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HomeMy WebLinkAbout0058 ORR'S AVENUE 5g 0<,-s Rve, �_ - � J ,r TOWN OF BARNSTABLE 27775 ' Permit No. ----•-=-------------------------- } Building InspectorSAINSTAS Cash ----------- --- M. rBond . --_----�J - .. "OCCUPANCY PERMIT _------ 4 Issued to ArZImr M. Lepri Address lots 13 & 14 58 Orrs Avenue-, Hyannis � w Wiring Inspector /6 �t Easpection date Plumbing Inspector; , , - Inspection date Gras Inspector i /�/f}- ,t� Inspection date %Engineering Department � ,r ' , f � Inspection date Board of Healthy. ,_ t _, ; Inspection date 11;:7 2 �y y J. THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT 'BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. Building Inspector �n a- ..� '�•, TOWN OF BARNSTABLE BUILDING DEPARTMENT TOWN OFFICE BUILDING y� rua 1639 HYANNIS, MASS..02601 t MEMO TO: Town Clerk FROM: Building Department DATE: . / An Occupancy Permit has been issued for the building authorized by Building Permit #..: Zlz issued to t ./ .. � ? »..».»».... l Please release the performance bond.. ; S�ggqq /L�y-y/.V.•/, f@r .�S/�,'�///A `. 3 gyp.+.Xry�_ _r • �'r 0. Assessors map,`and lot number...... 1......:......?......./............. iSTE UST 8EINSTALLED IN i?NEt I �Q.. Sewage Permit number ..........'........... ......�.w���.�i�...:1•. � r� WITH TITLE 15 GG /!' Z BAHH9TAD E i1.... �.... s. 6 � ;'moo Mb 9 House number ........ ............... L��, ��L U I i pj�p yaY Ar T( N OF, BA1 'NSTABLE ' BUILDING ". INSPECTOR . APPLICATION FOR PERMIT TO .....l. .k!t�-Q ...... ................... .............. ......................• . ............ TYPE OF CONSTRUCTION ^'..r a l.�P.�'t!f.. . .. rtI ............................................. .19........ ,TO THE dNSPECTOR OF BUILDINGS: The undersign hereby applies for a permit�qording to• the follo Ijng information: Location ........ ... . 00, .Proposed Use .. .Qfi....... ................................................................................................ Zoning District ................r ?........ :....... Fire District ............ ........ .. /,,CI7�iF!... . . .L..:..:. Address lam•.. ........:: .. ./.�.'� Name of Owner � _ �J Name of Builder .�.E..✓. C ! .......Address Aao! ... Name of Architect NO.�.... ........ ... -. :ar. .. JG .....Address .. ...:¢G. !.1................. Number of Rooms ..........� ...................................................Foundation ..... e&1*e .G Exterior ....................................... . ..........Roofing 4...5. .fJ'4�......clfl1 ........ Floors �Ape4.. .......... .....: .-............Interior �&..... ........ 000, �j r ......................Plumbin !�t47: ..O Heating /,:: ..CGS. J�!..�r..........:................... g',.;....�............... L/P� _ g0 C9aae. Fireplace �/tC, ... .......... ...................Approximate Cost ......! 7...11.0..°... ............. ..... .. .......... Definitive Plan Approved by Planning Board --------------------------------19---------. Area /............. .............:.. Diagram of Lot.and Building with Dimensions Fee ......... :SUBJECT TO APPROVAL OF BOARD OF HEALTH off. J_ P 4. CV LV OCCUPANCY PERMITS REQUIRED FOR•NEW DWELLINGS .I hereby agree to conform to all the Rules and Regulations of the Town of Barn7g.a.rding' the above construction. Name IdI� . Construction Supervisor's �icnse .................................... P'A, ARTHUR M. t No .....7........ Permitofor ...: ...Story............ ~ Single Famil.. Dwelling......... ...................................... ............. ... Location' ..,,Lots 13 & „14„ 58 Ores ......................yannis..........:......... _ ........ Owner Arthur ..M....Lepr a ; Frame Type of Construction- ................... .. ........ .........`.................... ........ r _ Plot �k .......... ......... . Lot................................... M r Perm ...April 18.E ,:.... :19 85 J o `� 4Date of lnspection-7,,.