HomeMy WebLinkAboutBLD-93-646 ,,-�� YAC ,' 4a� 8�t�iQ3
0 TOWN OF YARMOUTH aKE gb-7/a2
0 ' A—H'
'x,,"4..::.,+5,$, r Application for a Permit to Build No.
T
UPON FINAL APPROVAL i gc '4° MAP_- 19 LOT _ 4y
---- - --- - --------
FEE MUST ACCOMPANY THIS APPLICATION. DATE Au4utTAD 1993 i
The undersigned hereby applies for a permit to build W /%3
according to the following specifications 0 P-519-3
1. Name of property owner ewJARa 'X Al-io Bernd A. GI-KA-net Tel. 394-0111
Address CE 1 E1-E BEA04 WV/ , S"-iRiwlown MR 0z wog,
2.Name of Architect(if any)/_SARA PORTER Tel. 31.2.-‘40
a Name of builder RoEMDc 1'AD
e-le6ETf BLDPS 7 ,- P. ow, iia
Address i 6i Scwo_ sT. COTuiT,MA O2b35
4. License No. 443859 Tel. (50e)i2-6-0001
5. Name of Mason I-V A Address NA-
6. License No. 424,51 1--1A Tel. OM I
7. Construction address SZ ThBgL.e -RICH W41 S. `I1\RMOu1M 1 MIA .
Flood
— District R y0
8. Date of subdivision Approval' s plain zone Zone
9. Private dwelling Igl Estimated Cost .4.,,f DO NOT WR9 E IN THIS SPACE
10. Multi family 0 14-01 OTO " g-i3-' r,, ,00 f l?u Type of room No.
11. Commercial 0 De. ..•4;1..14:47;
r¢:i� /W441 T
Kitchen
12. Other 59tr3.NiJserra TS,rorrx2eP"r*w.✓ iat. 5j fr n4/ SY
Dining Rm.
13. No. of stories I t 4L `pit-iyj/e' beeg / ,rzie,�in.e/ S!' Living Rm.
14. Foundation — Full 0 Half El Crawl 0 Slab 0 7 / v 5!^ Bed Rm.
,y5` Bath
15. Materials — Wood CO Cement 0 Other 0 ) Deck /4/xiG I(
16. Type of heat — Oil 0 Gas1121 Electric 0 Other 0 3itex 3S•� Closed porch
17. Garage — 1 ❑ 2 ❑ Pi/It r f7'O15 Family Rm.
18. Swimming pool - Side PM ° 'O9 all,Sun room- , /
T-773 7'0-6892- Garage
19. Storage shed — Size ,s/A Shed
'
20. Stove . . Wood 0 Coal 0 rT/A , ' . ' Alterations
21. Size of lot: No. of feet front l08. 68l No. of feet rear 100,5 - No. of feet deep x-5.31-
22. Size of building. No. of feet front Syi No. of feet side slog No. of feet rear 54
/23. Distance from nearest building: Front Ft. side Ft. side Rear
24. Distance back from line or street 32' Film ear to line 12- Side line Z.0 + 23�
/25. H.I.C.R. No. /00131 1/ /,
LOT RELEASED BY Signature f • ,' / • Air"
PLANNING BOARD Address
/20 .&0 133
Date COMA/71 Mil 02(. 35
APPLICANT: EDWARD 3: M413 BE-Trt A. CildlhtlA BUILDING PERMIT II:
Sz Pe BALE BEACH Wily .
ADDRESS: , `Z/} ax-n-i MA. TELE. NO. : NBC) 39tf-0111 DATE FILED: 06)13
BLDG. SITE LOCATION: y
�1YME As A$V6 MAO: 71 LOU:LO
THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED -TO OBTAIN A-PERMIT TO BUILD,
ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER-
MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD
PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH
THE FOLLOWING DEPARTMENTS:
RESIDENTIAL AND/OR CO MERCIAL BUILDING
•
WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY. .
ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE. ,
CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E. : IF LOT(S) BORDER ANY
JAPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH
LAND, ETC.
HEALTH DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E. : REQUIRE-
MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES.
FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL
SAFETY, PROPERTY PROTECTION, I.E. , SMOKE DETECTORS, SPRINKLER SYSTEMS
ETC.
