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HomeMy WebLinkAbout0064 PITCHER'S WAY " � R4ci,e s (Ua/ � _ _ _ __ \ . - _ 1 �� I 7/zI )a r o Town of Barnstable =Permits to' l ►� Q, FapiTrs6nrorrtlxs raauredate s Regulatory s ��fl�ilV� FeeNAM - _ Richard V.Scali,Interim Director Building Division TOM Perry,CBO,Building Commissioner 200 Main Sweet,Hyannis,MA 02601 JUL 13 2016 t v«'.town.bamstable.ma.us TOWN OF BA q �O�fi�1�aix- �62.0 Office: 50$-$62-4038 muss pnmrr A LPLIc&TTON - RESEDENTL41 ONLY Map/parcel Number Not Valid without R4ed- X-Press bi orinf �.�� 0�0 Z Q© � _ Prop -Address_l y ('2, r_�,PA/c A)A v Yesidential Value'of Work S244" .--Minimum fee of S35.00 for work tinder$6009.00 Owner's Name&Address- L;n � Contractor's Name-n Telephone Number l()O I-2 g-cl ko—o Home Improvement Contractor License_(if applicable) /7 3 7 �4, Email: Construction Supervisor's License E(if applicable) pci �:Zt)-7 [gWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I-am the Homeowner I have Worker's Compensation Insurance Insurance Company NameVol (Da„,, Workman's Comp.PolicyTr �r1lG �8D 4: 3�S2 3 9�l Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(snipping old shingles) All construction debris U-I'll be taken do ❑Re-roof(hurricane nailed)(not stripping Going over- _- existing layers ofroot) ❑ Re-side [Replacement Windows/doord/sliders.U Value . ?j O (maximum 3'-of windows a I of doors: ❑ Smoke/Carbdn Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. "R'hete required- rssuamx of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. --`Note: Propertylp mer ins&sign Property Onmer Letter,of Permission. A copy e#the Home Improvement Contractors License&Construction Supervisors License is required. 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SeG�li9 W 4ie e1eV.1' f115� e�iiis�,�E�tUf�19e'' Ll I�5*a�fi9 ek ' � 1,? �iulum, ry��ot f�- -rlh4 dip e 7 ii I 7__ rato i$ by tL i�:� f.W �lu�oa(p ij�j ilia xi i el f #(c?ci heljh:alJLy4eL6 d�tthe� mwm of chb AWnfo`ic"farad b i.(m! lwd a"a4 pI*wi_p Ap'Mult i I.df�.-I i 6[ oitM 4I iriat.,En id g elie e; r !ee:� l €N u i�el of hgehl drill aafu a6-(Aitio-ilim,WI:Mil we grid )Wo�,f��II�:G�!•�iaiilrtll Q i��ir.e4 awr tl d'IN !6@r ertvi3i5B�. N"011CH TO OWNER, elhh 8i3 0,11e L 51 it"t fei Llwul:to,a,opy of 110�cont ac±!`ruir&IBA(GIii7t oil AksIh° YOU,THE BAR o bvfsY CANCEL THIS. ON ATAINY UJAR Nor;SAT It IFS NUDNIGHITI V [ICHEI R'DIVr` E.I . I'EP.SEE THE ATTIV:C1-ED NOr.r CE OF OwCuLunomromi FORztN LANW-11ON Of TTMS RIGHT. i lg�lttiif,e ioiFs9k5kic++11' I(Ih�l'klia h"bl lh 641i' Pail C61hboy LIM, Kllo (}rams:tMajlii lf'salog Ver5i_im Ptir N'°H C N';iuiib Southern New England inflows doboa Renewal by Andersen of SNE - Massa nusetts-De ar`?e^=of uhiic Saie?r tj i [Boar of_�'^.iiMing RegLi2L s and Standards 1 7 3.E1'kM POND 10 e '•?` _ i CherTe0n BE4 016m t .. A fL so— ` I - i I i _ Lf.L rX7 /r7�.�ltZtls�OP f2 o i%f r id`Q?.�.s!y Office of Consumer Affiks and;3usiness Relation 10 Park Plaza-Suite 5170 - Boston,Massachusetts 02110 Nome improvement Contractor Remsteation y7 Registration: 173245 a Type: suppiemenl Card Egpirafion: 8i19 MS SOUTHERN NEW ENGLAND WfPQDOXk%f$LIL DENNISON BRIAN ------- ---- 26 ALBION RD -- LINCOLN,RI 02865 Update Addren and r=m rid Mart-revon for «, Addrzo _Rmewsl `i Empia rm—1 T-2 I.oA Card - d/.f (fa nrCan,ecsr TRACTOR arr i-a Fc Hminas R¢u!�uoa Licnse or�l Iioa%-5u for iri nd' dal n only dE!?3PROVE ENrCON beforerhee=oirrtian^ lfioondranrnra: - i ,� - af[7o of Coaaarr:.Sairs aad Bnziness Regulation .Registra0on: 173245 7Ype 10a=&.Finm-Snile5170 Eapi"z on:9119=16 'Suppiemert Lard gin,.XA 02116 SOUrrfr.RN N=-A'--NGLAND WRZOUIS LC- P.ENEWALBY ANE35MON DENNISON BRIAN r� I 26 ALBION RD LINCOLN.Rl 02865 tad ererarr tint valid whhhootsc r m . Tad a Coro-man WRa-162 Department of IndusfHaUxidenls arm Massed 0'�`�fi Workers' Compensaldon -a-r once dgvij- Applicaif:1 afo -h- on Please Pam$Lie. Name(Businesslorganiz�on/L--idivi-duall- SOUT;-��Pl\I SDI 111 ENGLAND WINDOWS Address:25 Albion Rd City,8ia�:Lincoln, Rl 02865 PIlQnz :401?28-9800 Are you.an employer? Check the appropriate box: Type fDf project(reed): 20� T_ Q I air a general dontractor and I I-Q I am a employer with _ New construction employees(Bill and/orpaivime� have hired the sub-contractors S Q 2.Q 1 an a sole proprietor or partner- listed on the attached sheet 7_ Q Remodeling ship and brave no employees These sub-contractors have S. Q Demolition working, for me in any aci employees and have workers' Q g addition � � l capacity. 