� ......... ,..19 Date! Complete . . ..............19P3" ti r . i - 00, Assessor's map and lot number,..... ................................ Q f THE t a Sewage Permit number ...................... —3 ...�e� BARNSTIBLE, i �P� OUSe number ........ 4:.......................................... T MA86 039. a TOWN OF BARNSTABLE --- L BUILDING INSPECTOR ' ° APPLICATION FOR PERMIT TO ....... r.............................................................................................. TYPE OF CONSTRUCTION ;✓i� C ......... .. ............................................. ............. ...... ...... ..................................... .......19........ TO THE INSPECTOR OF BUILDINGS: The undersigned, hereby applies for a permit accordingto the following information: Location / * - ............. .................... ...........:.......................... :.: .... .... Proposed Used..r.....�............ Zoning District ................ ..... .......... .Fire District ............... Name of Owner/.,.? aC ............. .. .Address t!....��.......f'`,!.�✓..................... ,r';;�.. �'"r..`�,�.�r1�� Name of Builder, .�.iiY' / f C ?'r / r-'s ......Address ................. /✓'�')�........ �'7/, .........................." t ' ..... ... Name of Architect ,t'Zot>+ a....... '�!!eyt .....Address .......................................................... Number of Rooms .......... ......................................................Foundation .....r�"�P . e. Exterior »--� ).?c ...Roofing ..... s_/,✓`,'/r'T�'....... , ✓<�/ .� "... .:........ , ............................... ✓.................................... ,may Floors ✓ l / ' ( Interior ....�.. /Y e,e e. ....... .................�':..................... .r:............ /............�...................................................... Fieatin Plumbing .......... Fireplacen ./................................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board ________________________________19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH w t . OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 1 hereby agree to conform to all the Rules and Regulations of the Town of Barns bleTregarding the above construction. Name .:......................... �i. Construction Supervisor's License .................................... LFPRIf ARTHUR M. A=291-1 9-200 No 27775. Permit.for .. v...S. 9.Xy : ........... ........... ..........Single...Fami.lY....l?ti?�. 1' ng.......... . Location ...L......ots........7.3�...&..7 4..58...Dz.r.s,..Avej_ ..................HY.aS i1.a 5........................................... . Owner ..... }.li `.M.....Lapri..................... Type of Construction .....Zram,e........................ ................................................................................ Plot ............................ Lot ................................ }•f v ' , Permit Granted A' r11 1 Date of Inspection .:..................................19 Date Completed ......................................19 i r a� } N t i go 10 LOT /- 14 eoN.�3 iN6p V3, s�o $,2,710 SF !UD'MtN.W�OfN g 34GFry L or (LOT / R.) . o �C3 fouNpRrto�► � 32.0 7 6 u/w Ov . N47°oq( oo s f2 R'S AVE, �o' PRrvArF- WA va Of !A CERTIFIED PLOT PLAN � As��cy bT /3+ lq(comswa) OIZR'S AVE,. Q ROBERT of B. H Y)q A/ nr 1 s ELDREDGE IN No. 19357 ,s • r• Q'�Frs��eGrSTE�;���y�m � �� �� � � ;r 4 Lt1 h - SCALE, / yo' DATE# 41 115 S7 EN I CERTIFY THAT THE .t SHOWN ON THIS PLAN 13 LOOMED t�0$TERED REGISTERED " No 850/ ON THE GROUND AS INDICATED M r CIVIL LAND CONFORMS TO THE ZONING { ENO SURVEYOR DR,®Y' : . OF. i9 RNSTABL , MASS. ' T t 2` M A I N STREET CH..DY� H YA N R I S, MASS. SHEET..t;..OF..