BP-2001-19643 Permit No. BP-2001-19643 '`n' -
GE ° Is; 43$0 00 " airiti ."" ''' a�' 'gym `s
ap. r ..0080 r .omnzoriwe , i o 1 a�e
TOWN.Of -DAR,_ 'MOUTH
-Y i 400 Slocum Road,Dartmouth`,1 IA'02747 '� °
,. oj�eNct"i�,:},.�`E� �'S-20�01-0768 .{T.', = Phone' (508�):999-0720,,i Fax: 508'1999-7,38 11
Est Cost t F S 83411 01! �'�$d as, ;x .$" ipsi y �y q�71, ' fi u b ?
Fee t ' 'WOO 00 3 � " '. PERMISSION IS HEREBY" 'T O' ' -, ', t,
:Const Class 't;p _ r j ,r j ,I , ,
Usk�tQuli �J� .,��', "a,��s �. - A i— ±��` `� ''"=e�`J� '.�,�, 1 •.
., : r� Contractor {
3• L)ice' ,; 'Phone#:
'` t Size i$9� .. Engineer: : . K _ F
Iw9 il s((.) 1�1'lA §*� �Sr g � • - ,License -� Phone#:
Zoning R6 �t , ''
�'grt cS -. .i.l xw K g 1 _
e t
New Const. 3.6-4h716 sq ft. g 4 b ' i
.-- � Applicant �p ��+_� _ �� ��� , � Phone#:
'Alt.Const _ `�_ ' RILEY PETER M `g '%(508)998-8157
Date Typed } Yk -05 I0-2001 N OWNER: -T1t -• ^ o �r,„„} -_� `
RILEY PETER NI&PATRI A RILEY_
DATE ISSUED: s
TO PERFORM THE FOLLOWING WORK:
10'x 14'shed and 24'x 24' garage
_ BuILDicb PERMIT
Project L cation: 11 PINE ISLAND RD
V
Approved/Issued By: A - /.21.--er-2 , -
JOEL S.REED,Lo 1 AL BUILDING INSPECTOR
All work shall comply with 7: I • II' 6`m Ed. (MGL Chap. 143) : I d any other applicable Mass.Laws or Codes and plans on
file.
POST TH/S CARD SO/T/S VISIBLE FROM THE STREET
SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS
REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.7(NOT MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON
ISSUANCE OF A REGULAR OCCUPANCY PERMIT.
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 jurisdiction are not met; not
withstanding the issuance of this Buil 'ng/Zoning Per I.'t.
Signature of Owner/Agent: ,I
Comments:
REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD
COPY
TOWN OF DARTMOUTH
2
BUILDING ECEIPTS
COLLECTOR'S OFFICE
Name: i.fi Property \.i i w_t Date: I 1 € i
s t Owner: - ..a
Job Location:: I - t i lc '
-',\, White Copy-Collector's Office
`,. s j, \" Yellow Copy-Customer's Receipt
Plot: ,s 1 Lot: '\J 4 Pink Copy-File Copy
Green Copy-Building Department
Phone: e
ri __
Description eirger#'s Ref.# Amount
License&Permits-B11
01000-44105 ti I
License&Permits-Bufmg 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:
TOWNS DARTMOUTH1964
3
BUILDING4RECEIPTS
COLLECTOR'S OFFICE
Name: Property - Date: ' /
Owner: .,
�; •: !. ,f
job Location: Y �..,c F G RT''c NTH ys
, , i"1 to ,,_,_. TOWN
Trnl I FCTOR'S OFFICE 1 White Copy-Collector'sOffice
Plot: Lot: 7 Yellow Copy-Customer's Receipt
-.-~' ?ink Copy-File Copy
APR 2 6 S Green Copy-Building Department
Phone: -2 F.: / i fp
l
Description General LeLger Ws Ref.# Amount
License&Permits-Building 01000-44105 r "' : 41
License&Permits-Building Misc. 01000-44105 f . f'
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107 t ``
T#
Other Department Revenue 01000-42420
l
at /-f,
This is not a Permit or License for Building,Plumbing or Gas Received By: . 'F , {'6 a
TOWN. OF DARTMOUTI 7BL ING DEPARTMENT
TELEPHONE 508-999-0720 FAX.:508-999-0738"
APPLICATION FOR ZONING AND BUILDING PERMIT
Insiroctions
The applicant shall complete this application to the best of their ability prior to submission.leaving no item unanswered.The
Department staff will be available during regular business hours to assist as necessary.N/A should be inserted for those sections
which do not apply.A properly completed application will help avoid unnecessary delays. N. Fang fee is mot udumieiie.
