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The Commonwealth of Massachusetts
_: _ Department of Industrial Accidents
e"fel= 1 Congress Street, Suite 100
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_.� E ��" Boston, MA 02114-2017
5v' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 8 # Ofridpvt i k i 4e / 7
Address: is .Ba r"bra ,171
City/State/Zip: jo„Mt,ce, # 6Z/ 7G Phone #: `/7— Y7T-63/7
Are you an employer?Check the appropriate box: Type of project (required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2. I am a sole proprietor or partnership and have no employees working for me in 8. Cemodeling
any capacity. [No workers'comp. insurance required.]
9. ❑ Demolition
3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t
10 Ej Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees.
12.o Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.El Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
152,§1(4),and we have no employees.[No workers'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: PcJ6,/, "a
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: `./7C if/ i' kv. le,"ec,.fq City/State/Zip: A.it. et Awe og,,
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ` �;,�-.+,/ oL Date: 02A7-- 42a 2.0
Phone#: f 7 -11151'(Y3
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
a .
TOWN'OF YARMOUTH
1146 Route 28 ,South Xarmouth, MA 02664
508-398-223• ;ext 1261:Fax 508-398-0836
" Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at ti 7,---°#`t-e-Y4Work Address
Is to be disposed of oat the following location:.f r ES C a
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
d-1 0
40.2.64
Signature of Appli tion ate
Permit No.
giECEIVED
RECEIVED
7,<DC747`711-7;:,4> [FEB TO V OF YARMOUTH vim` 10 202� A TH DEPARTMENT
F5gBUILDING DEPA LLr�nLL'W„„ HEALTH DEPT.
• ‘ , t• 1.A I" ON SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
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Building Site Location: e171p -f�. 2g Aro'?uv
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Proposed Improvement:
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Applicant: /j -yj II() yf c„7 Tel. No.:647 -V S5-63f j
�y
Address: 1$ Net . il In /'7, 1.rt Date Filed: 2.7- 2u O
**If you would like e-mail notification of sign off,please provide e-mail address: he.t..4124Jibila. e 114A,i I.tom
Owner Name: . � i �, f r,4-4 ,
Owner Address: A 11144 an IP, O 1 `'1)3 Owner Tel. No.: 7"6-t 07.
04604.. l -- 0 -+-)1S•
1
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: lAz.vtoect/ DATE: /O o90I
I
PLEASE NOTE
COMMENTS/CONDITIONS:
MGL AND FIRE
TOWN OF YARMOUTH
REVIEWED FOR CODE COMPLIANCE.
wK � ERRORS OR OMMISSIONS DO NOT RELIEVE
THE APPLICANT FROM THE RESPONSIBILITY
/ OF"AS BUILT COMPLIANCE.
DATE: �u 3-7- -
II\ PE"T
YARMOUTH FIRE PREVENTION
Commercial Construction Building Transmittal
Project Name: Aiden Hotel Address: 476 Route 28
Contact Name: Brett Avallone Phone: 508-815-6444
Y NO NA Subject Regulation
E
S
X Access for Fire Apparatus 527 CMR 1; 18.2.4.1
X Building Numbers MGL Chapter 148; sec 59
X *Flammable gas/liquid storage 527 CMR 1;42.2.2.1
X Fire Lanes 527 CMR 1;22.3
X *Service Stations 527 CMR 1 ;16.2.3,16.2.3.1,30.3.2
X *Hazardous Materials Storage 527 CMR 1;60.1
X *Kitchen Exhaust Systems* 780 CMR,527 1; 50.1
X Extinguishers 527 CMR 1; 13.6,Chapter 148;sec 28
X Fire Alarm Systems/CO detection* 780 CMR,Chapter 148;,527 CMR 1; 13.7
X *LPG Storage Chapter 148;sec 9,10,28&527 CMR 1;69.1
X Use and Occupancy(FH Building Class) 780 CMR;302.1
X Sprinkler Systems* 780 CMR&Chapter 148 sec 26 A-I
X Storage inside/outside Buildings 527 CMR 1; 10.19.4,4.4.3.1.1,19.1.2,34.1.1
X *Upholstery 527 CMR 1;20.6.2.5
X *Trash Containers 527 CMR 1; 19.1.1, 1.12
X Any Hazard to the Public Chapter 148;sec 28
X *Curtains,Draperies,Blinds 527 CMR 1; 12.6.2
*YFD permit required-depending on occupancy and submittal
*Per 527 CMR 1 13.1.8, a permit is required from the Fire Department to shut down any
fire protection system.
Compliance with the following: 527 CMR 1 Chapter 16 "Safeguarding Construction,
Alteration, and Demolition Operations." 780 CMR Chapter 33,NFPA 24. Per 527 CMR
1 16.1.2 "A fire protection plan shall be established and submitted" This plan shall
include the following: 16.3.1 Fire safety program, 16.3.2 Contractor is designated fire
prevention program manager.
Plan Reviewed By: Lieutenant Jason Moriarty Date: 02-07-2020
Copy for Applicant Copy to Building Department Copy to Fire Prevention
Entered in Firehouse E-1 Final Inspection