�,,,. DATE RE®. LAND SURVEYOR w c� Town of Barnstable VOc+ ��aJ� Expires 6 months roM—, Regulatory Services Fee •Mwff"M "'"MPk Thomas F.Geiler,Director sbg9. � FO MA't A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �y /� QNot Valid without Red X-Press Imprint Map/parcel Number - t 1 l 1' Property Address f � i t5> esidenfial Value of Work $ � /Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address-7���f— � 6�O7r�.•� Contractor's Name c. Telephone Number Si / Home Improvement Contractor License#(if applicable) �� Construction Supervisor's License#(if applicable) j�/,� [�Ko/rkman's Compensation Insurance OCT' _ — Check one: 'OWN OF BARNSTAi3LF- ❑ I am a sole proprietor ❑ I am the Homeowner EJ-1 ave Worker's Compensation/Insurance' � t Insurance Company Name 2%:t �M i ry f�t�✓���-, /,�', , Workman's Comp.Policy# —6) Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side A #of doors acement Windows/doors/sliders.U-Value CC.V`'C�maximum.44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: �-G- C:\Users\decollik\AppD4ta\Local\N4icrosoft\Windows\Temporary Internet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 vy The Commonwealth of Massachusetts 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/Organization/Individual): B S N S a W a Address: ��. �o� /b® City/State/Zip: / AV4 Phone#: O K Are youan employer?Check the appropriate box: Type of project(required): 1.2 I am a em to er with 4. ❑ I am a general contractor and I p Y � 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 workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑.Building addition [No workers' comp.insurance comp.insurance? required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.0 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.]f c. 152,§1(4),and we have no employees.[No workers' 13.�ther/�?� e..- G✓i►-a� 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.#: //O✓�9 O Expiration Date: �p 11 � a,�aas Job Site Address:< r� 4yt City/State/Zip: /�ry �1 4 D2dO l 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 under the pains penalties of perjury that the information provided above is true and correct Si afore: -� Date: Phone#• r0)fTkihadse only. Do not write in this area,to be completed by city or town ofciaL own: Permit/License# Authority(circle one): of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector I�.AUG-03-2009 12:09 From:MARK SYLUTA INS 5084209227 To:15087906230 P.1/1 1 DATE LMMIUUIT T f 08/03/2009 1 A&C RD,N CERTIFICATE OF LIABILITY INSURANCE P �i2uceR Serial# 103846 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS. NO RIGHTS UPON THE CERTIFICATE MARK SYLVIA INSURANCE AGENCY HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 771 MAIN STREET ALTER THE COVERAGE AFFORDED-BY THC POLICIES El-OW- OSTERVILLE,MA 0206E TEL:' e08:a284440 FAX: 608.420.0227 INSURERS AFFORDING COVERAGE NAICN INpURFjh • • •• INSURER A FARM FAMI4Y CASUALTY INSURANCE CO DOYLE 8 THOMAS CONSTRUCTION INC- INSURCR B; j PO.BOX'1138 r INSURFR a: CENTERVILLE, MA 02532 INGVRRR D. INJURER C COVERA13Es ]THE POLICIES 0;ONSURANCE LISTED BELOW HAVE'BEEN ISSUED TO THE INGURED NAMED ABOVE FOR THG POLICY PERIOD INDIGATGD.NOTWITHSTANDING .ANY REQUIROMCNT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH.RESPECT TO wMICH THIS CERTIFICATE MAY BE ISSUED OR MAY'PFR-THIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS GUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,A®OREGATC LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS PbI F i T P L Y X TON LIMITS TYpL'OF INSURANCE' POLICY NUMBER CACH OCCURRONCl y 1.000.0 aBN6RAI.I,IADIL'ITY O ji: Tr.n S 50 00( A Ix COMMIrRCIALGaNRRALLIABILITY 2001XO485 O7I21/2009 0721/2010 5,00( CLAIMQI MADE Q OCCUn MED ITXp (Any one ongtonj PRRI]ONAL 6 ADV INJURY 6 C113NCRAL AOORNOATE a 2 OOO OOl 6&L AaakdATO LIMIT APPL.ICS PpR PRODUCTG..coMP309 AGG u 2,000,00( X. PDLIGY ..... AUTOM0131LE.IIADILITV COMBINED 131N0LC LIMIT 6 ANY AL'1T0 I6a oaaidanq ALL OWNI;p AUTOS pODILY INJURY • (For Poroon) JCHEOULCD AUTOO HIROD:AUTOS DODILY INJItRY y IPor onoidonq NPN-OWNED AIJTOG PRROPERTY DAMAGE g - (Por eoe,don0 AUTO ONLY-OA ACCIDENT ....... .... OARAae LIABILITY ANY AUIO OTHER THAN I2AA ACC $ AUTO ONLY AGa S . .. EACH OCCURRENCE t L'XCC66NMBRQLLA LIABILITY OCCUR CLAIMS MADE A.00Rr0ATE 6 4 nQDUCTIp4© �, IrzcrTaNTION g O .1.