TILE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR
ISSUING THE REQUIRED BUILDING PERMIT:
REVIEWED BY: 7
I. WATER DEPARTMENT ',•�)(,, ;^ 4 Rr�t� DATE: S^ I� (1) -5 N/A:
2. ENGINEERING DEPARTMENT: DATE: N/A:
3. CONSERVATION: ^ DATE: N/A:
4. HEALTH DEPARTMENT (/J4�,-` Q DATE: g//le/e N/A:
I USTRIAL AND/OR COMMERCIAL PERMITS
S. WIRING INSPECTOR: DATE: N/A:
G. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A:
PLEASE NOTE
ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE
DISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING
PERMIT.O. _,
COMMENTS: IA);P;7 r;!- - ''9 V... -C---5 Z'_. `� --.a� si-A t q 77ti f IUB. DI CA OP gC/(/Se i
w 4)-124)-12-‘‘?cS-7,7r c. im.. Ac�4
sT 0-t , cC4el— Perk44 "Y3- 30a 4 SSW
3L Dc--$'/45c a s?int G- Fo u Nan/on (NF4-W IJU crt3e /iii#. 4 'ArtasTtO✓1-i
/y/r th Po✓/}Derir v S.Ks-&cris- (-Stet 11-�b cs/fl sK�nfl9
h l . /
I' ✓ec
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BLM/89 , I �-�/'0s 4-4
k '
ALTERNATE COMPLIANCE SECTION.2009.3
•
•
THIS STATED Uo (or U) VALUES OF ANY ONE ASSEMBLY, SUCH AS ROOFJCEILINC, WALL, OR
•
FLOOR, MAY BE INCREASED AND TIIE Uo (or U) VALUE FOR OTHER COMPONENTS DECREASED,
PROVIDED THAT TIIE OVERALL HEAT GAIN OR LOSS FOR THE ENTIRE BUILDING ENVELOPE
DOES NOT EXCEED TIIE TOTAL RESULTING FROM CONFORMANCE TO TIIE STATED Uo (or U) •
VALUES.
ENVELOPE ALLOWABLE Uo (PER TABLE 2009.1)
(Aw '0.031 + (Ac '0.651 + (Aoo 0,40) + (AoR 0.033) + (AoF 0.0 (Arm,(AowF 0.0S) . Ataow..a.c
9.0 Cr 93. 6 Z.c. %coy ?.o,gr
(S?6 :02:6)4.(I'!4' x0.44+( So x0.40)+�zS6. C .05�+�3•S� +cO•D3�
•
r Au.ownsti Pan TABU 2009.1 . .
•ELECIRIC RESISTANCE HEAT U-VALUE WALLS = 0.05, U-VALUE WINDOWS = 0.40
. .
• I
ENVELOPE ACTUAL. Uo (USING' ACTUAL VALUES OF DESIGN OF ENVELOPE)
(Aw Uw) + (Ac tic) + (Aop Uool + (AoR UoR) 1 (Ao• UoF) 1 (Aow= Uoww1 _
36. 82 4.176 T��•. ry
lG, 90
(pee .07)J1''(x.0,29 4 ct xa,y)4:0_2!.03At( )( '\+ / ex , a _
IJ l
•
62. 'IACTUAL
COMPARE VALUES
THE •- VALUES FOR ENVELOPE ACTUAL MUST BE LESS THAN OR EOUAL. TO . VALUE
OF ENVELOPE ALLOWABLE TO PASS. n
I t ASS f I FAIL
•
pre/
I •
n
CEILING ASSEMBLY
HIS' ceiling SlizzedceilingrequiresFZIIAL TOTAL R=1/.47
eaVe ati c' 7111= •TOP SURFACE u= 40.03:1- WINDOWS:
• ' • R=0.61 F ETIRED I7TAL R= 30.0
9" FIBERGLASS 1. 0.033
/INSULATION
//_f1.
