The URL can be used to link to this page

Home My WebLink About0061 CLAMSHELL POINT LANE �vl C lam s h e// ��'n� ��cl, - r Town of Barnstable .*Permit#31S��O�y Expires 6 months from issue date d Regulatory Services Fee sA�AB14 MASS, Richard V.Scali,Directo �� 1639. ♦� ' �� PE R Building Division �1,° Tom Perry,CBO,Building Commissi@&T 0 7 2015 200 Main Street,Hyannis,�VF B —C www.town.barnstable.ma.us Office: 508-862-403 8 RNS Tiq 8(I^�x: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONL Not Valid without Red X-Press Imprint Map/parcel Number Property Address �C ❑Residential Value of Work$ _5,48�r Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ! (2ajl Uap �f(ajjLL 31LeI �Qa'y\ 4 t_n Contractor's Name Telephone Number (_ CO r Home Improvement Contractor License#(if applicable) �b ys t Email: Construction Supervisor's License#(if applicable) 09.1 Z I ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Nameq Workman's Comp.Policy#, j�ltJL► ao�j 0 ( � d 1 ( C> Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side Ef Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows. #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Irequi perty Owner must sign Property Owner Letter of Permission. opy of the Home Improvement Contractors License&Construction Supervisors License is d. SIGNATURE: 773!� Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 I t 1 , ?lie Comitroyrivealtjh of-Massachusetts Deparbnext of'firdmbial Accidents Offike of Invmfigations 600 Washington Street ti Boston,4 02111 fault?mass govfdia Workers' Compensation Insurance Affidavit:BgildersiCnntracturs/EIectricianslph tubers Applicant Infarmation Please Print LegibIy Narue q(s,rinsesl�Organiza6ionlJndivi�a;}. �q y4fit k o.�a _ Address: /6 t/ City/Stat Zip-- o Phone#: O d d Are you an employeri C6eck the appropriate box: Type of project 1.El am a employer w El (required}: with 4- I am a general contractor and I 6_ ❑New est construction employees(full and/or part-ime * have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition woaiang far me in any capacity employees and have workers' [No urorkers' comp.insurance comp.insurance.l 9. ❑Building addition required-] 5. ❑ We are a corporation and its 10❑Electrical repairs or additions 3.❑ I am homeoumer doing all work officers have exercised their 11.❑Plumbingrepairs oradditions myself[No workers'camp- fight of exemption per MGL 12.❑Roofrepairs insurance required.]i c.152, §1(4h andwe have no employees-[No workers' 13-❑,Other comp-insurance required.] *Auy appBcanithatchedabox P1 must also fill out the sectionbelawshowing their w ulsere compensation policy informstiao. 1 Ho+*+..eK who submit this aidn f U.McItm-9 they axe dmiE6-all wank an4 then hits outside couttactors amst submit anew affidzuk indicating such. Icoutractors Tbst check this box must attached an additianal sheet showing the name of the and state whether.ar not those entities hzve employees.Ifthesub-contmctflts have employee%they=nTpmvidetheir xorken'romp.policy number. Lam an earapLgvr that is prouiduag workers'coaaaperasatiun insurance for my employ�em Betoav is Yitepoticy acid job site information Insurance Company Fume: 'Policy,45'or Self-ins.I.ic.;A� ✓-K.J Expiration Date: Job Site Address: City/State/Zip: �.- Attach a copy of the workers'compensationpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requ red.under Section 25A of MGL c 152 can lead to the imposition of criminal penalties of a fine up to$1,50a.00 and for one-year imprisonment,as well as civil penalties.in the form of a STOP WORK ORDERand a fine of up to$250-00 a day against the-violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations ofttre DIA insurance coverage verification- 1 do hereby cettafy ri tic s a natties ofperjury thatthe urfotmmtion-prmt i&d abmre is true and correct Sienature: bate: Phone ik Official use only. Do not writs in this area,to be completed by city artown official City or T'onu: PermitUcense# Issuing Authority(circle one): 1.Board of Health. 2.Building Department 3.Qtyfown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 9: Informa tion and Instructions Massachusetts Gerieaal Laws chapter 152 requires all employers to Isovide workers'compensation for their employees. PMMIMattD this StStUi,an.EnPIvyee is defined as."-.every Person is the service of another under any contrast of hie, eo`press or implied,oral or w7itt=" An mwfoyar is defined as"an individual,paztammhip,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint entapase,and including the legal representatives of a deceased employes,or the receiver or trastee of an individual,pmt aership,association or other legal entity,employing employees. However the owner of a dweIInng house having not more than three apartments and who resides therein,or the occapant of the - dvwelli g house of another who employs persons to do maintenance,consfzuction or repair work on such dwelling house or on the grounds or building appurh a thei eto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also staffs 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 applicantwho has notproduced acceptable evidence of compliance with the insurance.covex•agereqused." Additionally,MCM chapter 152, §25C(7)states"Neither the commonwealth nor;�3y of its political subdivisions shall enter into any contract for the perfoffiance ofpubho work until acceptable evidence of compliance with the insurance._ requirements of this chapter have beau presented to the contracting aufhoaty-" Applicants Please fill oiof the woikeas'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sob-contractor(s)name(s), addresses)and