• VIORKOR's COMPENSATION AND 2001 W6390 07/0112009 07/0112010 c X f� RMPLOYMRS'LIAD141TY kil.FACli ACCII)SNT W 500 OO AV PROPRU_TORIPARTNGRIQXCCU1iV2 r.:L oI(!I Asti.f.:A EMPLOYEE G 500 OO OFFICCR/MEMBI1 R VCI UDGD� ![yy 11 doporltie unded Yes fib DiWAtRO-POLICY LIMIT 500 00 3P(I IA .PROVIEIO i below 'OTHER. w9 DEJOCRIPTION OA OpL'RATION3)LOOATIONON6H1041381GXCLU810N0 ADDI30 BY fiNDaRSGMONTISPOCIAL PROVISIONS ) �i CARPENTRY L._.: �..._ TIE WORKERS:COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR TROY A THOMAS, SHAWN DOYLE...I z _ .CERTIFICATE HOLDER CANCELLATION .......... GHOULD ANY OF THfI ADOVG DpuCRIr3GD POLICIEM Or,CANCELLED 136FORI:TNH EXI°IRATIC DATE THL SUING INHURCR WILT.UNP6AVOR TO MAIL DAYS WRn1'EN TOWN OF SARNSTABL6 NOTICC' CATE HOLDER NAMpD'r0 TIiC'LL!FT,BIJI'FAILURE TO 00 GO SHALL BUII;DING DEPARTMENT ATTN SALLY IMPOr•N OR LIABILI' P ANY IND IIPON TRIG INSURER,ITS AGcN'rG OR HYANNIS, MA 02601 .r FAX-1 508-790-8230 JSD AUT RIz S V O A RD CORPORATION 1808 ACORO 20(200V08) / • qu tsx SPECIALIZING IN ALL FORMS OF ROOFING & SIDING doyle-thomas@comcast.net (508) 328-1635 P.O. BOX 168 Fully Licensed & Insured CENTERVILLE, MA 02632 LIC# 145954 Doyle and Thomas Inc.Proposes to perform the following work: Location of proposed work: Mrs.Jeri Lozada 58 Orr's Ave. Hyannis, MA 02601 -Date on which construction should begin: October 2009 r The homeowner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that cannot be avoided by the contractor shall not be considered as.a violation of this contract. The contractor agrees that when such delays become known to the contractor,the contractor will advise the homeowner as soon as possible. The homeowner hereby acknowledges that in certain remodeling work,the demolition process may reveal defects in the existing structure which must be repaired,creating additional work which may need to be carried out in order to complete the work described in this contract. In such case the homeowner agrees that the duration of the work and the schedule date of completion may differ,and that such variation is not to be considered a violation of this contract. The total cost for labor and materials under this contract: $5,621.02 In the event that the homeowner agrees and authorizes said replacement or restoration,then in addition to the above contract price,the homeowner agrees to compensate the contractor for any repairs or restoration at the hourly rate of$45.00 for a carpenter and$30.00 for a carpenters laborer, plus the cost of materials. -Remove old windows and re-install Harvey tilt wash,double hung replacement"Classic" windows -All windows to be replaced in the home except the bathroom shower window Thank you for Givinq us the Opportunity to Help You Improve Your Home Yy -Install of a Velux 104 skylight non-venting in the stairwell of the home -If homeowner decides they would prefer a venting skylight than there will be an additional charge of$198.15 to the above proposal price. -Remove rotted trim around windows on the exterior of home and install primed red cedar trim boards -10 yard container will be needed on site;and will be removed at completion of the job -Contractor will be responsible for all building permits needed at the property t NOTICE REQUIRED BY LAW With the agreement of the contract 1/2 of estimate total is due. The remainder will be due at completion of the job. Balance of all materials and labor shall be payable in full upon completion of work described in this contract. Payment as agreed upon shall be made when due. Any payments which are delayed shall be subject to a finance