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HomeMy WebLinkAbout0068 WINDING COVE ROAD 1 v ��� � ���' �� �� v a a x li 1 a �+.-.--vim` J y � ' i. - � �; ' � � �� 15 .. i � f� �i V * �. n � r' ,y � �� �� � .. �l �. o �� �� � n r� �. � �, ,, �, ,, �� �� o p �, , � �� � ,,, , �, 1� � , ` ., �� �� �� � „ ,� r �, j, �� t: i TOWN OF BAR14STABLE RISE 2012APR23P012: 33 Division of Thielsch Engineering,Inc. 1341 Elmwood Avenue ENGINEERING Cranston,Rhode Island 02910 DIVISI N Tuesday, March 27, 2012 Town of Barnstable Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 RE: 68 Winding Cove Road; Marstons Mills, MA 02648 Barnstable Building Permit#: B20120407 Dear Mr. Perry, This affidavit is to certify that all work completed at 68 Winding Cove Road; Marstons Mills, MA, has been inspected by a certified Building Performance Institute (BPI) inspector. The following weatherization/energy saving measures were completed: ➢ Perform 6 man-hours of air sealing to include all appropriate blower door tests, combustion safety tests and procedures. ➢ Install one Therm-a-dome (or equal) R-14 insulating stair cover with a perimeter of plywood. All work performed meets or exceeds Federal and State Requirements. Sincerely Erik J. Nerstheimer RISE Engineering Residential Installations Department RISE Engineering; A Division of Thielsch Engineering tit 401-784.3700 •800-422-5365 •Fax 401-784-3710 I . 13 - RISE ENGINEEMG Completion A division of Tbieiseh Engineering� 6 eiTtifcate ' 4 1341 Elmwood Avenue,Craastoo,R102910 PROGRAM 6NGL1f8tING R 4 9 Tr. (401)784-3700 FAX(401)784-37110 CLC-RCS CASE 126030 Page I CONTRACTOR 0998 RISE Insulation CONTRACT DATE START DATE ADDRESS � 11/28/2011 01117/2/11 r /-CLIENT NAME D1iary Jo Buczck AUDITOR'` z.`"> ' Ruben Valenzuela ADDRESS 68 Winding Cove Road CASP Marston Mils,MA 02648 I� HOME (508� 12603019-1044 WORK � 7(_ PROJECT NO CELL FAX RIS-01-11-0035.1331 PRETEST PASSED Perform 6 man-hours of air sealing to include all appropriat0 blower door tests,Combustion safety tests and procedures. Energy Specialiere NOTES:Attic sealing,at KWT on plate.W.S.door to bsmt,&If poe:tble W.S.slidor to deck. NOTE TO CREW:SEE NICK OR TOM G.ABOUT THE A/S TIME. Seal heating and/or Cooling ducts within designated unheated areas. Start at the largest ducts near the air handier. Highest priotitie6 are disconnected ducts and large holes. Seal carefully all wall and floor cavities In use as returns. Apply mastic to atl take-oft and duct size transitions. Seal all boots to ceilings and floors. 6 Man Hours. FOCUS ON BOOTS IN THE BSMT. AND ON 2ND FZR. �LCalG� Insulate and Seal 4 kneewall hatches by installing 2"rigid foam board that meets the sections R-316.5.4 and 316.6 '"requirements of building code. Install One Them►-a-dome(or equal)R-14 insulating stair cover with a perimeter of plywood. G_V C If cv w , CC) CM f W W ' LL_ !y t I confirm that the measures listed above have been completed to my satisfaction.I have received a copy of the Certificate of Completion and hereby authorize the release of any final payments to the Contractor.I understand that this Authorization of Completed Work does uut iln any manner void any warranties provided tome by the Contractor. IIInspectoes store Cu mer Signature ATE FATE 07/13/2012 3:40:15 AM 02/20/2012 MON 08:03 [TX/RX NO 5962) 006 CHECK #:�lsl�✓?