I Il/1IU)11hln nA n -
a \ \=SHEETROCR DOORS:
Wo R= 0.45
-BOTTOM SURFACE
R= 0.61 •
1/2"'PLYWOOD INSIDE SURFACE WALL ASSEMBLY
R= '0.62 X GJ R= 0.68 FGILTLTOTAL R= 13'78 G.W.A. W
REAR ELEVATION
WOOD I �� D= Oi 07 �`J 8a/
SHINGLES Th..-- 1
SBEETROCR
R= 0.45 RETIREDIOML )Z 12.5
R= 0.87J'r-31"
U 0.08 WINDOWS:
OUTSIDE FIBERGLASS /L
INSULATION
1 J= 20.0
SURFACE ' R=11 ELECIFZIC HEAT' LU 0.C6
R= 0.17 I •
•
U FACE RESISTANCE '
=SURFACE R=
J�� i 0.61 FLOOR ASSEMBLY
62 Com, =FINISH FLOOR ACILL TOTAL R= DOORS:
TWO BEADS VI R= 0.91 U=
C� f�T ff3D ICL I� 20.0
CAULKING / I 1" PLYWOOD U 0.05 RIGHT SIDE ELEVATI
vli
UNDER PLATE / 1C i SUBFLOOR
R= /�
OUTBID 0.62 G.W.A. O
SURFACE i` i -' V L' JU1 ,j O /t/u4',t'uU
R= 0.17 - I r WINDOWS:
//11//:}"
/-6}" FIBERGLASS /0
• /'' k • INSULATION FOUNDATION
ONCRETE • ' ; i R= 19 WALL ASSEMBLY
OUNDATION (may be used instead DOORS:
ALL SURFACE RESISTANCE
1.32 = 8" • , ' R= 0.61 of floor insulation) 3
�CI[PL TOidI. R= 0"'
LEFT SIDE ELEVATIO.
1.48 = 10 U= 0,oG6
i i R 1 .5G.N.A. V
-.INSIDE SURFACE 1. 7.08
f= 0.68
T/8" SHTROCR WINDOWS:
i 7' 1= 0.32 J0
• 0 "
• '• �c STYROFOAM
7.1 - /4/k DOORS:
` ' I / 7
1 1 t / . • , 1 : 1 - n , . ..
70TEE:
PEL9ANEyTL'i INSTAL_ED STC
W1:l3w. TO ::E USEL
cfL_, WALL AREA= c�a/ �b( SSG
W::z:: ARE 14 DI ,
. :,:::_,_ ' - 1 9 ,E
THE COMMONWEALTH OF MASSACHUSETTSA
i BOARD OF HEALTH D
C7� TOWN of YARMOUTH
No. r. .:. ) Ft _.._..
101npnnul �,huk (in�tntrurtinn Permit
Permission is hereby granted ..., .
to Construct ( ) or Re 'r ( an Individual Sewa Disposal system
. ........
str C ..
2 .
as shown on the appli tion r Disposal Works Cr ........a ,,,;�,ted .. ...___
p
C� �2' �� a` o<oiin
DATE._
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— Lc,cn �1"'"I`rig Yd, z S
---#19 b •''l i4 r of 3
' L. TOWN OF YARMOUTH .
BUILDING DEPARTMENT •
. • - _ .,CONSTRUCTION SUPERVISOR FORM -
PLEASE PRINT: . .
JOB LOCATION: Se. . ?EBOLE TJEACFI WA'i `S. �IA"RMt' u M
• NUMBER • ' STREET VILLAGE
OWNER OF PROPERTY: ' IEDVAIM LT. A-ND d]E-TN A• GHIAIIEA '
CONSTRUCTION SUPERVISOR: • 11ObERT R . PAp� E-rr • . 48059 Cloth tfz8-000 1
NAME LICENSE NO. PHONE •NO. .
•
ADDRESS: 1,0 ...I ( 135 (8t} A(.146% ST Antrim - MA n24035 • - •
LICENSED DESIGNEE: ' }1IA-
(IF OTHER•THAN SUPERVISOR) NAME LICENSE NO. • . . .
2.15 RESPONSIBILITY OF EACH LICENSE HOLDER . ..
2.15.1 THE LICENSE HOLDER SHALL. BE FULLY AND COMPLETELY RESPONSIBLE FOR ALL WORK FOR WHICH HE
IS SUPERVISING. .HE SHALL BE RESPONSIBLE FOR SEEING THAT ALL WORK IS DONE PURSUANT TO THE STATE
BUILDING CODE AND THE DRAWINGS AS APPROVED BY THE BUILDING OFFICIAL . . .
2.15.2 THE LICENSE HOLDER SHALL BE RESPONSIBLE TO SUPERVISE THE CONSTRUCTION, RECONSTRUCTION,
ALTERATION, REPAIR, REMOVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING
AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE
COPLMONWEALTH,. EVEN THOUGH HE, THE LICENSE HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB-
CONTRACTOR OR CONTRACTOR TO THE PERMIT HOLDER.
2.15.3 THE LICENSE HOLDER SHALL IMMEDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE
DISCOVERY OF ANY VIOLATIONS WHICH ARE COVERED BY THE BUILDING PERMIT.