charge of 1.5%per month. The contractor warranties the work completed under this contract for a period of one year from the date of completion. During the stated warranty period the contractor shall be responsible for the service of the repair or adjustment, but the contractor shall not be responsible for the normal maintenance, repair due to abuse,misuse,and or normal wear and tear,which shall be the responsibility of the homeowner. All warranties for the materials supplied by the contractor shall be passed directly to the homeowner. The homeowner may be required to register or mail in such warranty card or evidence of ownership in order to activate such warranties. Homeowner failure shall not create any responsibility for the contractor under the warranty provisions;the choice of repair of replacement shall be at the discretion of the contractor. The homeowner acknowledges that the form,content,and notices contained in this contract are intended to comply with the applicable portions of the Mass.General Law Chapter 142A, and regulations promulgated there under. In the event of any instance of non-compliance,only such portion shall be invalid and the remainder of this contract shall be in full force effect. In addition,any such portion not in compliance shall be read and interpreted so as to have its intended meaning to the maximum extent allowed under such law and regulation. Signed as a sealed instrument on this date: Date: 7 Homeowner Contractor J ,1 1111��1111I11 ) £6666 :�1 ZLOZI£Llti :u0llej%dx3 ZE9Z0 dW 3y-ji j�1�31N3O • �, 3Al2i0 WyHONI110N 660 St/W0H1 AOb1 .l k SMN3a :ol paioialsab £1666 is S :asua�ll f3ler�adS aosj.naadnS ua1 0nASU00 asua01-1 cur. cuoiri'Ins,i21 f,u�hl�ng .Ir! ;h.n�pur.�j 1 qv. rlar•••r1'� �W.Ir'� a!Irind.Irl ivauri.rr.daO arzwnu el�i „' �rr�ocz� u�ell� '� Re ulatrof►s and Standards License or registration valid for individul use only Bo rdPof Bur ding g before the expiration date. If found return to: x HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards Registration: 145954 One Ashburton Place Rm 1301 Expirations 3/1512011 Tr# 282668 Boston,Ma.02108 - �- Type: Private Corporation DOYLE+THOMAS CONST INC TROY THOMAS __—.. 499 NOTTINGHAM DR Not valid wit out signature Administrator CENTERVILLE,MA 02632 r ,4. �oFs r Town of Barnstable �erm � OExpires 6 rnonthsf.�enrrssrrtrdate Regulatory Services Fee 1:3 • snaNsTAsr.e, MASS.39. Thomas F.Geiler,Director ArF p�,I A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office:. 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �. Property Address �5 C (aV C-' > A��- �l�gNtu�S [Residential Value of Work 201 97 Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address W2lOA Contractor's Name La O� y-f Telephone Number 50% SOa/ Wo Home Improvement Contractor License#(if applicable)_ (21:61011-5 X.. S . ERMH Construction Supervisor's License#(if applicable) �(' ( (p� OCT •- 2 2009 ❑Workman's Compensation Insurance TO\NN ®F 13ARNSTA13LE Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [ I have Worker's Compensation Insurance Insurance Company Name L\ Workman's Comp. Policy# C)Li C) Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) eRe-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. - 'Note: Property Owner must sign Property Owner Letter of Permission. . A copy of the Home Improvement Contractors License& Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of IndushW Accidents Office of Investigations, 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/ 'on/Individual): Address: ®2blr�4 5E�$ S09 6 Lt-0 City/State/Zip: 4A.4jVtWN Phone.#: Aree u an employer?Check the appropriate box: Type of project(required): . 1.L�J I am a employer with . '1) 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part have hired the sub-contractors 2:0 I am a Sole proprietor or partner-' meted on the attached sheet 7. Q Remodeling ship and have no employees These sub-contractors have g.