�' CASEV: 126030 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 057 Parcel 016 _ Application # Health Division '' Date Issued (. Conservation Division :Application Fee Planning Dept. Permit Fee., Date Definitive Plan Approved by Planning Board . a Historic - OKH — Preservation/Hyannis �. Project Street Address 68 WINDING COVE ROAD Village MARSTONS MILLS Owner MARY JO BUCZEK Address 68 WINDING COVE ROAD Telephone 508-419-1044 MARSTONS MILLS. MA 02648 Permit Request PERFORM AIR SEALING MEASURES; INSULATE HEATING/COOLING DUCTS; INSULATE, ` ATTIC HATCH; INSTALL MOVABLE STAIRWAY COVER (THERMADOME)- ,,. SEE ATTAC D : COPY OF CONTRACT FOR OWNER AUTHORIZATION } '� Q Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new, Zoning District Flood Plain Groundwater Overlay Project Valuation $1184.00 Construction Type ;v sv Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family :❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Rise Engineering; A Division of Telephone Number 401-784-3700 XXTX Thielsch Engineering Ext. 6133 Address 1341 Elmwood Ave, Cranston RI 02910 License # 100459 Exp. 3/28/12 Home Improvement Contractor# 120979 Exp. 3/25/12 Worker's Compensation # 3730961-01 Exp. 1/1/13 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO RI Resource Recove Co : J hnst n RI SIGNATURE DATE Erik Nerstheimer for RISE Engineering y FOR OFFICIAL USE ONLY z APPLICATION# s � DATE ISSUED' MAP/PARCEL_NO. — � ADDRESS VILLAGE q I OWNER Is DATE OF INSPECTION: t: 4` _.FOUNDATION,," _ :d j f FRAME r INSULATION: FIREPLACE ( ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL _=- GAS: t ' ROUGH ` " FINAL ."4FINAL BUILDING i DATE CLOSED,OUT = — I� ASSOCIATION'PLAN NO: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RISE ENGINEERING; A DIVISION OF THIELSCH ENGINEERING Address: 1341 ELMWOOD AVENUE City/State/Zip: CRANSTON, RI 02910 Phone#: 401-784-3700 OR 800-422-5365 Are you an employer? Check the appropriate box: Type of project(required): 1. X❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 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 working for me in any capacity. employees and have workers' insurance. 9. ❑ Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑X Other INSULATION 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. lContractors 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: THE PRESTON AGENCY, INC. Policy#or Self-ins.Lic.#: 3730961-01 Expiration Date: 01/01/13 Job Site Address: 68 WINDING COVE ROAD City/State/Zip: MARSTONS MILLS; MA 02648 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 verification. I do hereby certify er t air id pen s of perjury that the information provided abov is tru and correct. Signature: Date: ERIK NERSTHEIMER FOR RISE ENGINEERING Phone#: 401-784-3700• EXT. 6133 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#• THIEL-1 OP ID: 27 CERTIFICATE OF LIABILITY INSURANCE 1 DATE01/13112 OIYYYY) y, 111 I HIS CERTIFICATE IS 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(ies) 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 endorsement(s). 401-886-8000 CONTACT PRODUCER NAME: The Preston Agency,Inc. PHONE FAX 401-885-1700 1350 Division Rd Suite 303 A/c No E:t: A/c No: PO Box 810 E-MAIL East Greenwich,RI 02818-0810 ADDRESS: Judith A.Wright CPCU AA1 ARM INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Zurlch-Amerlcan INSURED Thielsch Engineering,Inc. INSURER B:American Guarantee&Liability Thielsch Group Inc. Hi Tech Realty Inc. INSURER C:Twin City Fire-Hartford Attn:Trent Theroux INSURER D:North American Capacity 195 Frances Avenue Cranston,RI 02910 INSURER E: INSURER F: _ COVERAGES CERTIFICATE NUMBER: 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. tLEFF TR TYPE OF INSURANCE POLICY NUMBER NR MMIDDY/YYYY MM DDTI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERALLIABILITY X 3730962-01 01/01/12. 