Loading...
BP-10293 UILDIN - PERMIT 82 MILLERS DRIVE SPECIAL PERMIT.PER 780 CMR 111.0 Dartmouth Building Department Plat: 70 400 Slocum Road-P.O. Box 79399 Lot (s) : 13-38 Dartmouth, MA 02747 Lot Size:42,734 Telephone 508-999-0720 Zoning Dist//..� :SRB March 24, 1999 (t d Permit No. : �( 7 3 Issued Date: 3 / Clerk: SAS Project Location: 82 Millers Drive Number Street Subdivision Name: Millers Farm -- Lot 38 _ Nearest Cross Street: Person Permit Issued To: Kristine Sousa Address: 117 Gagnon Street, Fall River, MA 02721 Applicant/Agent: Same / Melissa Sousa Contact Person Phone #: (508) 672-6053 Type of License: Owner: (x) Const. Superv. License #: ( Architect: ( ) Engineer: ( ) Other: ( Proposed Use: Residential Residential,Commercial,Industrial,etc. Permit Issued To: To Install Type of Improvement,Add,Alter,New Const.,Demo,Land/Move,etc. Foundation Only indicate no.of bedrooms and bathrooms and other rooms Gross Area of Const. : Cost of Const. $7,200. 00 _ Cost-Other Const. : TOTAL FEE: $ 50 . 00 Owner (s) of Record: Kristine Sousa _ Address: 117 Gagnon Street, Fall River, MA 02721 All work shall comply with 780 CMR 6th Ed. (MGL Chap. 143) and any other applicable Mass. Laws or codes and plans on file. I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdi tion are not et; not withstanding the issuance ^ of this Building\Zoning Permit. /D ) Signature of Owner/ ent: tom/ Address: ******************* **** *** ** ********************************* Signature: . J, Approved/Issued By: oel S. Reed, Tit : Local Building Inspector COMMENTS: PLEASE P ST PERMIT CARD SO THAT IT IS VISIBLE FROM THE STREET. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. 0 ORIGINAL 0 APPLICANT 0 ASSESSORS 0 CLERK 0 COPY/ ( ray TOWN OF _DARTMOUTH 103 r, , 0 Ti3/4x issurUBUILDING RECEIPTS COLLEC OR'S OFFICE Name ) �, J Property G/ "'' / / -V - r'r // 4 1 C-::}L ,>_;t.iL"- -a.s" / ate: //. // ,' Owner: J•'✓�iz.L.,_=vc...;..- ,r..�-<c.;,^ .sm _ / 'd; / /" Job Location: (7 l J � j 1 `'tit- ,ti t ��, . .."'v ^ '`YUWN OF DARTMOUTN Copy Plot: ` Lot: / '•; COLLECTOR'S OFFICE Yellow Copy-Customer's Receipt / / / Pink Copy-File Copy - - Green Copy-Building Department Phone: - MAR -- �- R 2 6 1999 ,,-u Description General Ledger#'sC M B / Amount ) i License&Permits-Building 01000-44105 !r (/ ( l -9 / License&Permits-Building Misc. 01000-44105 License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 This is not a Permit or License for Building.Plumbing or Gas Received By: vkj-C 14 1,; /W -_..v _ / TOWN O={ARTMOUTH lfl2i 4 BitilLtiNG RECEIPTS COLLECTOR'S OFFICE y / i > ftr� Name: % 4 i n �P�operty �__ Date: 1 `i 1 j J /'`-%Z Ic:-G n{� E ) L / ner: - ��a " Job Location: JU'' Q� i 1 j // • C n White Copy-Collectors Office Plot: " Lot: 2 Y TOWN OF DARTMOUTH Yellow Copy-Customer's Receipt �V /..2 DL% COLLECTOR'S OFFICE Pink Copy-File Copy Green Copy-Building Department Phone: - - j / MAR 19 1999 / t Description General Ledger#'s R # ! Amount - License&Permits-Building 01000-44105 C M ES 08 License&Permits-Building Misc. 01000-44105 ('.1-'-� SJ p"?01 r License&Permits-Electrical 01000-44106 ‘./ V t License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 This is not a Permit or License for Building,Plumbing or Gas Received By , •-r-U• t - f-1 V 7/ i Residential O DATION ONLY 1999 °"T"\ DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED jai. io A: r 400 Slocum Road, P.O. Box 79399 `r Dartmouth, MA 02747 3 �g y�• IRfi......... 508-999-0720 FAX 508-999-0738 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWFO.LING ..;...Fi. i :: ...a:F CiAVAS ONL":;;"gni g's!:'Mii::;i :! :N; ::c,:, . 4!7 ids :::.2::.:s: U:<:>:<:::::::::::::<:>r:ax:e:>:<.