(for office we only) 0 TION ONLY
Total Cost $ Received By Date Rec'd
Less Application Fee$
Total Permit Fee $ Permit# I &73 Isased Date
100 LOCATION OF PROJECT • TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS' PLAT_= LOT 7 ZONING DISTRICT
OTHER ZONING OVERLAY DDISTRICT/S,if/applicable
V/NUMBER & STREET // ' ` i€ ._Y' I L c: cX
NEAREST CROSS STREET
SUBDIVISION NAME & LOT#
or BUSINESS NAME
PREVIOUS TENANT / OWNER
200 RESIDENTIAL- PROPOSED PROJECT - one & two family residence only
THIS SECTION NOT APPLICABLE
- Single family - number bedrooms number baths
Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2
• Accessory apartment Total gross sq. ft.
- Accessory structure:
Garage - detach - attached to dwelling, imensions L - I W •-�-r .��
- Carport - detached - attached to dwelling, dimensions L W
e
- Shed - dimensions L /4 W /(1
▪ Deck- dimensions L W
- Gazebo- dimensions L W
▪ Swimming pool above ground in-ground Size
Chimney - number of flues
- —e
Woodstove - used (will require inspection prior to installation), new (provide manufacturers
instructions). Location(s) (list)
• Fireplace(s) - (includes flue) List location(s)
Game Court - describe(include overall dimensions)
- Tent, Trailer(Mobile Home) or Other- describe
300 COMMERCIAL-PROPOSED PROJECT/USE-INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Article 3,AS NOTED) (See the
Code)
- Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
Bu
siness - office, assembly with less than 50 occupants - indicate Medical or other professional (see Code
Section 303.0)
- Educational-structure for training including child day care for those over 2 years 9 months(see Code Section
304.0)
• Factory Industrial - (see Code Section 305.0)
- High Hazard - (see Code Section 306.0)
• Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
- Mercantile - retail stores (see Code 308.0)
Residential - three or more family, hotel (see Code Section 309.0)
- Storage - includes garages (see Code Section 309.0)
Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0)
- New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
- Tent or Trailer - temporary purpose?
• Other
Describe the proposal briefly,INCLUDE-amber of dwelling units and bedrooms or occupant load as applicable,
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
New Construction and/or Addition- total gross square feet
(For commercial only total gross cubic feet) -indicate
It will be considered new construction if there an increase in square footage in addition to any
alteration(s).
If project is an addition to existing structure - Total gross square feet of existing
FOR COMMERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL(over 35,000 cu.ft.) Yes
see Code section 127.0). Designer to submit Code Synopsis. No. (If yes
Will this project require Peer review(over 400,000 cu.ft.) Yes No (see Code Appendix 11
APPLICANT TO PROVIDE
= Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
= Demolition -describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration required.
= Moving- (Provide copy of D.P.W. moving license) Type of structure
from where (plat/lot or address)
to where (plat/lot or address) •
Number of dwelling units Number of bedrooms per dwelling unit
= Re-roofing- (for existing only, is included in new construction)
Number of square feet Number of layers already existing
Number of layers when complete
A separate disposal declaration REQUIRED
= Replacement doors and windows- (for existing only) (only where doors and windows exist and will not be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be
considered as an Alteration, otherwise will be included in new construction. (see Code section 3401.10 for
residential and Articl- 8 ft-.commercial)
Temporary structure-includes when allowed, trailers,tents and the like and only for limited periods of time.
Describe
500 CONSTRUCTION PLANS
I - = ne submitted. Why?