01/01/13 PREMISES Ea occurrence $ 300,00 CLAIMS-MADE FRI OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO" LOC Emp Ben. $ 1,000,00 AUTOMOBILE LIABILITY Ea EII ED SINGLE LIMIT 5 2,000,00 A X ANY AUTO 3730963-01 01/01/12 01/01/13 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED (Per accident) AUTOS AUTOS ( )BODILY INJURY P E HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS Per accident $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE E 10,000,000 B EXCESS LIAR CLAIMS-MADE AUC-4857188-01 01/01/12 01/01/13 AGGREGATE $ 10,000,000 DED RETENTIONS y WORKERS COMPENSATION - X I WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN T Y IMIT R A ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/.A. 3730961-01 01/01/12 01/01/13 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDE D9 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 C Property Section 02UUNHE6930 01/01/12 01/01/13 Property see belo D Professional Liab DVL000026802 01101112 01/01/13 Prof Liab 2,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space la required) When required by a written contract. CERTIFICATE HOLDER CANCELLATION l TWNHARW Town of Barnstable k SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Division 1 ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street I Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �r�►w uctall� Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety Department of Public Safety Licensee Complaints License Type Construction Supervisor License# 100459 Restriction WS,IC Name Erik Nerstheimer City,State,Zip North Scituate,RI,02857 Expiration Date 3/28/2012 Status Current No complaints faxid for this Licence. Back.To Search IA�;1l'II 1� �, Hn:u►!of Hr►iltlinL' Itf•, t irl'd'irlilrr• Construction S 1►I:Uirin>.; Lice uPervlsor rnil t:rnrLu�l. nse: CS SL 1 SPecia Restricted 10; Wg 00459 y L►cense c 28 GLEANER CHAPEL ROAD NORTH SCI7_UATE R►02857 ..,.ar,. Exprratron. 3/28/2012 TM 100459 http://db.state.ma.US/dpS/licdetails.asp?txtSearchLN=CSL100459 4/20/2011 91teljja O ice o onsumer �ai/a4nkusmes`s�egguation 10 Park Plaza - Suite 5170 Boston, ]V� ssachusetts 0.2116 Home Improveontractor Registration s—_ Registration: 120979 Type: Supplement.Card J ' w Expiration: 3/25/2012 THIELSCH ENGINEERING M ERIK NERSTHEIMER 1341 ELMWOOD AVE. CRANSTON, RI 02910 � w - f�'�,y Sv Update Address and return card.Mark reason for change. Address ❑ Renewal Employment Lost Card PPS-CA1 Co 50M-04/04-G101216 Office of Consumer Affairs&Bu iness Regulation License or registration valid for individul use only' OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registrationtnb979 Type: 10 Park Plaza-Suite 5170 Iry Expire J _ .12 Supplement Card Boston,MA 02116 THIELSCH ENCACS ERIK NERSTHE 1341 ELMWOOD � CRANSTON; RI 029 Undersecretary Not valid without signature • i Control No: 34244 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF LABOR d DIVISION OF OCCUPATIONAL SAFETY J• 19 STANIFORD STREET,BOSTON,MASSACHUSETTS 02114 LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER RISE Engineering A Division of Thielsch Engineering, Inc. 1341 Elmwood Avenue Cranston, RI 02910 WAIVER: LW000672 EXPIRES: April 15, 2015 t IN ACCORDANCE WITH M.G.L. C. 111, § 197(B)(b)AND 454 CMR 22.03(3)(b), THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER IS ISSUED BY THE DIV. OF OCCUPATIONAL SAFETY TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF PERFORMING LEAD-SAFE RENOVATION WORK. THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVERMUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE WITH M.G.L. C. 1113 § 197B(b)AND 454 CMR 22.04 WHEN PERFORMING LEAD-SAFE RENOVATION WORK. HEATHER E. ROWE,ACTING COMMISSIONER L� Printed on Recycled Paper w A RISE ENGINEERING reueral ID#06-0406629 RI Contractor Registration No 8186 I A division of Thielsch Engineering MA Contractor Registration No 120979 CT Contractor Registration No 620120 1341 Elmwood Avenue,Cranston,R102910 (401)784-3700 FAX(401)784-3710 CONTRACT Page 1 R I S PROGRAM THIS CONTRACT Is ENTERED INTO BETWEEN RISE EAiG[AIEERING CLC-RCS ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE Client 0 .. Mary Jo Buczek (508)419-1044 11/16/2011 126030 SERVICE STREET BILLING STREET 68 Winding Cove Road 68 Winding-cove Rd SERVICE CITY,STATE,LP BILLING CITY,STATE,LP Marston Mills,MA 02648 Marstns Ml,MA 02648 I JOB DESCRIPTION Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks,foams,weatherstripping and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) $420.00. RISE Engineering will provide labor and materials to seal heating and/or cooling ducts within designated unheated areas. This work will be performed at the rate of$70 per man per hour,which includes materials. 