HETZEL r_ T2_pINE CONE DR• dersecretarr r Sjv.YARMOUTH,MA 02673 ' Massachusetts Department of public Safety Board of Building Regulations and Standards License: CS-104384 Construction Supervisor STEVEN L HETZEL �72 PINE CONE DRIVE WEST YARMOUTH MA 02'673 - Expiration: Commissioner 07/27/2017 m TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 2L/ Parcel b Ll d 00 TO!,N PST BLE 'Application # Health Division r j „A r # Date Issued l u-7h(p I: 5�3 3 P � Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board " r x' Historic - OKH _ Preservation/ Hyannis Project Street Address 666 J( 3 �/ Village Owner )MIICC't- Ind( ym'IN�A'Z?�3 Address AS6 Telephone_ Permit Request L C—+Kr►U G SIGH/CAS-�f-' — SArYI6 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation '07), r)� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ 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 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 wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name /mil zgG. Telephone Number Address -7 Z ?//i /tj if g, License # T Y/A !i!/R&-714- M dL 6 Z6 7.3 Home Improvement Contractor# Email 'a f l►?A?Z_�, <fz"' Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE /,� d FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE } ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ' ASSOCIATION PLAN NO. $ Town of Barnstable Regulatory Services t BARNUMM f _ MASS. Richard V.Scan,Director qua►� Building Division. Panl Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.ns Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I. \/4014A21"Z6 ,as Owner of the subject property hereby authorize �<� Z � to act on ray bebA in all matters relative to work authorized by this building permit application for. (Address of ob) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are perfomaed.and accepted. a Signature of er tore of Applicant I 1 Ifs YQ M 4-1-7=s �Tu� Print Name Print Name Date Q:FORMS:OWNERPE &SSIONPOOLS h Town of Barnstable Regulatory Services oIFTME Richard V.Scali,Director Building Division t t Paul Roma,Building Commissioner MASS e39. ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities, many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doe 06/20/16 j i i Licens&.or registration,valid for individul use only before the expiration date. If found return to 01'fce of Consumer Affairs and Business Regulation .10 Park Plaza-Suite 5170 Boston,MA.02116 165rl /-/ter Not valid without signature ='f Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-104384 Construction Supervisor " STEVEN L HETZEL f r 72 PINE CONE DRIVE �, WEST YARMOUTH MA!tl2 73 i.4. •3Si41�` �„M CA-- 'Expiration: Com missioner 07/27/2617 7 777- 7-7 LICENSE 4d NUMBER ,11 ,,A $ .a- `_ •1 "�) `NONE�r�O�6�Z3�� �7 ,Y:L e1 ti< a 72 PINE�E�dE � � // �W YARMOUTH MA 026735422� �� c J s� Yachtsman Condominium Trust Board of Trustees 500 Ocean Street Hyannis,MA 02601 DATE RE: Unit ,Yachtsman Condominium Trust, 500 Ocean Street, Hyannis To the Town of Barnstable Building Commissioner, The Board of Trustees for the Yachtsman Condominium Trust voted and approved the attached proposal to be perfo e a is delineated in the request we received from the Unit Owners. Contractor been contracted by the Unit Owner to perform the work as efi n the proposal. This letter serves as notice of the Board's vote to approve the proposal, which has been noted in the Minutes of the Board Meeting. Signed Under the Pains and Penalties of Perjury this day of _, 20 l6. d Secret r Board f Trustees tsman Condominium Trust 500 Ocean Street(c/o Manager's Office) Hyannis, MA 02601 Enc./File f The GtrrtsDttaM€EUM qfMassachmseft Depwhawt of I strid Accidea tv ke Of I1 IOW 600 Wrr *k#on Street Bastaar,,MA 02 wn�w.rr�uss:gvs�dia Workers' CompensatianIusurance Affidavit Builders/C-Gn1z-a:ctorsf iciansMumhers PPfca>at Infarmat on Please Prof Legibly Name au/Individnai): //}- zuf'l. N - S iGwq P10 VE CMG yG-! c tyfstat&I — 4A'y#-tL 1061.t,y- Mk aw,73 Phone 4- 54'C-,-25 9-c' Z 5z Are you 2m employer?Check t e apprapr&fe bo= Tn3.e of ect •r 4. I tIIn� _ cogaixactoar and Z l�3 � ��= L❑ I am a employer with ❑ 1 6- ❑New nr nStUCfiD* employees{full arWorpmt-ime-* have hired the 249I am a sole proprietor orpartner- listed on the attached sheet y- ❑Rr=d h g ship and have no employees These sub-contractors have g_ ❑Demolifioat woricing for me is any capacity empiGyees and have workers' 9_ ❑Building addition [No Workers.' coalp:ins rrmce comp_iMSM xr I 5-❑ We are a c�orafimand its 10-0 Electrical repairs ar additions. 