<.;::<::a:;: : :::: ;:: : ::� :>::>:r..... i a S�GTit�l4'iFRti �. .......S�.i]...t.1C..._..... ....._......... .._.................................... . ... . tt:ECEIV : ;.:.:.;:;_:.;:.:<.;:.;;;:.;:.<:::.>::::,:_>::;;:::::::::<:>::1.,.,;.::::: ig s: i'' r`3 En z:.:: . : ..;i n::;:.: Ea�'. .. .:, ,: BUlt,ittL+1�PERMIT 1sR#�SER s#3A't`�:SEPVT'F >.;:........ " : il:::>:.:. <::;::.:::::;::_:::::.:::::. :_:::;:>::: :;r:>.; «li;.: `rl`I'kZ `::i: l�:i:_>''ai_i->:):si ):ii :'::i"ii>ii ;:<:a >''' > ': <><aai<i" 'aA33zik1:SISSUf$...........__....:.:.:.:::.::..._._:.._.. ..::.::..:..::.:.. ::OQKr.ra.'... f:....-S4NAIi:�`:>3e': !_ z3>t�'::!::�> 2 t":< >": :1::: !&az;S!<_ '" _ >''3 I:!:!:? _{:'5: ;': 'z!' ::'T.P. ::i:j:! <i: : :>e;»: :: :. ?:!�t::'.:. if.:?::?.: T�"�S11S BiG71'tl'I'[1ETLr w�: . .; ._;.. I3A'I'E... ,.. "a:<$00.-iaiiaiiinisifika.- .1:4s:":.44j:4»f8�itid3"0.:ii:4: i::'Ni;;_:;!;;�:::_ ;:::::5.t;:; sr:,'t?):r:`:.::;:: ;'» .>:::'::.�"+:::":::3i• :'.; Zoniin gist <i:::�'!2:::;_ itiposssd i::E ;:<t j S'': f4::26.1i i:'!s's,'::`:54...:i; : :::cAutsi eFlo Jx::� om:::-Ei. : ine.r7, .i.:::..>.:: !:....... g D.„:„. t 3*ropased::iis� Zane: _II C.:Ci S ©A II V CJutstde Flood. are:II .....„ r Z.one :. .::.::.......:... .:.:.:::.....�...::.::. ::.. :.:..:.:. ........ . :. ..::.:: .:.;:.....:......:.:.;:.:.--is:.:»i :::<----:::':>-::.:;:t;!r;.i:::: : �::-:: �-...:.:.?::2: s.::-:::,:-..:.:;.:e:::,,,,: ::::..:..-:':.:- ;:.:..�:.::::::::::'::::: .1'fl;E: 'Y4*(024t0.40.EPI:gtES:SI'F4lI;XO.::8E:1!1O.O..O.P.6.:»+ msn:; cs. z:>.::.::: ;s:: : xa:;::. :i:!;g ..: .::.: :g......:.:..::.;.;:r:;R::_::;_:::::�:,.:::;:...:. :i.5i . 0 ` ," ,.`:` '.::': `<<_::;';"'U i! <>" in '` a;3!<>' ?'_<?. : ` a;<' _;`"":`a; :> :(:: :::....,::_ :2,! ::.�jport. j i: hoard Ot ward 4t OPO from;;. gt 400.0 Ll PRI §1#:5. l nni.qs Ite opt A cats>::> ::::;::::«;.. :::::::;::.::>:;;::;:::;:::::;;::<:;:<;;:;:»;;::::>::>:>:;:; ....::::.:::.:.:.:He�LLfh::::::.:.................. ..................AffEdavtt::::< : 1 :>cBa#e:Addr>rss.tsard;:.;:::::>:>;eut.f?ff.;::::.;:;<:;:Foliow-u .:: <.;.:.;:.:::::::::::;: chief itiai4a 'r"?:: A0 ft' 0wer _an £2'1 aeritittf5>i><i > i , :.; :.OizFlp.,:.:: .: . .:...,:::: ::r 13re Chief lwt was. L'l,Plann➢fig, Li Suer Card ..�7 Water f"ard €�7.�nuag Ci Other : : tiit;(I£f >' :?dvaecE: :f.:::Ciit:K71f£.>:. 1U:Y[e5x:: .:. .::..:.::.:::...::..:::::.:..:,,: 'f:.}.t g0:li it§:; :ii.it: ig§ii'`€: 1<:iiiiiiitri NCtDS:i. ::»`::.:: _ ":.::::: . . ..: ::.::.��.r:.:.:,:.::��;:<::;::;:.:::;.::».:>::.::.;:.:.::..R�Et�tTITa;ES�:INSPECT(!13?S`�:ILYiitIl`'!i1:.T5EFY)RE``#.`HE:#SSi3�ANG'L`.Ctrl,:A..#Et25fITi:..;�:.a::.:::::::::::.:::.:::... ..: ::.:�:�:�:�:^:�::.�.:::::::; Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: 1 'NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes 0 no .• 1.1 Property Address;/rid(c r-s e t iE Lot 3 1.2 Assessors Plat&Lot Number: `Nearest Cross Street:D1d .( t 11vE( i'�Gf Plat 74 Lot/- V"Subdivision Name:V)` (I er n 'M 1.3 Historical District 0 yes 0 no 11 3�( Has application been submitted to the Historic Commission? /Dotal Land Area Sq. Ft.: I ❑yes 0 no Date: _ J 1.4 Water Supply(MGL c 40§54): 1.5 Sewage Disposal System: 0 MunicipalD Private Well 0 Municipal 0 On Site Disposal System :..::..::.::.::::::: :::tt::::r::>:: _::<: ::>::>::isr::S•EGT?ibi!t!2'.�<:FkT.t)i' `t�::€��`£llrkt •I•ti'•:.•13•:. : .,.. .i 'E.•T':::::°: ::.:.>." :::f: ;':.:: :;:,.;.::'-::".:'::':::.;;;.::. 2 1 Owner of Record: r1 ntact Address Name(print) i I C noo �Y t 1`tI I [ Iilfri Iv rJ `P-77(4-cs P ) phone number c:\wpwin\forms\bldgapp.res Page 1 January 20, 1999 Residential _. 