2.15.4 ANY LICENSEE WHO SHALL WILLFULLY VIOLATE SUBSECTIONS 2.15.1, 2.15.2 OR 2.15.3 OR ANY
OTHER SECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, AS AMENDED, SHALL BE SUBJECT
TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. .
2.16. ALL BUILDING PERMIT APPLICATIONS SHALL CONTAIN THE NAME, SIGNATURE AND LICENSE NUMBER OF
THE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION; RECON-
STRUCTION, ALTERATION, REPAIR, REMOVAL OF DEMOLITION AS REGULATED BY SECTION 109.1.1 OF THE
CODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISING
SAID PERSONS, THE WORK SHALL IMMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED
ON THE RECORDS OF THE BUILDING DEPART`ENT. . '
I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CC1-
STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTAN:
THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING
OFFICIAL. '
INSURANCE COVERAGE: : • ,
I have a curre/yt liability ininsurance❑ polity or its substantial equivalent which meets the requirements of MGLth.152
If you have checked v`s, please indicate the hype cwerage by checking the ap;rcpriate bcx. •
�
7( 1
A liability insurance pcUcy i" Other type of Indemnity 0 Bond 0 '
•
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required :y
Chapter 152 of the Mass: General Laws, ana that my signature on th:s permit acplication wanes this requiren ert.
• . • Check one:
OwnerD Agent 0
Signature or C,.n or nee s g t
v •
SIGNATURE: 1.4/ \� -4 6i 'BUILDING OFFICIAL APPROVAL: i•
•
DEPARTMENT OF PUBLIC SAFETY
o
n COMMONWEALTH 1010 COMMONWEALTH AVE.
OF BOSTON,MASS.02215
• MASSACHUSETTS
LICENSE•
EXPIRATION DATE CONSTR.. SUPERVISOR
08/31/1993 g EFFECTIVE DATE LIC-NO. g
•
RESTRICTIONS 09/01/1988 048859
•10 & 2, FAMILY HOME
i ROBERT' R'• PADGETT'
184 SCHOOL/ggThPOB• 133
SS II 267-64=0800, COTUIT MA• 02635
PHOTO(BLASTING oRR ONLY) FEE: •
O.DO,
NOT V QTR S•NE• SEE H• • ICNLLY
HEIGHT: STA •IR•la , ;'M..MAR i
DOB: l
02/22/1944 "Jr, Y 4
THIS DOCUMENT MOST BE S I IF LICENSEE
CARRIED ON THE PERSON OF L1/
•
THE HOLDER WHEN EN0A0- ,j I / C•MMISSIONER
OTHERS•RICHT THUMB PRATT ED M THIS OCCUPATION
200M-2•B1.81128
1
•
1N
'�PppMER.ON4ArQErM1 o�✓f�amar�naem
HOME IMPROVEMENT CONTRACTOR
Registration 188131
j C r_ g Type - PRIVATE CORPORATION
;OChWil Expiration 86/89/94
• Padgett Builders, Inc.
Robert Padgett
aux a 184 School St
1NIST ° Cotuit MA 82635
ADMWOR•
4
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only 'NAME OF CITY/TOWN
Permit No. 1 ARMO In k
Date
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGLc.142Arequires that the"reconst ruction,alteration.renovation,repair.modernization.conversion.inprovement.removal,demolition.
or construction of an addition to any pre-existing owner<xcuoied 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: ADD;Tiorl h*fo EM1SiDR Dam En. Cost 1-01l-to
Address of Work 52 ?eat 357\x1-1 wA1' S. yARtlnut-j
Owner Name: fib' JARO r1N11z) i3rr l GIkIA�-
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s): ti A
•
_Work excluded by law
Job under 51,000
_Building not owner-occupied
_Owner pulling own permit
_Other (specify)
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. -
Siened under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
9hf Pince-7T BLOtS,it-x
(093 oNmrrP .VI c n 100131
Date Contractdr Name . Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
,
a.
FOR LOT "n /` �' ��1� 7 \
Indicate location cf garage or accessory building •
Additions with dashed lines
Sewerage disposal (cesspool) e
Well m
1 1
(lot /00,6 2 ft rear) I
4buttor's I #
Abutter's
vame IName
Lot ( Lot if
REAR YARD
:f this is a If this is
orner lot, ft. corner to
'trite in name I write in
if street. I name 'of
•
(ac I ET
^ ether
a
Ic Nino, ___--7.4L _
SID? RDi _ SIDE Yeti..