Submitted, usually three sets required. Four sets for food service\uses. Number of sets submitted 3
600 SITE PLAN
❑ No required, why?
ubmitted When? = Previously, date With this application
700 UTILITIES
Water supply- required_yes no, public ? _yes_no, on site well? ✓ yes— no,
existing? _yes _no
If required and not existing have necessary permits been issued? _no_yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal- required_yes_ no, public sewer_yes no
private septic - on-site yes _ no. Submit copy of permit as soon as available.
f
800 MECHANICALS &PRIMARY FUEL
' = Furnace(hot air) - Fuel gas (natural or propane), fuel oil, electricity, other(specify)
Boiler(heating)- Fuel gas (natural or propane), fuel oil, electricity, other(specify)
= HVAC (combined unit) - Primary fuel, natural gas, propane, electricity, other (specify)
= Air conditioning - (separate unit)
None of the above to be provided
Hot Water Gas Electric Fuel Oil Other
900 SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, plans provided, .-plans not provided, why?
= Not required, not to be installed, Why?
1000 REQUIRED OFF-STREET PARKING- for ZONING &Architectural Access
NOT APPLICABLE
= Parking Plan submitted To = Building Department Planning Board Date submitted
Number of spaces - indoors outside total provided
Handicap spaces - required yes no. If yes, how many as a p"rt of the total required number. .
Is Route 6 (State Road) Entrance permit required? yes = no =. If yes has it been issued yes = no -.
Submit copy of application and/or permit as soon as available.
1100 IDENTIFICATION(print or type except noted)
ivi
Current owner- name . e c ✓', c. Kt j
address 1 t Ps 1,..42_ j C.'i_,_£ '(e C Ck ) (JG,, H1.:,j t &I . ® -7 T'
phone## 56 r- 91 f-f/5 I
If corporation, officer in charge
Architect/Engineer- for overall design
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans. affidavits and other documents SHALL, BE originals and not
reproductions.
Architect/Engineer- project supervision and reports •
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
General Contractor(if Homeowner, state homeowner here then complete section 1300)
Company name
/ Address
Phone number
Construction Supervisors license number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to(7S0CMR-6) ?Yes No_If no go to next section!
Are you claiming exemption from the requirement? Yes No_If yes, submit the required affidavit!
Rea Adel contractor name (please print)
Address
Registration number(it none state"none")
Phone number
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE
GUARANTEE FUND! QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration
One Ashburton Place - Room 1301
Boston, MA 02108
(617) 727-8598
(print) /4t ,
Owners name (p •-`- � ��' �
,(e_At
Signature / =7
Date 26 o
1
1300 OWNER.SIGN- OFF
I. the undersigned,am the owner of record or authorized lessee(provide documentation)and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true and correct and that the permit requested be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or
six months after the last inspection if work has begun and.that the permit may be extended for six months if no work is
anticipated if I request such an extension in writing.
tut . I understand rand that the permit may be exten
ded
ed only three times by
written request.I understand that once the permit expires a new application may be required,including fees and current
other requirements (including Zoning).
i/ Name
Signature
The above signature is my sloluntary act and is signed under the pains and penalties of perjury.
,
Date 7/.2-6( 6
Who is authoo ed to pickup the a-nit at the Building Dee artment? (please prints �Y —�- ( .T e^` `
Add ( I s(� & Phone 5`
1400 HOMEOWNER EXEMPTION-ONE &TWO FAMILY ONLY
FOR HOME OWNERS 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 127.0, 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 accorda++ce with the rules and regulations promulgated by the BBRS enti!'ed
Rules and Regulations for Licensing Constriction Supervisors.
Exception:Any Home Owner performing work for which a Building Permit is required shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work ,that such
Home Owner shall act as supervisor.
For the purposes of this section only,a"Home Owner" 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
two-year period shall not be considered a Home Owner.
If yet are applying under this section sign below:
nature
. Your signature carries certain responsibilities eluding but not necessarily limited to, general liability
NOTICE 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
2.15.2 of section 5)
1500 COST
Cost of Improvement 5
Items to be installed but not included in the above cost: Electrical 5
Plumbing
HVAC
Other
/
TOTAL $ ,
1
The following section for official use only.