1 officers balm exemsed diem 1 Plumbic airs or additions 3_❑ I am a home-owner doing all woik 1-❑ g�' , myseM [No W063 rs'Doing. toght-of e�emgfion per IYFEzI. 11❑Roof c-15Z §1(4),and we hn a no repairsin�xnnre sequusd rN Q' S9 employees comp_]11St1Ia IeCIIFIIed. 4,, r/v<J� ;lay that cheers boa f1=st also fM Dirt the section below shrw*g @�wa�c��one gaiicg .�Hnmeown�who submit this aiiidsvif inigcsting they am dcong ag wwk snot&en hire Rmride rontractncs psi scaIxisit a sf dsrit m�cst soli Fg K.00IIBctnm that check this b=mazmt x=rhEd sa xMiti— sb Ahederocnatthusz STiMW mnpk rfees Ifthe sib-contiac[ors hire exopIbyees,they>zmst pxomde ter warps'comp policy number .[am art employer€hatispt stiib�W rt�orkam'congummz an an=rartce f or My.enTpLqyem Helots is fhepa8cy artd,}ob site irtfnrmaTttan_ Insurance CoffiganyNams: Policy if or Self-ins-Uc-4`- Expiration Date: Joh Sirm Address: Citj ISt W2r p: Attach a ropy of the ssorkers'compensation policy declaration page(sung the policy number anal expiration date). Failure to secure coverage as reg6reduuder Section 25A o€MGL c. 152 can lead to the imposition of criminal pem lties of a fine up to S 1,500_©a and/or oar-year in3prisoument as vm2 as civil pemdties in the fowl of a STOP WORK ORDER and a fine. ofup to$250-00 a.day against the violator_ Be advised f f a copy of this stdanmt maybe forwarded to the Office of Investigations of the DIA fior men-ar,re coverage vrerificalion_ Fdd hereby ender tka ' s an p es of'gerfury€Itstff�e arrfDnrurtiarnpravrdW above' bb7ze d corm tune: Ss>nta PhD=9- 2S0g-Z-g q-5 2 5, Off Zcial use onT . Do-not write in this area,to ba campi`eted by c4 or mien of fical Cite'or Town: Peratiff keuse If ISsu.IIIg Authority(drde fine). L Board of HeAth 2.lJ•mTfng Department I'CitFfraw t Clem 4_Electrical Inspector S.Plumbing inspmtor 6.Other Contact Person: Phone#_ I� 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an wTloyee 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 Iegal representatives of a deceased employer;or the receiver or truster of an individual,partnership,association or other legal entity,employing employees. 1:Iowever 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 stars that"every state or Iocal 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 compaaice with the in�ce requirements of this chapter have been presented to the contracting authority.- Applicants Applicants Please fill our the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certficatc{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 ins rr-a„ce- If an LLC or LIT does have employees, a policy is required_ Be advised that this affidavit may be submitted to the Depar-anent of Industrial Accidents for confirmation of insurance Coverage. Also be sure to sign and date the affidavit. 'lfie 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 rr self-ins ance license number on the appropriate line. City or Town Officials Please be,sure that the affidavit is complete and primed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address'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 Elled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NTOT required to complete this affidav-_t The Office of Investigations would ae to thank you i a 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. fie CommanwWffi of M ssachus,�,tls DepaitmL-nt of IndusttEial Aockdents Office oz IrLve.igatjom GQ0 Washington Stz�t Dastoa,MA 02111 Tel.A 6I 7 727--4 W 406 or I 477-MASSAFE Revised 4-24-07 Fain 9 6I7 727-7-749 www.mass-govIdia