ROCS:
G 23 FT. 0 GelocleV _ eo_ _ _ , •
• (4
M
V
a` 4 • �S
N
SET BACK
31 Ft •
1.1
Q I c
I
lir 1Q.fel' (oa fes. frontage)
•
\ / ? asu )EAc)-1 v.IR`r
\ /
\ / (NAME OF STREET)
\ r
/ \ . .
I
D4838 CENSUS TRACT // -i
CLIENT : Attorney John Sullivan DEED BOOK 2846 PAGE 168
OWNER : Larry L. & Olga Firrantelo PLAN BOOKS lbo .:d.'.. PAGE 37 LOT
APPLICANT: Edward J. & Betty A. Chiazza ASSESSORS PLAN ' PLOT
MORTGAGE INSPECTION PLAN OF LAND
I N
YARMOUTH
SCALE : 1°= I{0' DECEMBER 20, 1985
LOT 122
LOT 123
c ' t4-1-'
/—. --�'
LOT B
14.9OO±s,F .
MRP19 LOT r\-z. t`, LOT 156
LOT A Lo
r`
Iron. IL ,
d52 .
;,..-; 1 STORY
+1
N
M
• 108 , 68'
PEBBLE BEACH WAY
THE LOCATION OF THE DWELLING AS SHOWN HEREON .,
IS IN COMPLIANCE WITH THE LOCAL APPLICABLE Vit' " at i` yl�t
ZONING BY-LAWS WITH RESPECT TO HORIZON', AL .f. i r::.;.. L: ... 'i
DIMENSIONAL REQUIREM ENTS , 7 ' ' ''
; .
THE DWELLING SHOWN HERE DOES NOT FALL WITHIN) ,•.
A SPECIAL FLOOD HAZARD ZONE AS DELINEATED
ON A MAP OF COMMUNITY #250015A DATED 5/2/77 •:,
fir,.r n,.
BY THE F . I ,A, •
Lend Surveyors i Civil Engineers
• ®the pada. ub un ny 010., PIIL
172 Ain= jt.
4S lebforb, cliktk02740
GENERAL NOTES: (1) The declarations made above are on the basis of my knowledge, information, and belief as the
result of a mortgage plot plan tape survey inspection made to the normal standard of care of registered land j
surveyors practicing in Massachusetts. (2) Declarations are made to the above named client only as of this
date. (3) This plan was not made for recording purposes, for use in preparing deed descriptions or for con—
structions. (4) Verifications of property line dimensions, building offsets, fences, or lot configuration may
be accomplished only by an accurate instrument survey. ...... .........
cJ/9
e COMMONWEALTH OF MASSACHUSETTS
• t,.,--- r'
a DEI'AICTMEI'T OF LNDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
dames J CampbellBOSTON, MASSACHUSETTS 02111 •
Cpmm:ss,one' WORKERS' COMPENSATION INSURANCE AFFIDAVIT
I, �1oBERT R. PA—GE—n— PR r—rr 3uh-o> , IOC
(licensee/permittee)
• with a principal place of business/residence at
eP,o . 130)( 133 l (roti Sr. c.a-cu r( MA 07b35 •
(Ciry/State/Zip)
do hereby certify, under the pains and penalties of perjury,that:
I am an employer providing the following workers' compensation coverage for my employees working on this
job.
'TRW ELERs (oo -u6-/Ooi'-K2'1ia -1-93 - .
Insurance Company Policy Number
•
[ ] I am a sole proprietor and have no one working for me.
[ ] I am a sole proprietor, general contractor or homeowner(drek one)and have hired the contractors listed below •
who have the following workers' compensation insurance polities: •r•-•-•-•••• -
Name of Contractor . . Insurance Company/Policy Number . ... .. .
Name of Contractor • Insurance Company/Policy Number . -
Name of Contractor Insurance Company/Policy Number _
a I am a homeowner performing all the work myself.
NOTE:.Please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a
dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generally
considered to be employers under the Workers' Compensation Act(CL C. 152,sect. 1(5)),application by a homeowner fora license
or permit may evidence the legal status of an employer under the Workers' Compensation Act.
I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents'Office of Insurance for coverage
verification and that failure to secure coverage as required under Section 25A'of MGL 152 can lead to the impoiition of criminal penalties
consisting of a fine of up to 51500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 510s 00 a day against me.
Signed ��o day of , 19g3
r � S '►�
•Licensee!Permiaec I • Licensor/Permit-tor