9. Buildin=, [No worlcers'�comp-insurance comp. insurance.- • Electrical repaiis or additions required-] 5_ Q We are a corporation and 10.Q 3.17 1 am a homeowner doing all work or zcers hwie exercised their 11.0 Plumbing repairs or additions myself_ [to workers' comp. right of exemption per, i/iGL 12-Q Roof remirc c irsurance required.] . 152, §1(?),as-td we have no employees_ [No workers- U_l�Other IJtr1c�(7�J S i comp. insurance required_] re (�l a c t-g e,.-t-S Any aoplicant that checks box rrl must also MI out the section below showin E their workers compensation policy information. Homeowners who submit this affidavit indicating they am doing all work and than hire outside contractors mastsubmit a new affidavit k&carmgsacb- =Corrt;=- tors that check this-box mast attached an additional sheet showier the nine"of the sub-con=turs and state whether or not those entities bave employees_ If the sub-contractor have employees,they must provide their %voraers comD.policy number. jam an employer that is providing workers'compensation i1rsicrar_ce for nary employees Beloru is thepolky and yob site informatioM Insurance Company Name:ARGONAUT INS- CO. Policy#or Selma ins.Lic_9:WC 928058352394 Expiration Date:8121/2016 Job site Address: -e &It PL L L� ' �li City/Staie/Zrp: Attach a copy of the workers' compensation policy declaration page(showing the polite mau�rer need e�inta®� Failure to secure coverage as required under Section 25Aef-IGL e. 152 can lead to the imposition of criminal penalties of i fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a foe of up to $250.00 a day against the violator. Be advised that a-copy of this statement may be forwa-ded to the Office of Investigations of the DIA foA insurance coverage verification. I do hereby certify under the arras aIndpenaxeiof pejyurY that the in rmadon provided above is true and correct Si turd. 3##;- Date: Phone# 4012289800 Off kiaL use only. Do not wrke fit.tM area,to be completed by city or toluff offr" City or Town: Permi/lAcense# issuing Authority(circle one): t.Board o'Health L'Building Department 3.City/Town Cleric 4.-Zleet Beal Dspeetor S- 6.Other rnntm t,tr PPrcnn, Phone#: SOUTNEW-01 SHETTYSHT DATE(MMIDD1YYYY) CERTIFICATE OF LIABILITY INSURANCE. 8/19/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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). coNracT Willis Certificate Center PRODUCER NAME: Willis of New Jersey,Inc. PHONE 877)945-7378 FAX MCI-(888)467-2378 c/o 26 Century Blvd AIR No Ext:( Century E-MAIL cer ificates@willis.com P.O.Box 305191 Nashville,TN 37230-5191 =AF1 G COVERAGE NAIC S INSURERA:SeleCompany of RE Southeast 39926 INSURED INSURER B:Onee Company 21970 Southern New England Windows LLC INSURERc:ArgCompany 19801 DB/A Renewal by Andersen INSURER D 26 Albion Road i Lincoln,RI 02865 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EXP LIMITS ILS,RR TYPE OF INSURANCE INS WVD POLICY NUMBER MMIDD MMIDDIYYYY E 000,00 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2029459 0811012015 08/1012016 pREMISES Ea occurrence 100,000CLAIMS-MADE F OCCUR 10,000MED EXP(Any one person)PERSONAL'&ADV INJURY 000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER $ 3,000,000 PRODUCTS-COMP/OPAGG POLICY®JECTT DO LOC $ OTHER COMBINED SINGLE LIMIT S 1,000,000 Ea accident gD LIABILITY 0811012015 08/1012016 BODILY INJURY(Per person) I S A S 2029459 ED SCHEDULED BODILY INJURY(Per accident) S AUTOS PROPERTY DAMAGE $ NON-OWNED Per accidentTOS X AUTOS $ EACH OCCURRENCE $ 5,000,00A LIAR X OCCUR 5,000,000ALIARcLAIMs MADE S 202945908/10l2015 08/1012016 AGGREGATE $RETENTION$ ;WORKERS