6 man hours. $420.00 Provide labor and materials to insulate the back of the attic hatch with 2"rigid foam board that meets the sections R-316.5.4 and 316.6 requirements of building code. $124.00 Provide labor and materials to install an easily moved,insulating cover for the attic access folding stair. A small flat•surface of plywood will be created around the opening within the attic. This will allow the cover's integral weather-stripping to restrict air leakage. $220.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for eligible. measures,the Cape Light Compact offers a 100%incentive. -$840,00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for eligible measures,the Cape Light Compact offers 75%incentive,not to exceed$2,000 per calander year. $258.00 [E D NOV 2 1 2011 WE AGREE HE FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Eighty-Six&00/100 Dollars $86.00 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 70 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 6- 67 AUTHORIZED SIGNATURE-R E ENGINEERI G CUSTOMER ACCE P, CE - NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 3� SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK DAYS. AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE l i Town of Barnstable 2omit# `� P� 'b Expires 6 months front issue dat& Regulatory Services Fee -3 �a BARNST'ABLE, v MSS. Thomas F. Geiler,Director 163q. �m plED MA't a Building Division pfl Tom Perry,CBO, Building Commissioner R 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 05 / 0 Property hAddress / LJ a r' nn Co e V� rO Residential Value of Work 6;roo,('0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 0\_()f A tJS i C L' LO(f J'`IV r 1 C)C P C.s N(o t:y t o iy.`, I f l•S Nt A Contractor's Name e1gC r' �c�Nis f t LC i01V Telephone Number S pug' Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance ����S PERMIT Check one: ® I� ❑ I am a sole proprietor 2��0 ❑ I am the Homeowner APR — I I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name y JYi N; 1 P t ei P 1 n�S�.j Q r�; Workman's Comp.Policy# y Q([� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken-to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side 0�,< <r e c cC q © zv (Y #of doors ❑' Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is required.� SIGNATURE: QAWPFILESTORM%building permit forms\EXPRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations ' 600 Washington Street Boston, MA 02111 wfvw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information i, /t Please Print Legibly Name (Business/Organization/Individual): Meas,.P/ CLITU-S l r ye F/1e DV Address: '�? fG� L k; - City/State/Zip: Phone M Are you an employer? Check the appropriate box: Type of project(required): 1. am a em to er with .4. ❑ I am a general contract6r and I P Y �employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7, ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ 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 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. I j Insurance Company Name: 6 rq ru i t e S fel1 P Policy# or Self-ins.Lic.#: `[S o)O q Expiration Date: Job Site Address: t 1tv C (lo �' 1_� City/State/Zip: �(�a!Sf"G,u? 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under theepains andpenalties ofperjury that the information provided above is trice and correct. Signature: /�4i�t,,��//� Date: Phone#:,D$ Official use only. Do not write in this area, to be completed by city or town offcciad. 