1999 7.2 Authorized Agent: \ ::tau Address /� r f Q ��i �A5� l�(� fiGnDn S� } II ?fl v A 50" C,7L( ( 3 Name(print) '� bk /bl-e III SS Q -Co tAS Vim.) Telephone nionsimmumEigEmmimonsiammettomaW0)1000:ettOMStRVICtsanommiggimiiii:,:, ,E,:,i,:emig :R:nRg::i::::,::i::: 3.1 Licensed Construction Supervisor: ..� Not Applicable 0 . Licensed Construction Supervisor License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor: Not Applicable 0 Are you a Home Improvement Contractor subject to(780 CMR-6)? 0 yes 0 no If no,go to the next section! Are you claiming exemption from the requirement? 0 yes 0 no If yes,submit the required affidavit! Company Name Registration Number(if none,state"none") Address Signature Telephone Expiration Date 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton Place-Room 1301, Boston,MA 02108, (617) 727-8598 Owners Name(print) Signature by signing the above,the home owner acknowledges that there will be no eligibilty to the Guaranty Fund Date 3.4 Homeowner Exemption-One&Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982,no individual shall be engaged in directly supervising persons engaged in construction,reconstruction,alteration, repair,removal or demolition involving the structural elements of buildings or structures,unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. • Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this s tion;provides that if a Homeowner engages a person(s)for hire to do such work, that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner"is defined as follows: 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. If you are applyng under this section sign below: - Signature: 1 ,'1 1�.' Sl, � 'vl Your signature carries certain responsibilities, including but not necessarily limited to,general liability c:\wpwin\forms\bldgapp.res Page 2 January 20. 1999 Residential 1999 TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction Supervisor,whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) ,SECTION� yt RKER'S cO!M.PENSk.TIQN INS R iNCE.AFl: DAVIT;(MGM a 152§52) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑yes 0 no SECTIQIv� DESG`A2;iI'TJAN Q k1tS)PQSEp 1S'Q (check o41 appl)cable) ❑ new ❑addition ❑alteration ❑repairs 0 chimney/fireplace 0 woodstove construction* ❑deck 0 pool 0 accessory bldg. 0 replacement window/door 0 other 0 demolition (shed/garage) no.of windows doors (specify below): (specify below): * If new construction,please complete the following: Single Family: no. of bedrooms no. of baths Two Family: no. of bedrooms unit 1 no. of baths unit 1 no. of bedrooms unit 2 no. of baths unit 2 / Brief Description of Proposed Work: SECTION. 6 ESTIMATED CONS I'Ri7GT'IOX coSTs; Item Estimated Cost($)to be completed by permit applicant 1.Building 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 5 Total=(1 +2+3+4) * Estimated Total $ 7 01° 1/ SIW£T[QN'�A ;L}R'IIERr4tiTHOlt)�h'i'[oN ': (to he completed when<owiterrs agent or contractor applies for building permit) (please print) I, ,as Owner of the subject property hereby authorize to action my behalf, in D matters relative to work authorized by this building permit application. )-*kit u 3I1q (13 Signature of Owner Date / _ SI;;f:`I:'JQS 78-O\VNER/AUTIIORIZEDA NTAECLAR.&TION ,as Owner/Authorized Agent hereby declare that the statements and information /on the foregoing application are true and accurate,to the best of my knowledge and belief. / Signed under the pains and penalties of perjury. • V _�RiSfilne SOUS PrintName -i Signature of Owner/Authorized Agent Date c:\wpwin\forms\bldgapp.res Page 3 January 20. 1999 • Residential 1999 SECTI<O's$-It*1pECTOR'3 REUfEW/C(314 ME1oS 1. Date plan reviewed: 2. 