COMPENSATION X STATUTE ER W AND EMPLOYERS LIABILITY 0000068026 08/21/2015 08121/2016 E L EACH ACCIDENT $ 1,000,00 B ANY PROPRIETORIPARTNERIEXECUTIVE Y� NIA 1,000,000 OFFICERIMEMBER EXCLUDED? EL.DISEASE-EA EMPLO $ (Mandatory In NH) 1,000,00 If yes,describe under' EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C928058352394 08/2112015 0812112016 See Attached Corkers Compensation DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, VTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD L 114E Tpk, Town of Barnstable *Permit# Expires 6 months from issue date sAnrsF ros�rn,retE. Regulatory Services ces Fee 639; 1. Thomas F.Geiler,Director N m Building Division Tom Perry, Building Commissioner ®® 9 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 JUN 1 1 2005 Fax: 5087790-6230 EXPRESS PERMIT APPLICATION - RESIDENTI O BARNS-TABLE Not Valid without Red X-Press Imprint Map/parcel Number �Aqorrt�f)o Property Address '� C �✓` esidential Value of Work Minim fee -f$25.00 for work under$6000.00 Owner's Name&Address �' I �/✓\ cS �� 4 I Contractor's Name (, �/✓' Telephone Number 7 71 lk5� Home Improvement Contractor License#(if applicable) ] Construction Supervisor's License#(if applicable) w, ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ Homeowner ave Worker's Compensation Insurance ��V Insurance Company Name � J Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to � !L G� ❑Re-ro (not stripping. Going over existing layers of roof) e-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. mature Q:Forms:expmtrg J7 Revise063004 f t he c,ommonweatin of lvlussucnuseus Department of Industrial Accidents Office of Investigations > 600 Washington Street t Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual):_ TIM(0\, l� Gl� �A Address: City/State/Zip: m 1A Phone#: Are7am n em to er? heck the-appropriate box: T e of project(required): P YYP P ] 1. a employer with 4. ❑ I am a general contractor and I 6. El 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. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' �1 ]. 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 tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: (� ✓ Policy#or Self-ins.Lie. #: U r 74iragon ate: ` C Job Site Address: "T d �� City/State/Zip: A�11/Q Attach a copy of the workers' compensation policy declaration page(showing the policy numb r 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above ' tru/e nd correct': Si afore: Dater .2 Phone —7-7 ` Official use only. Do not write in this area,to be completed by city.or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Engineering Dept. (3rd floor)`Map „?��7 Parcel Permit# Li House# - Date Issugd 6 �f Board of Health(3rd floor)(8:15 -9:30/1:00-- 3$) p Fee �/ ; IPL Conservation Office(4th floor)(8:30- 9:30/1:00'2:00) ti(e — �� L4 SrF z- nnl Arlmin R1t10� ��®p�� ^� Dafi rd 19 .Q/V� L - ��FD MAC a` ':a TOWN OF-BARNSTABLE �4 9 1 Building-Permit Application Project Street Address Village A11V/S Owner_1dAK :57 .K(A M t e? Address Telephone 15"0 a—7yS-/(9 8 Permit Request .B Q)jib DECK -First Floor square feet Second Floor square feet ,Construction Type \Ajoob = Estimated Project Cost $ •—16Cam© Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family 9-' Two Family ❑ Multi-Family(#units) Age of Existing Structure 46 YtZS Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ErVull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) cg, Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing 'Z •New Half: Existing C_> New C, No.of Bedrooms: Existing 4 New 0 Total Room Count(not including baths): Existing New O First Floor Room Count Heat Type and Fuel: ❑Gas gbil ❑Electric ❑Other Central Air ❑Yes E No Fireplaces: Existing t New ® Existing wood/coal stove ❑Yes UrNo Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) Elfione ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes &No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# 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 SIGNATURE z4 1SrJ,4DATEJ ?