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#: 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,constriction 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 conunonwealth 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-contractors)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 permi0license 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 ().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 Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia �YHE roh Town of Barnstable Regulatory Services BARNSTA$LE, ' Thomas F. Geller,Director Mnes. fn 3;.�06. Building Division Tom Perry,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 S L , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this buildin permit application for (Address o o/b) / / AS S � CCS 41- ~ l G 1116 Sig lure o er Date 101 F2--C-1-5 t Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the-reverse side. O:FORMS:OWNERPERM1SS10N ! `S ! f 5 Town of Barnstable t' Regulatory Services +� Thomas F. Geiler,Director RA"SrABLE, Mass. t6yg. �0� Building Division �lED MAt a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION PleaseTrint DATE: JOB LOCATION: ' number street village "HOMEOWNER": name home phone# work phone 4 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 Note: Thiee-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 dQ 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.lhe 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/certifrcation for use in your community. Q:\WPF.ILFS\FOPMS\bomeexempLDOC from:Erica Barrett Si:Ci Cape Cod Insurance Faxi 01-DE CAPE GOD INSURA To:Meagher Date:72EZ-11:09 11:34 AM Page. of i i G +8T3 $31 $599 T-443 P-001/002 F!'�7TT--7 7 T ' F 1 Yr:1 mtz 61 w• :)q — —ru ) UTTcr p aDUC FR E E;- ,.Y AND cO Ft A Old Cape 0od'Iftw1i Agency I10 t4i Rp "V A E `-- ni N9 I ..'M ALTE ;TIEF .I 1 01,�I,t,Eli 11:11 Sill)RANCE Nvannis,WA 0=1 Cofp!P�MES 113 vi 14blL,;�4^-E-'iSURANCECO-MPANY w coMPANY A INSURED DBa,kwagher Corai 97 SMerzAd kznP Nui milia,NIA 01646 �WeWA�I�jESS =-11-777 I LL4 TKF pOLIcIES op INSURANCE USTED Kii RA/E m.'N'.SEUfx1 Tri THE Itrotim.11D NANWASOVE FOR i THIS ii CE11i T"iAT IM OkOONDITION OF ANY CONRACT 110'1 HER ""EQUIREMENT, THF F-AFFOIR=THE -FACUCY PERIOD 1 ANCA."Iii NOT W4 j ISSUEDID MAY TYLA TAIN 4F IN SLKAINC D=iil WITH RESPECT TO lhiillii WS ii V--ky @ - N AND r POLICIES DESCRISS�HFFMN IS Si TO ALL THE TERMS,19! �Oipg)jnONS OF SjC�j POLk,4ES.Ukl SHOW MAY MVE$FEN RFV'J=-U U'-, PAI 0 C ITR A Ty"WOMAW � 0 Wnoyi MEPROMeMAI 4C� D -rnturaR�'r an-~ i to at2ooll 45:211 e 1-9 i $ 2,lwAACCMKW Wopai COMPENSATION POLICY GOES mar,PPOVImi r-1:14KAGE F Ojk Wail 41'01 L�k- CERTIFICATE HOLDER NO-EILLAPON TOVVM, OF BARNSTABLE- ,Cojil MV Cf THE AR.-W MWF40D Eeax"UN i Tfli Tm lil CCWANYW"E= BLDG DEPT =FIVWTE"OLM NAME3 TQpie Li 31JT 23o sou'm srr Won No OMMy0i OR i OF FAURV-M UQ-SUCH Wi 8 HYANNIS,MA 02601 cao'lNY,rig 109 I ' 1lassachusetts-Department of Puhlic Safetl Board of Building Re!-ulations and Stantl:u•tls Construction Supervisor License License: CS 102260 Restricted to: 00 -'j MICHAEL MEAGHER JR 97 EMERALD LANE MARSTONS MILLS, MA 02648 Expiration: 11/5/2012 ( •umii..i un•r Tr#: 102260 i fie -r°a!S•,,,r,•or�uP.¢/.C/z `�'`��%uraau/zccvet�+' f Board of Building Reguiatioos and Standards 4 HOME IMPROVEMENT CONTRACTOR Registration: 162938 ExpiraBon: 4/27/201.1 Tr# 283438 3 TYPe: DBA MEAGHER BROTHERS CONSTRUCTION MICHAEL MEAGHER JR:' 97 EMERALD LN ` MARSTONSMILL.MA 02648 Administrator i License or registration valid for individul use only before the expiration da e. If found return to: Board of Building R lations an tandards One Ashburton PI 'e Rm I30 i, Boston,Ma.0 I r f N valid witbou s Assessor's map and lot number .. -l' ." .. ��... 1. 0 THE o F t Sewage Permit number ........................W.