INSPECTORS' REVIEW
Date plan reviewed
30 days to review period expires
• OK to issue date
OK to issue subject to requested submittals (see project review worksheet) date
DENIED see project review worksheet date
HOLD reason date
HOLD Subject to Zoning Board of Appeals action
Comments •
Inspectors signature
MAY 0 4 200iDate
Applicant informed of above- Date time staff (fax, phone, in person)
ssssmxsxxms:sxssmsssssssst:sttsssssssssxszsxssssss:sssssstssssssssxsssstssstsss*sssstssssssssassssmsssssss
Over six months since approved for issue - DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
Inspector .� Date
Advised applicant Date Time staff (by phone, fax or in person)
ssssxsssasssssssssxsssssssssssssssxsssssssmss:sxsssssssssssssssssssssssssssss:ssssssmssmssxssssssssmssss
OFFICEWVSPECTORS NOTES
TOTAL FEE 6 2 Ea
Gross area - new construction ✓/ -, Total Sq. Ft.
alteration Total Sq. Ft.
Permit is issued to
i
v X r Y ram- --_- - . '4/ 'K ? .a. .2....—_
Comments/notes on permit
I
1600 TO THE APPLICANF/REFERRAj,AND APPROVAL
Date of Application submission
Plat Lot Street
Aquifer Zone
•
Owner
Owner mail address
Owner phone#
ssss:::::::ssssss ssssssssssss*:ssssssssssssssss:ssssss:::ssssss*sss:sss:ssss:ssssssss*ss*sYssssssssssss
OTHER INVOLVED AGENCIES-The following agencies require separate jurisdictional
proposed project. CONTACT THEM FORpermits or approval for your
REQUIRED SUBMISSIONS.
® TAX COLLECTOR Approved HOLD By
Date
❑ Board of Appeals = Approved By
Date
❑ conservation Commission, E Approved By
Date
❑ D.P.W. Water L- Approved By 0 D.P.W. Sewer _ Approved By Date
❑ D.P.W. Cross Connection 7 Approved By
Date
❑ Treasurer(Bond) 0 Approved By
Date
❑ D.P.W. Engineering 7 Approved By
Date
!care' of Health (well) = Approved By
Date
a s oard of Health (septic) = Approved By
Date
a Board of Health (food service) = Approved By
Date
❑ Planning Board (parking) = Approved By
Date
® FIRE DISTRICT (I - II - III) 7. Approved By
Date
BU DEPARTMENT APPROVAL: t.ILDING
❑ ZONING IIIMAY 04 2001 ".)
I ez..,„
❑ BUILDING INSPECTOR/BUILDING COMMISSIONER
a CONTROL CONSTRUCTION AFFIDAVIT
sss:ssssssssss:sss*:ssssss:ssssssssssss::ssssssss:ssss::sssssssssssssssssss****:ssssss::sss:ssssss::PROJECT SUMMARY:
new construction/ alteration/demo sewage disposal - public/private / /
[A1teradd interior walls] [add rooms] [add footprint]
water supply - public/priva well cj....
[pool] [garage/shed/deck] [game court] [food service]
DescribeOle .
sssssssssszssssssssssssssssssssssssssssssasssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss
To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have any
questions please advise. If any reason to withhold the requested permit is found, please advise. Your assistance and
cooperation is appreciated.
The Building Department- Date sent for review
By
Permit No. BP-2001-19643 Project Location: 11 PINE ISLAND RD
Commonwealth of Wassachusetts
TOWN OF DARTMOUTH GIS p#: 4350.00
400 Slocum Road,Dartmouth,MA 02747 Lot: 0007
Phone: (508)910-1820 Fax: (508)910-1838 Sublot: 0000
BUILDING PERMIT CateProject r NEW
S 001-0768 V
FIELD INSPECTION Est. $53 0.00
Const.Class:
Use Group: U
Contractor: License: Phone#: Lot Size(sq.ft.) 1.1A
Engineer: License: Phone#: Zoning: SRB
New Const.: N/A
Applicant. Phone#: Alt.Const.: N/A
RILEY PETER M (508) 998-8157
OWNER:
RILEY PETER M&PATR7i7
A RILEY
DATE ISSUED: d
TO PERFORM THE FOLLOWING WORK:
10'x 14' shed and 24' x 24' attached garage
DATE TIME TYPE OF INSPECTION&REMARKS INITIAL
"71I30/0/1 //,,'/'S 62-(,07Y.%-i .."&z.....ell,. i' ' " 6-,a __...)-a-k e t 4-A-e _
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BEO/Orri!cEiti ionlgtErseAgEui:jait.iCONTRACTOR
Registration: 119870
Q1+5/ Expiration: 9/11/2007
Type: DBA
• FNIc FRARNCI S DSDEtAs EMEEFRS 1-10ME IMPR..&REM.