� BUILDING PERMIT DENIEDJZ E FOLLOWING REASON(S) 77 �� FOR OFFICIAL USE ONLY PERMIT N-O. DATE ISSUED. MAP/PARCEL NO. ADDRESS -* { VILLAGE OWNER .. .a + ` + � � 1 s , . .S . .. i i } _ i ;�• DATE OF INSPECTION: FOUNDATION= /�'C�U' FRAME � ' , LL -` ,E - � � � - • �: � ,: � ; a INSULATION FIREPLACE - - ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: e3 ROUGH FINAL FINAL'BU;14L4RI9!G*co , D - t DATE CLOSED ASSOCIATION PLAN.NO ell • TOWN OF BARNSTABLE ; BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. . DATE •'3-I 6f JOB LOCATION P/?e/1z_-/ZS 1.4_)A�/ Number Street address Section of town "HOMEOWNER" • 90_. . . Name Home phone Work phone PRESENT MAILING ADDRESS //y/1/V/v1s City/town State Zip cod The current exemption for "homeowners" was extended to include owner-oca-= dwe llinas of six units or less and to allow such homeowners to engage an i dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person (sj who owns a parcel of land on which he/she resides or intends to side, on which there is , or is intended to be, a one or two family dwell4h, attached or detached structures accessory to such use and/or farm struct-"' A person who constructs more than one home in a two-year period shall not I , considered a homeowner. Such "homeowner" shall submit to the Building Off: ' on a form acceptable to the Building Official, that he/she shall be res=onL for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the Building Code and other applicable codes, by-laws, rules and regulations. he undersigned "homeowner" certifies that he/she understands the Town of arnstable Building Department minimum inspection procedures and require-man nd that he/she will comply with said procedures and requirements. OMEOWNER'S SIGNATURE PROVAL OF BUILDING OFFICIAL ote: Three family dwellings 35 , 000 cubic feet, or larger, will be required, 0 comply with State Building Code Section 127. 0 , Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which :.a:==buildi— permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that is Home Owner engages a person (s) for hire to do such work, that such Home Ow, shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuminc the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for . licensing Construction Supervisors, Section 2. 15) . This lack of awaren often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the :nlicensed person as it would with licensed Supervisor. The Home " weer ac= as supervisor is ultimately responsible. d. To ensure that the Home Owner is fully aware of his/her responsibilities, m: :ommunities require, as part of the permit application, that the Home Owner ertify that he/she understands the responsibilities of a supervisor. On tl ast page of this issue is a form currently used by several towns.- You may: are to amend and adopt such a form/certification for use in your communit_:. 1 ' The Town of Barnstable KAS&• uar,srnat� • 9e� �e�' Department of Health Safety and Environmental Services AlF059. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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, 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. Type of Work: Est.Cost 2- Address of Work: 64 R ECHERA' WAY /7 Y14 NIV 1 S- MA Owner's Name M A R K� Q. K L I M M Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. 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 IMPROVEMENT 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: Date Contractor Name Registration No. OR '5-16-1U M&RK -�T_ )iumn Date Owner's Name information and Instructions Massachusetts General Laws chapter 152 section 25 requires all ern plovers to provide workers compensation for the employees. As quoted from the "law'. an einpinree is defined as every person in the service of alithlier under any contract of hire, express or implied. oral or written. _ An emplor'rr is defined as an individual, partnership, association. corporation or other legal entity, or any two or mor the fore�_oin�- en��a�_ed 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 th 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, he or oft the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employe MGL chapter 152 section 25 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 common%iealth 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 been presented to the contracting authority. 