-r / Z MAUSTAMLE, p/ House number .................. ..�?...........................................' 90o M6 9 e0� 0 YPY Or TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO YFF .���� �`�..��........................................ TYPE OF' CONSTRUCTION ...WPPKa .........r.- t ................................................................................... C� ........... /` ..Y. ....... ..........19.E6 ..... . ..... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .�- ?T. U.;31�J'?t i J CrV ............... ........... .... Proposed Use ..S.t.►J`cl"C .l.a......Y....... n�.. ................... Zoning District ► l Fire District 1-� Name of Owner _ REA4 k.y....— C. �LJ 1 M11S_ „ Address ............ G....................................,..........c.... Name of Builder ��.F'���"�-...CC�I�)S i. — ...:a-)e-::Address ................. `. ..� ` ,'��5� . Nameof Architect ....................:.............................................Address ...................................................................a................ Number of Rooms D..�� .................................................................Foundation ............ ...................C,Ez=T�.........I..........i Exterior Cl_( ��t�,...... ....`.��....Sff/tiG/--f�....Roofing ........ :.... �`'� �- T.......................................... Floors hK t.L.iC?n\....-..W Wl VJPt-Cam...............Interior ` ...Z/7..... .............:............ ................. g �cF s...� �...tt1h ..... V ......0�Ln ........ g .c-7 Heatin ' ......... Plumbin .................................................................................. 111" �'�`�.....!.� 1..........................................Approximate. Cost 1,5 0. 000 Fireplace �... .....................y............................................. Definitive Plan Approved by Planning Board/ _r� __� -/jr ---- - 19 = Area .............�.�..l�.. tla........ Diagram of Lot and Building with Dimensions Fee ,'........................... � SUBJECT TO APPROVAL OF BOARD OF HEALTH -------------- XA to k l c f ti ' 97-p �x 3q' �® I G j 1 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name !........ Construction Supervisor's License ..041...`...Jr......... W. E. REALTY TRUST A=057-016 28043 1 - story No ................. Permit for .................................... ......... ly.DWkling..................... Lot 86, 68 Winding C6ve Rd; Location ................................................................ Marston Mills ............................................................................... Owner ....W.........E.....Realty...........Trus.t................. ... I .. ............. .. Ty I pe of Construction Frame.....................I..................... ................................................................................ Plot ............................ Lot ................................ Permit Granted ......June.......... 18, ..... Date of Inspection ....................................19 Date Completed ......................................19 7o' ~��y •`�., TOWN OF BARNSTABLE BUILDING DEPARTMENT s Daaa�r = TOWN OFFICE BUILDING rua �� s6�9• �� HYANNIS, MASS. 02601 eIFO�`!M• j i �i MEMO TO: Town Clerk FROM: Building. Department DATE: An Occupancy Permit has been issued for the building authorized by � �03 Building Permit/$�. ._,.�_..____ .� _ _ w,..... ...._..._.... ........_....................... .. issued to 1 //._!�"! _ .. Please release the performance bond. TOWN OF BARNSTABLE Permit No. 28043 Building Inspector Cash -- ---------- x"46 OCCUPANCY PERMIT Bond - ------ ------- --- Issued to W. E. Realty Trust Address iot #86 68 Winding Cove Road, '4arstons Wiring Inspector Inspection date Plumbing Inspector Inspection date 4&1— Gas Inspector Inspection date Engineering Department Inspection date Board of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. . ... ....... ................. ...... ....................................................................... 