30 days to review period expires: 3. OK to issue date: 4. OK to issue subject to requested submittals(see project review worksheet): Date:_ 5. DENIED(see project review worksheet): Date:_ 6. HOLD reason: Date' 7. HOLD subject to Zoning Board of Appeals action: 8. Comments: • 9 Inspector's Signature: C Da@*AR 2 2 mg SEC'Flit g :AYP CANT I•I0TI4CATIffN ' Applicant informed of above Date - d % Timer 7 P'Y1 Clerk Comments: a'101 .:„:,*,:,:,,„„„„,„,:„,„„„,E„,„„„E„,E„,„„„,„„,„.„,:„,„,..,„:,„,„„„,„,,,,,„,„,,,„,,,,,,,,,,,,„„,„,„„ttatimotipottemstikettitiNNOtkgmouninginanommemison Total Permit Fee: $ 367. ) Less Application Fee: $ 25.00 Remaining Balance: $ TOTAL FEE: Gross Area-New Construction total sq. ft. __ Gross Area-Alteration total sq.ft. Permit Issued To• �on'�-} O MENEMEN.Engi]E•MEMENMSterlifkkIti;!WillAtidNaCtOtitilOtIctOMMIEORSIOniiiiinagniliiiinfiNEMEMB c:\wpwin\forms\bldgapp.res Page 4 January 20, 1999 _ REQUEST FOR ASSIGNIENT OF HOUSE NUMBER /i Owners) of Property fry'1 S) 1 rje_ Sir t(_EICti., Present Address / 1 7 6-4_0 u.JOjr3 $ . F2 12.f e, tr A-/6 Telephone Number bap \J6i7 House Location: Plat 10 Lot / ?J- S? \\ n e' Subdivision Ph /Let 1S F to-...__ Lot VV 1j�00-Iv6p3 Corner Lot�j? Yes No Street 4p, 11l//eii$ if / ' Sinsle Family Multi Family Condominium # of Units Site Plan Submitted ? Yes No V Date Submitted th " S'a LIWner V Q/(( 4 no9S°- tt House Number Assigned 82 MILLERS DRIVE Date Assigned 3-23-99 Date Assessors Notified 3-23-99 Date Building Dept. Notified 3-23-99 Date Owner Notified t Supeii•It.ic,rt, Department of Public Works 'J>: Dartmouth Building Department G�. 166i %' 400 Slocum Road P.O. Box 79399 508-999-0720 Dartmouth, MA 02747 FAX 508-999-0738 FILE COPY STATEMENT OF REQUEST FOR SPECIAL PERMIT PER 780 CMR 111.0 PERMITS I, hereby request a Special Permit pursuant to 780 CMR Section 111.13 for the below described project. I understand that I assume all responsibility for proper compliance of Zoning and 780 CMR The State Building Code. This is pursuant to 111.13 Approval in part and will, if required, make any necessary corrections for failure to comply with the applicable code and regulations including but not limited to removal in its entirety of any work performed. Location of Project: .I I I I��� !J� t ll mot 3 2 — Description of Project: u-0un(-Lo1 on an I Li — A A Si /9 I — Signature of Owner or Authorized Agent Date Excerpt from 780 CMR The Massachusetts State Building Code 6th Edition: 111.13 Approval in pan: The building official may issue a permit for the construction of foundations or any other part of a building or structure before the construction documents for the whole building or structure have been submitted,provided that adequate information and detailed statements have been filed complying with all the pertinent requirements of 780 CMR. Work shall be limited to that work approved by the partial approval and further work shall proceed only when the building permit is amended in accordance with 780 CMR 110.13. The holder of such permit for the foundation or other parts of a building or structure shall proceed at the holders own risk with the building operation and without assurance that a permit for the entire building or structure will be granted. c:\wpdocs\forms\special.wpd_ -3 The Commonwealth of Massachusetts ^T _- — FILE COPY ( ' Department of Industrial Accidents r__ — OB/ceof/e�estlgat/ees 600 Washington Street - J• Boston,Mass. 02111 V Workers' Compensation Insurance Affidavit ili2 •fr4ti. i$i'7"ii . f}f.,rt°a irre_____it i, - E `37 8Ailk9C"-ftakt '. - , name: -<.RI (*Ife SJOSCC -- 4ation5: c��t\\P($ ORN Ofi ?) �5 Illen 0 01 t Anh phone 6 OE) 617 2 &OS 1.3 I am a homeowner performing all work myself. ����111F I am a sole proprietor and have no one working in any capacity IMIIIMEM ❑ I am an employer providing workers' compensation for my employees working on this job. company name: address: - - insurance eo. policy# I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: - - - - - address::-- city phonel insurance co. - - - ooliey ft _ company name; - - _ address: - city: - - - - - phone#: _ insurance co. - policy-# - - ; d1P r4fl r 45370 'C; a�M "ti d5'2;gin fi 27Z,, - -'% N` •Y, +.•, v'r f" t ,.<, ;, ., Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. do hereby certify under_ __�the pains and penalties of perjury that the information provided a ye is true and correct. Sig ature ��/2.-/\�54I�l f -.Q Dat /J [1 ci iq riot name 14-6 11 file. YOU j� Phone# (SU s3 () -]- 2(4 0 5 2 i`" official use only do not write in this area to be completed by city or town official t city or town: permit/license# ('(Building Department Licensing Board 4 0 check if immediate response is required DSelectmen's Office ❑Health Department contact person: phone#; riOther •ems. (revised 3/95 PIA) " 3 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee 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 legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity,employing employees. However 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 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 commonwealth 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 have 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 required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed 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. The affidavits may be returned to 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 questions, please do not hesitate to give us a call. • ex The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 The Commonwealth of Massachusetts III - ► (ye Department of Industrial Accidents r le llllcnlIn estIgstloos gar —= kilt:: _ 1 600 Washington Street . v Boston,Mass. 02111 Workers' Compensation Insurance Affidavit ,.. : ni1FF'i r .i ul Fisni:urur:+'__�_. .. - •. ,., .lap}�)bl:i.G u.a ufqlii t. . _.._ _. name: I I'l6�yti e I -i ski ne , citisf location:/(0-m' (leis 0411 v� city D tca l . pi-ft D 1 U t1 phone# 5)8ib72-6t 3 Gyi am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. company name: address: city: nhone#: insurance co. ooliev# 0 I am a s•.'e proprietor,general contractor,or homeowner(circle one)and ha'.:hired the contractors listed below who have the following workers'compensation polices:. company name: address: city phone* Insurance co: - nolicv#- : romoanvname: address: city: - phone#: insurance co .. noliev# Failure to secure coverage as required under Section 25A of DIGL 152 can lead to the imposition of criminal penalties of a fine up to 51500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby c fr un the pains and penalties of perjury that the information provided above is true an co ct Signature ' J U lf "+i�'�y _' Date 3� 9 cj Print name R-tSt(1E_. SC l)<'ft _Phone# 50 FS (0 7 Z c c 3 official use only do not write in this area to be completed by city or town official city or town: permit/license ft °Building Department OLIcensing Board p check if Immediate response is required ❑Selectmen's OfficeHealth Department contact person: phone If: rlOther__ Crease 3/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee 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 legal representatives of a deceased employer,or the receiver or trustee