phone number(s) along with their cerli dcate(s)of has rrance. Limited Liability Companies(LLC)or Lim t dLiabilityPmtaciships(. with no employees other than the members or partaer,me not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 retommed to the city or town that the application for the pemait or license is being requested,not the Department of Industrial A_ccidenfs. Should you have any questions regarding the law or ifyou are iced to obtain a workers' compensation policy,please call th5 Department at the number listed below. Self-insan ed companies should enlmr their s elf-ins ce license number on the appropriate line. City or Town Officials . t Please be sate that the affidavit is complete and pried legibly. Tlie 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 sur-e to fill in the permit/licrose number which will be used as a reference number. In addition, an applicant that must submit multiple pemsibUcense applications in any given year,need only submit one affidavit indicating current policy inn%rmation Cif necessary)and under"Job Site Address"the:applicant should write"all focations in (city or town)_"A copy of the affidavit that has been officially stamped or maikml by the city or trown may be provided to the applicant as proof that a valid affidavit is on file for future permit's 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 vesnture (i_e. a dog license or permit to bum leaves eto.)said person is NOT regakcd to complete this affidavit The Office of Investigations would like to thank you is 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 mmmber. Tie C-N�Watth of Massa.chusetb-, , Depazbnent of 1udUsizia.I Agents , �7i�e of�,ve�g�tio� 6�4 T�a$hin�tan St�� Basko,MA 0�1IF Tf,-L#617-727-4900 ext 406 or 1477-M ASS Fax 9 617-727-7749 Revised 4-24-07 .m gavidia I i • BAENSPABM 9� 1639. Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601- www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230. Property Owner Must Complete and Sign This Section. If Using A Builder I, D 0d) fo 11 , as Owner of the subject property hereby authorize 4Z Y,Clc ti to act on my behalf in all matters relative to work authorized by this building permit application for: (A (Address of Job) 1 Signature of Owner Date L Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMS\building permit forms\EXPRESS.doc Revised 040215 Town of Barnstable ' Regulatory Services �oFT tgry,� Richard V.Scali,Director Building Division 1 t saxr►szesr.E Tom Perry;Building Commissioner MASS. 9 200 16S9. �� Main Street, Hyannis,MA 02601 �b,,rEO www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# . CURRENT MAILING ADDRESS: - city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER 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. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official I Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 Uhe anr�rcoiuuea��/i a:)�/�iia d L+cense or�reg�strat►on valid for md►v�dul use only Cr Office of Co�isumer'Affairs&Business Regul.-hon " r �a ry t ig r .h _. beford the es �rat�on,date�If�found return'ok OMEIMPROVEMENTrCONTRACTOR ;p� ` f.3 T e `Office,of Consumer Affairs=and BusinessRegulat N' �A gistration �16452l Yp /0 Park+Plaza Suite 5170, Expiration 10/1912015 Individuate �E Boston,MA 02116. ; , 4 FRANK DONOVON-"- FRANK DONOVAN iNl 245 SO..MAIN CENTERVILLE,MA 02632'` " Undersecretary }' of va i without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-091391 I FRANK DONOVA14 104 Carlotta Avenfie I ¢ l Hyannis MA 02601 Expiratidn. Commissioner 10/28/2016 I 11H�16 -Oct, 7. 2015 11 : 01AM No, 9560 P, 1 CERTIFICATE OF LIABILITY INSURANCE Di0(7 2015 CERTIFICATE 13 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms 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 endorsomen s. PRODUCER CONTACT Melanin Begley The Fair Ineuranoe AQenoy Inc, PN Ne (508)775-3131�- F (6081 7 90-1677 619 Main street aoopless:melania@thefairagency.ccm Suite 1 INSURER(S)AFFORDING COVERAGE NAIC/ Centerville MA 02632 _ INSURERA;AMd - 26159 INSURED INSURER a: Frank Donovan 1m.90RERC: 104 Carlotta Ave INSURER 0: INSURER E: Hyannia MA 02601 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1510701109 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. _ INSR LTR TYPE OF INSURANCE POLICY NUMBER MPM/D0� PO CY P LIMITS y^- COMMERCIAL GENHRAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED CLAIMS-MAOE OCCUR E Ea o rrence 6 MED EXP(Arrf_no orlon S PERSONAL&ADV INJURY a GEITL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGA7E 6 POLICY jE,CT EILOC PRODUCTS-COMP/OP AGG S OTHER: 6 AUTOMOBILE LIABILITY 6dem1 $ ANYAUTO BODILY INJURY(For person) s ALL OWNED SCHEDULED BODILY INJURY(Per acddwM 6 AUTOS OS NO AWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS _ s UMBRELLA L AO OCCUR EACH OCCURRENCE S PXCESSLIAB CLAIMS-NWOE AGGREGATV t [)ED RETENTI N$ S WORKERS COMPENSATION E AND EMPLOYER/'LIABILITY PE� ANY PROPRIETORIPARTNERIEXECUiIVE YIN N/A E.L.EACH ACCMENT $ _ _ 100 000 A im�tEIn�NNiEXCLUbED? VWC10060199012015A 3/12/2015 3/12/2016 E.L 018EASE-EA EMPLOYE 6 500,000, II a,desnlbe under D ON OF OPERATIONS below E.I.DISEASE-POLICY LMOT 1 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEWCdFS(ACORD 101,AdMonal Remarks Schedule,may be ahaohed If more epaoe k r<gldred) CERTIFICATE HOLDER CANCELLATION (508)790-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVENED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 Aun(oRUEo REaaEeeNTArnE Jackie Stewart/FAIMCI 019BB-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD