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Home My WebLink About0175 SEAPUIT ROAD � � � Y� l �oF T Town of Barnstable *Permit#C_,;0Cq0 Expires 6 months front issue date -.Regulatory Services Fee_ * anxtasrABLE, • . M^S& Thomas F. Geiler,Director �A 1639. Building Division Tom Perry,CBO, Building Commissioner 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 � O) 06 o,7 Property Address C [Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address /✓��Q�/ � /%j Contractor's Name �t71/�,h �/�'L�' Telephone Number 772 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) / �"� �� S PERMIT ❑Workman's Compensation Insurance NOV 3 ® 2009 Check one: ❑ I am a sole proprietor TOWN OF BARNSTABL5,--` ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# ole9 lc��/�7 2 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 #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 quired. SIGNATURE: Aj .-e!e� Q:\WPFILES\FORMS\building permit formS\EXPRESS.doc Revised 090809 i A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations f= 600 Washington Street Boston, MA 02111 _ �P y wwm mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /f Please Print Legibly Name (Business/Organization/Individual):/ Z4 Address: City/State/Zip: l/Z hone #: Are you an employer? Check the appropriate box: Type of project(required): 1.Ia 1 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-dontractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. [-Remodeling ship and have no employees These sub-contractors have g• 0 Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp.insurance.1 • required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I 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•0 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 41 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. tContradtors 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: Policy#or Self-ins. Lic.#: //� �/O 7Z�f�Z 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 verification. I do hereby certify un er the pains and penalties of perjury that the information provided above is trice and correct Signature: Date: Phone# Official tcse 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#: 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 bum 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 4-24-07 Fax # 617-127-7749 www.mass.gov/dia I 1Lt1 11 � �THETo,,y Town of Barnstable Regulatory Services 9a"RMAE& Thomas F. Geiler,Director 039. 3� 0 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 I, �/j� (��,f' �,*�/�; , as Owner of the subject property hereby authorize X;V'eZ--0 to act on my behalf, c in all matters relative to work authorized by this building permit application for. �7� a� 7 ,fir? (Address of Job) 1 Signa of Owner Vate Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION Town of Barnstable o Regulatory Services HAMSTABLE Thomas F.Geiler,Director MASS.9� : ,�� Building Division AIEp �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 Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone#t 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 pen-nit. (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: 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\FORJvI S\homeex empt DOC i Massachusetts- Department of Public Safet- Board of Buildinl; Revelations and Standards Construction:Supervisor License f .License: CS 63537 Resfricted.,to:;_00..., DAVID R.COX N. PO BOX 401,'° S YARMOUTH; MA:02664 Expiration: 10/15/2011 ('ummissiuner' Tr#: 5822 GT1zze i�ari zom�uea Board of Building Regulations and Standards HOME IMPROVEMENT: License or registration valid foi-individul use only CONTRACTOR before the expiration date. If found return to: Registration 100497 Board of Building Regulations and Standards Ezpirato 6 18/2010 Tr# 268012 One Ashburton Place Rm 1301 {{ j = Typ�gFrivate Corporation Boston,Ma.02108 1 (r ! DAVID COX,INC; David Cox f ,19 LAVENDER LN i YARMOUTH,MA 02673Z46�` I Administrator . Not valid without s' nature Frc:,::Kalhy Gedci s FaxlD Northwood Insurance Page 2 of 2 Date:1 1/12f2009 09 59 AN)Page.2; 1 ,JCOOR CERTIFICATE OF LIA13ILITY INSURANCE OF►D KG DATE(MMICDIYYYY) PRODUCER DAVID-2 11/12/09 THIS CERTIFICATE IS ISSUED AS A MATTE OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Northwood Ins. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 540 Main, Street, Suite 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 Phone: 508-771-1632 Fax:508-393-2955 INSURERS AFFORDING COVERAG.E NAIL# INSURED _ INSURER A: Travelers Insurance Co. ( INSURER 9: Trawlers Insurance company David Cox, Inc. INSURERC' P. O. BOX 401 S Yarmouth MA 02664 INSURER,.: II IN&AE.a E: -OVERAGES ---------- THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.M)TWI;HSTANOING ANY REOI)IREMCNT•116W OR CONDITION OF AJaY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CER71FICATE MAY BE ISSUED OR MAY PERTAIN,THE.INSM\NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN r'S SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH' POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. LTR NusuFn L TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDlYYYY) DATE(MMlDDIYYYI') LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A C'OMMERCIALGENE14ALLIABILI'IY 11-680-148114796-COF-0903/14/09 03/14/10 PREMISESLE�acc��ce) $ 300000 (:,AIMS MADE a OCCUR NED EXP(Any c.e person) $ Cj 0 0 0. FXX Business Owners ' PERSONAL 8A.DVINJURY $ 1000000 GENERALAGOREGATE $2000000 GENL AGGRCGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2000000 POLICY PRE I — �Ecr LGC CSL 2000000 AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT ANY AUTO (Ea accivant) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (PerIp,son) ; HIRED AUTOS O�— NON-OWNED AUTOS BODILY INJURY $ (Pol'accident) -- PROPERTY DAMAGE $ I (Per nccidant) I GARAGE LIABILITY AUTO ONLY-EA ACCIUENf $ ANY AUTO OTHER THAN EA ACC AUTO ONLY. AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE` $ OCCUR LJ CLAIMS MADE 1 AGGREGATE $ . $ DEDUCTIBLEWOFNE $ RETENTION $ $ RS C v e AND EMPLOYERS'LIABILITY I( c _ y/N iTORY LIn1iT�.L_ ER B ANY YPROMEM9EEXCLUDED'7 C-TiVE ❑ 6KUB91OX742209 07/15/09 I 07/15/10 E.L.EACHACCIDEn; $ 100000 (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 100000 II es,descrlbelundor SPECIAL PROVISIONS belay: E L.OISFASF-P(x ICY I WIT $ SOOOOO OTHER --�—^�— DESCR ION OF OPERATIONS O O r•i I L CAT( NS 1 V H Lfis I EX LUSION$ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWNBAR DATE-THEREOF,THE ISSUING NSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TITHE CERTIFICATE HOLDER NAMED TO T4E LEFT.BUT FAILURE TO DO SO SHALL TOWN OF BARNSTABLE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR BUILDING DEPT 367 'MAIN STREET REPRESENTATIVES. HYANNIS MA 02601 AUTHO REPRESE TATIVE ACGRD 25(2009/01) m 1988.2009 ACGRD CORPORATION. All rights reserved. The ACGRD name and logo are registered marks of ACORD