of an individual . partnership, association or other legal entity, employing employees. However 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 section 25 also states that every state or local licensingagency shall withhold the issuance or P c)'g 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, 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 have 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 required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed 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. The affidavits may be returned to 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 questions, please do not hesitate to give us a call. 41', -.aaq,�,T`- 1. .a-_:23J. • - , ..� .A�kY� ti�Z .�-tJ'Y� I/1 -Ji f .. ��' { :- • The Department's address, telenhc:•_and fax The o:na?......._c::! . _. rigs.zc4t:rs.:�:. l)enartrhyrt o_ J,r_c...am Mice of lnvesllllations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406. 409 or 375 r 7a /3 30 BUILDING PERMIT 82 MILLERS DRIVE SPECIAL PERMIT PER 780 CMR 111.0 FIELD INSPECTION Dartmouth Building Department Plat:70 400 Slocum Road P.O. Box 79399 ©C[,r1 ETI Lot (s) : 13-38 Dartmouth, MA 02747 ll��ii IIIIUf L�L"J Lot Size:42,734 Telephone (508) 999/-0720 Zone Dist/. :SRB Issued Date:�3 ia&9/ ' Permit No: /(,;Xq Project Location: 82 Millers Drive Number Street Subdivision Name: Millers Farm -- Lot 38 Nearest Cross Street: Applicant/Agent: Melissa Sousa Contact Person Phone #: (508) 674-1034 Proposed Use: Residential Residential,Commercial,Industrial,etc. Permit Issued To: To Install Type of Improvement,Add,Alter,New Coast.,Demo,Land/Move,etc. Foundation only Indicate no.of bedrooms and bathrooms and other rooms Owner(s) of Record: Kristine Sousa Address: 117 Gagnon Street, Fall River, MA 02721 DATE TIME TYPE OF INSPECTION REMARKS INITIAL BLD. CODE 6TH ED./ENERGY CODE (yes no) ,—/— 9 9 3 3-Y ie_e_e_, ,/_Q ep L c d../ —9 • CC , ,ETE® OOc r=ETED 5 BUILDING PERMIT 82 MILLERS DRIVE SPECIAL PERMIT PER 780 CMR 111.0 Dartmouth Building Department Plat: 70 400 Slocum Road-P.O. Box 79399 Lot (s) : 13-38 Dartmouth, MA 02747 Lot Size:42, 734 Telephone 508-999-0720 Zoning Dist. :SRB March 24, 1999•.�(t , pd7 (jl Permit No. : / 3 Issued Date: , J /t(� 1 Clerk: BAS Project Location: 82 Millers Drive Number Street Subdivision Name: Millers Farm -- Lot 38 _ Nearest Cross Street: Person Permit Issued To: Kristine Sousa _ Address: 117 Gagnon Street, Fall River, MA 02721 Applicant/Agent: Same / Melissa Sousa Contact Person Phone #: (508) 672-6053 Type of License: Owner: (x) Const. Superv. License #: ( Architect: ( ) Engineer: ( ) Other: ( Proposed Use: Residential Residential,Commercial,Industrial,etc. Permit Issued To To Install Type of Improvement,Add,Alter,New Const.,Demo,Land/Move,etc. Foundation Only indicate no.of bedrooms and bathrooms and other rooms Gross Area of Const. : Cost of Const. $7,200 . 00 _ Cost-Other Const. : TOTAL FEE: $ 50 . 00 Owner (s) of Record: Kristine Sousa Address : 117 Gagnon Street, Fall River, MA 02721 All work shall comply with 780 CMR 6th Ed. (MGL Chap. 143) and any other applicable Mass. Laws or codes and plans on file. I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdi tion are not et; not withstanding the issuance of this Building\Zoning Permit. Signature of Owner/ ent: Address : ******************* **** *** ** ********************************* Signature: 4 Approved/Issued By: oel S. Reed, Tit : Local Building Inspector COMMENTS: PLEASE POST PERMIT CARD SO THAT IT IS VISIBLE FROM THE STREET. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. 0 ORIGINAL 0 APPLICANT 0 ASSESSORS 0 CLERK 0 COPY