•
209 SHARP ST
—zz,„...--4-7e-re:t. •
- N.DARTiVIOUTH,#AA02747 Administrator
gze
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 084295
Birthdate: 091112/1961
Expires:09/13/2008 Tr.no: 1818.0
Restricted: 00
FRANCIS NI DENIERS
42 GRANDVIEW AVE
FAIRHAVEN, MA 02719
commissioner •
•
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copy
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TOWN OF DARTMOUTH
.--) __. .
- - -
)-- .2) y :),(- '4 -
- I RECORD PLAN
A Copy of This Endorsed :,::.• --.
.--.._:
Plan Must Be Kept On Site
C lb
I
During onstruction
Date
i 1 1
FILE COPY
1600 TO THE APPLICANT/REFERRAL AND APPROVAL
Date of Application submission
Plat Lot Street
Aquifer Zone _
•
Owner
Owner mail address
Owner phone#
OTHER INVOLVED AGENCIES-The following agencies require separate jurisdictional
proposed project. CONTACT THEM FORpermits or approval for your
REQUIRED SUBMISSIONS.
TAX COLLECTOR = Approved = HOLD By
Date
❑ Board of Appeals = Approved By
Date
❑ conservation Commission- ` Approved By
Date
❑ D.P.W. Water = Approved By 0 D.P.W. Sewer _ Approved By Date
❑ D.P.W. Cross Connection = Approved By
Date
❑ Treasurer(Bond) 0 Approved By
Date
❑ D.P.W. Engineering = Approved By
i1 Date
•,oar r - • .. wet _ •p. ;y: '411 i -`�
Date
❑ : � )
oard of Health (septic) = Approved By :- /�� c �
J- 6l mate o ;� 5
❑ Board of Health (food service) = Approved By
Date
❑ Planning Board (parking) _ Approved By
Date
O FIRE DISTRICT (I - II - III) _ Approved By
Date /
BUILDING DEPARTMENT APPROVAL: •
❑ ZONING ,e4._ M MAY 0 4 2001 /
02
❑ BUILDING INSPECTORBUILDING COMbIISSIONER ,
❑ CONTROL CONSTRUCTION AFFIDAVIT —
PROJECT SUMMARY: us
new construction/ alteration/demo
sewage disposal - public/private
[Alter:add interior walls] [add rooms] [add footprint]� ] water supply - publicipriva well
[pool] [garage/shed/deck] [game court] [food service]
Describe �C�G ``
c13,,sLcS, A„atf-/-4
To the various departments: (7fq e (7�
✓ :4r
This notice has been forwarded to you for your information and any appropriate action. Should you have any
questions please advise. If any reason to withhold the requested permit is found, please advise. Your assistance and
cooperation is appreciated.
The Building Department - Date sent for review
By
` ''�—� The Commonwealth of Massachusetts
�) _ _ ( ' Department of Industrial Accidents
= Office offnvestfgations
600 Washington Street
-At
� �y�
e. —„ Boston,Mass. 02111
_�.:.- Workers'
or ers' Compensation Insurance Affidavit
Ica or nation y/r r rr +i Please R r e v , > ',C, iy l"`e ,, ' ;
1
name: Faer e+ 1
location: / 1 r R.e�5 tc.,. J f ze----
city -tt�tti v T Y1'l l=� , "1 phone# Cad 1!�d /,�7
all-m a homeowner performing all work myself
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: phone#:
insurance co.' policy# .