19 ... / - /Puilding Inspector Assessor's map and lot'numb'er SEPTIC SYSTEM MUST BE yoF THE cc t01� Sewage Permit number ........................C�.rJ.� y Q, 'INSTALLED IN COMPLIANCE • / 9IN® M TITLE 5 Z BAHB9TODLE, i House number .................. F D0�M69. ..:............. ............. E� 3� TOWN REGULA`IONO �0� TOWN OF BARNSTABLE of BUILDING INSPECTOR I�Z f M Ir T7/'/l .2 Cf'e APPLICATION FOR PERMIT TO .........�Y.'.. �.........................��..�..p........ .......................... � TYPE OF CONSTRUCTION .... Z?P ......^ AM .................................................................................... ......... ............9.S! TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 1 G CO E Location t� .............(p........W.W4 iN...................V........... .:........Mi47 �f—...............................y..�1 .............. ProposedUse ..5.(.1J�s�.E.....`��t�M`, .. ....... .................................................................................. � /c^Y/LLE Zoning District ..........1 .� Fire District CL �y���-� Name of Owner .Yv.+. ...Address vNT .., .�.... Name of Builder ... ' t .. .. :Address L/J v. 4.4.... � .:.............. �. ............ ...................... Name of Architect ..................................................................Address ................................................................... . . ............. �cJ •— o� Number of Rooms C ...............7.............................................Foundation .a.......U............ .- ..... Exterior .... W e --V//"uGl�. ......... ... ........... ........Roofng ........ 5P .........................................{..l..�..I..G..�..Floors .-.. U.....A ,u ........... CT.. 4..... .. .........................1R • 1 � .Interior �c_ ` &C 6W Heating ©fit .... ?\... 1�-..... '�1f.......Ok1—.......Plumbing .. � .. Fireplace .............�N ......6)..........................................Approximate. Cost ..... ,/ 00© // �. ........................................... Definitive Plan Approved by Planning Board ---------19 Area ....... t. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH aq 3q o l Z5•� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ....fX/la �? .0 ' ............... Construction Supervisor's License .................................... W. E. REALTY TRUST 28043 11, Story I've No ................. Permit for .................................... .........Single..Fanxily...Dwelling. .ling...................... .... ............. ...... . ........ Location .`.Liot...86 68..Winding-Cove-Rd.- ...... .... .... ................ ......... .... . Marston Mills ............................................................................... W. E. Realty Trust Owner .................................................................. Type of Construction Franke.............................. ........... ................................................................................ Plot ............................. Lot ................................ Permit Granted ........June . .................... .1...8........ 19 85 41L Date of Inspection .../.... 19 ....................I Date. Completed ...... . ... ............19 ta, ,al AV, _DES/G/V . r S/NFrL� -AM/LY - 3 13EDRooM ` W ITN 6-AK(3AGE C-KINDER DAI L' FLow I10,� 3 -330 (So/) = 4g5-G.P•.D. SEPTIC TAQK = 330 x 20070 = 6(,o G.-RD. USE . 1500 CAL..TAOK, D l5 PO-5A L RT— v5E I 000 UAi-.v.f 2' src��►� Z/6 �� to 1 S.I.QEvJALL- APeA = 184 S. F LoT .I88 k Z,5- = 4-70 PD.. B0TTDM Al2EA . .= 79 5. I✓ 83,+ Z9 SZ¢ Sq FT 79 .x /, p 7 9 G. P. D. I�t r'oTAL DESIGNj •= 5"4q G.P. D. T6-rA L. DA I L,v 1=low= 49 9- G.P. 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