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 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 require: to obtain a workers' compensation policy. please call the Department at the number listed below. Citv or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom c tite affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pie be sure to fill in the permit/license number which will.be used as a reference number. The affidavits may be returned 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 questioi please do not hesitate to give us a call. ' ,....y..,._r+._.... ..-.•�.....:..... ..-�...w.r.-r+..,.�.<-...v.r-n-ter....-.......�•.•r�..-*-'...�_.-....+w�rv. _ .. .. ...�.. Tile Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents office of investigations 600 NVashington Street <.•- - Boston,Ma. 02111 - fax#: (617) 727-7749 phone #: (617) 727-4900 eat. 406, 409 or 375 The Continottivealth oj4fassachusetts •ri _. ty� Department of ladustrial Accidents 1 \- office0 Wyestf9wons 600 !f a.vNitt run Street ' = ' 19MV1 nr,Man. (12111 Workers' Compensation Insurance Affidavit �nnlicant information: Plcnse PRINT'Ia@"'""""'-"""' name 1�°lA9I/L 7, A L/M m Location- r'r� / l7-61/15t?S U MY city Alm/V/5(/,/` 1 A nhane 0 V1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity M 1 am an emp lover providing workers' compensation for my emplovees working on this job. cnnraarn•name- - add resr. ' city• nhane#• . insmrance co. polio•# [) I am a sole proprietor. ;eneral contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comn:tnv name- • titlres�- sits phone#• instirnnrr co nolier# emmonnv nnmr: aticlress• rift- phone#• insurance co nolicv# Attach additional sheet if necessary �_ -_ _ --+%^ __ • " ^r-�'•. ^='► ''•" -�� Failure to secure cuvcratee as required under Section:5A of DIGL 153 can lead to the imposition of criminal penalties of a lineup to SI.500.00 andiur une%cars'imprisonment as..yell as civil Penalties in the form of a STOP WORK ORDER and a fine of5100.00 a day against me. I understand that a cope of this statement mac be forwarded to the Once of Investigations of the DIA for coverage verification. 1 do herchr cerrift•antler- re a,is and r Uics of perjun•that the information prorided above is true and correct. Sicnature Date Print name L Phone# 27S -`6 8 / nflicial use only do not write in this area to be completed by tiny or town ofrrcial city or town: permit/license# r'tBuilding Department OLicensing Board Q check if immediate response is required ClSeleetmen's Office F • �1lealth llcpartment contact person phone#: nUther r. r• rn..e;:i •n14� \ tLL / LOT 9 �/ice 24- 8S 14 , 372 f S. F. r age I �o�/ _�..4 9Q 2214 oak TEST HOL E 98x3 Existing I �+ 94x8 Cesspool — p p ' 97x l 97x 4 1+ co f •1 ,+ 2 -97x5 14"ook 4 ' DIST. L , 97xB co N a j _ I of-24�� BOX II' .��.' �'133.44 '' 16"oak ;�. I` '( �•,� —� ----�j , 1 RESERVE C`e 97x3 A RESSERVE ; I 0 1500Ga1 2-----\4 ` J U pole � 141, 6'diam.x 6 deep(1000 Gal.) i - x rASEPTIC (pine 14 LEACHING PIT with — t{ pine 6�diam.x6�deep j TANK 1 ft. of stone all around. (1000 Gal.) 20 l z �7 L EAC HING PIT �20He-'.' with Ift. of stone mi gn. i is n all around. I k "32 ' 97x0 96x9 97x/ 4 97x 4 _� BEN ,H MARK 19, E x i s t i n g Fir s�t, Floor s --- . I Elev. 100.00(Assigned) �.' p 9, / HOUSE 3 o ' 11.3 o �• H 3 0 35.8 97x2 Cr 40 o �p a, o co to v LOT A 14, 2 90 S. F. / a + �V / LU 0.75� - 135.67 \ \ PITCHERS PUBL IC— 40' WIDE WAY ' A V t . J Cv rq to. 17 - Fj �,, 'X Z ,- IC7I i TTI =Ell CID I , - �-- -------- EL- -- 0 6, Oij i -- ------i t t ; i i i iI - ---- _ - �►' yTAMS I I • I I � � f l i i R' —[:jl� if 18' g (COSTS � �+; ---_ ---- -_ -� .. DECKI 2 " x 6 " T/ { SC i A PA ,per ,..� _ 5TAIR ?AOS 4 _.-- ----------- ._.1 _ ---- - -- NAB UWA R�= - z o` __ _........-_.- _.�_ .- --- Nay�s { a E rV p ._.__ } 2