0 lam 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: phone#:
insurance co. policy#
"// 17 ri y" �r/,, / / rA,,, ,x?"r? :4/',a / u m motor ir�riii i/' // .7%v' 'px/ r; r/-%. .y �i. "� r.�� '/� - i.B /y�i//.�v,w,c,tis,�, ...,�; -.,»i/,.a/if✓x.'�',c�'r� i'�/r� "^�"'�' �:�" 9 .�/v'�,,.r/�'",
company name:
address:
city: phone#:
insurance co. y policy#
e 8 8 ///lb l'lt°rPr,�t,, , iii„ai.', ,."7 'aF:: '/,4 ✓., :. ///.v.;: /;ILEM.,Y h. ' / '/./' ' //6 / / ✓r''./�i„1:,'.
Failure to secure coverage as required under Section 25A of iIGL 152 can lead to the imposition of criminal of a fine up to S1.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 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 certify under the pains and penalties of perjuly that the information provided above is true and correct.
�'. /� ,� `/
Signature '. /
Print name_t� � i l a
/ Date 7 �D Phone# 5-6e—!I€Pf/57
official use only do not write in this area to he completed by city or town official
city or town: permit/license# ['Building Department ti
['Licensing Board
['check if immediate response is required ['Selectmen's Office
['Health Department
contact person: phone#: ['Other
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(revised 3/95 PM)
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
ti 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.
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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.
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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.
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
�, Department of Industrial Accidents
lr=
{;; �lil� t Office of Investigations
c __:iti t 600 Washington Street
07. _ th=� Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A plicant Information Please Print Legibly
x
a e (Business/Organization/Individual): ' 'Z I44ddr ss: 2 S�`L/' e `1
9
/State/Zip: ,,, _z ?( k Phone #: -c19b r3 ' 6
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 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. 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
required.] officers have exercised their 10.0 Electrical repairs or additions
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 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 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.
$Contractors 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. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 verifi n.
I do herebirelai s awl., allies of perjury that the informati -provided above is true and correct.
to ..... Date: ,: "...2 —
Plrcfie#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License# FILE OP
_
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,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, §25C(6)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,MGL chapter 152, §25C(7)states"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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
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.
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
APPLICANT : lA SLSJUK" t Lr,ti I Lv
* MORTGAGE INSPECTION PLAN OF LAND
1 N
DARTMOUTH
SCALE : 1"= 80' MARCH 19, 1992
LOTS .
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FILE Copy
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LOT 12
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DRNE Pan Must De Kept en Sa
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PISLADRDLIE_
I CERTIFY TO PRESCOTT, BULLARD & MCLEOD, NEW BEDFORD INSTITUTION FOR
SAVINGS BANK AND ITS TITLE INSURANCE COMPANY THAT THERE ARE NO VISIBLE
ENCROACHMENTS OR EASEMENTS EXCEPT AS SHOWN AND THAT THIS PLAN WAS PREPARED
UNDER MY IMMEDIATE SUPERVISION ,
THE LOCATION OF THE DWELLING AS SHOWN IS
IN COMPLIANCE WITH THE LOCAL ZONING BY-
LAWS WITH RESPECT TO HORIZONTAL "141
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DIMENSIONAL REQUIREMENTS .
1C£n1NE7
THE DWELLING SHOWN HERE DOES FALL WITHIN A FERREir .
SPECIAL FLOOD HAZARD ZONE AS DELINEATED �fr
°• ' - ,m/
ON A MAP OF COMMUNITY #250051B, DATED \le RF i o a�r .
6/1/83 BY THE F , I A, p��a�Ai+u \1'/
NOTE: ZONE A IS AN AREA OF 100 YEAR FLOOD;
BASE FLOOD .ELEVATIONS AND FLOOD HAZARD Land Surveyors Civil Engineers
FACTORS NOT DETERMINED. :Ise oston lEunb ,4urbeg (Igo., Pint_
•172 iiil illium t.
Ietn !tdforb, 4111j1 02740
GENERAL NOTES: (I) 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
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.
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QUAINT WORKSHOP
FILL COPY .
HPM 1301 ._
- Price code C
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los. /` _ � �= a window planter box,and an entry
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of the roof adds to its charm. Inside,a z=
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T_ —` perfect setup for weekend projects. '
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Price code C
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This model has front doors and windows along what is traditionally the sgfjping Construction
the unit.The high window flower boxes leave room for plantingikirrdbs and
bushes against the wall.The inside is roomy enough for storing toots an eq
ment,with enough extra space for a workshop.
112 GARAGE AND SHED PLANS '}
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