•[]Demolition world for me in as aci employees and have workers' � Y capacity. 9. []Building addition [No workers..-comp:insurance 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.[ taof repairs insurance required.]t c. 152,§1(4),and we have no employees.(No workers' 13.0 Other comp-insurance required.) *Any applicant that checks box#1 musf also fill out the section below showing their workers'eompeasation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aidavit 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. Ifthe sub-contractors liave arnployees,they must provide their workers'comp.policy number. lam an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site Information. p , � Insurance Company Name• ..t;t�vte'�2--c+1 J `� L— Policy#or Self-ins.Lic.#: {w)C.`Z..��, �J C7 � Expiration Date: 12' Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)- Failure fo secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crir nirial penalties of a fine,up to$1,500.00 and/or one-year imprisonment,as well as civil penaltiti in the form of a-STOP WORK ORDER and a fine of-up to$250.00 a day against the violator. Be advised that a copy-of this statement may be forwarded to the•Office of Investigations of the DIA for insurance coverage verification: I do hereb der the pains-and pen o erjury dhat the information provided above is a and co ect Si11 Z Date: 1O ©`Z Phone# cSiCJ�C V Oft-scial use only. Do not wri a in this area,tb be completed by city or town qfficiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health-2.Building Departiuent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: G. 18974 JI ejQ so� f erl IS .Y ROOFING JTH V ,,IRNXICITIH PWFAX 502' 775 4498 -VA-REGJI 128957 52664 I.XC. 99167 INSURED LOCI:$ bar .- " )' Y.jie.(i tu lea;*6fff Lozac!a cF53' Orrs,Ave. Ilyanr�s Ma P1,0110se CO Ali mater. -as 'PI, mis and labor nc��, sary io .reutove cxIsting and i IdIl a ,).-,f at-dit a,'drcss above. .o Lc ou inovcd to lows transfer. it;te Aloo-,mun-i drill eep-to be installed ort all caves 09n-,I _nab rane tc 1.)e 4)smIled on the first three feet _11. I'laper tc)be installed on re* ainder of roof ssck A . .pip ',fTAVMtI.IjjcbooI toberep edw* 7 LS i&z Ah nerv. e ?,c ins on=0 re-mg.th of d t a, i�lut CO3L of,$21000 U! ri., S ch,A u le, a)w ic ,kr n A c rm vp I et i 0 n- Vy 9 ' cc;p,t e d b Date 200 -P`abt y mid 1,xep on foy�� you r., ,,-c�ords- o,pleasc Sri d TeL One;cop )ropocsJ is .,acid for 4 5 days-fro.t.p &4N- above 1,-'Ir vi ec)A-O_ct ,"',�- '11a,*achat,ctt�.:= Ocp:»'tnic�it iit Pull ` t r#Ltg : Soactl of Butl€iimJ Red-,ul►lion% tncl Stand�:a' , ..�;�rC� iaC SCYk "sty3 T! �r dafty!dtyE s?SE {.icense: CS SL 99167. Re4ricted,ta;.,RF W,3 OLIVER KELLY 9 PEREGRiNE LANE H MA 02664 SOUTH YARMOUT f • �. Expiration;.9(28/2011 (, nmu�.ac�fcr Tim:.99167;•.. '�. i m dgguilaVon-sFdn an ar sBoar o u g One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration ' Registration: 128957 Type: Individual s Expiration: 6/14/2011 Tr#.284841 Oliver Kelly Oliver Kelly 9 Peregrine lane S. Yarmouth, MA 02664 Update Address and return card.Mark reason for change. Address Regewal Employment Lost Card DPS-CA1 0 40M-08/08-DBSLIFORMCA108212008 i Boa 4,fl Ili g guladods anf tan a,-,es License or registration valid for individul use only. HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 128957 One Ashburton Place Rut 1301 Expiration 6/14/2011 Tr# 284841 Boston,Ma.02108 Type Individual Oliver Kelly Oliver Kelly 9 Peregrine lane "- ..•� — -- -- South Yarmouth,MA 02664:"'' Administrator Not valid without signature i Cl •1 ice'► i �l ! e.. yQ .z t � µ i �(. 'i S J•.' �f 1�'.�� ,+��.1R �/•,�t~I /r17 '4•�' �• � � � �.. �i7 �•• �` � �•, �h �p t„ `� � N: /r�'�+ �1 � '� , * L LA 2-10 Pd n EL lea tea 400 7 IU w j� � � � 40k7 CD cr o ze to IN r. ocl it .. w � IE a