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Home My WebLink About0123 TOWER HILL ROAD t Z3 Tawe-2 A << e,,-4 t i t F pFT►+E rgty Town of Barnstable ZP e orm i t# Expires 6 months from issue d e Regulatory Services Fee awisNsrne—, �cb ,"�: `� Thomas F. Geiler, Director ATED MAr p Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www,town.barnstab le.m a.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number OUD Property Address Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name .,�)eh-t-k Sm1—LS Telephone Number Home Improvement Contractor License# (if applicable) Construction Supervisor's License#(if applicable) Xworkman's Compensation Insurance '° PERMIT Check one: ❑ I am a sole proprietor OCT -.. 6 2010 ❑ I am the Homeowner I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name M�}� Workman's Comp. Policy# � � Y � � �� ' 3� �A CD Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) QQ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to� ��(yl U�J+se ❑ Re-roof(hurricane nailed) (not stripping. Going over existing layers of roof) ❑ Re-side # of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .35) # 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 Ho k1rovement Contractors License & Construction Supervisors License is required. I SIGNATURE: Q:IWPFILESTORMSIbuilding permit forms�EXPRESS.doc Revised 072110 The Commoirivealtl! ofllfassachrlsetts Deparhnent oflnduslrial Acciilenis OJy7ce of Investigafions I� 600 Washington Sheet Boston, 1'4 02111 � ! r'4'3671r.AlaSS.g'Ovl(Ira 1Vorkers' Compensation Insurance Affidavit: Builriers/Con.ti-,ictors/Electricians/Pl.iimbers Applicant Information Please Print Legibb; Name (Business/O gauizotiou/Individnai): Address: V City/State/Zip: -2 v l Phone#: �S'�a�'� (o�o Are you an employer? Check the appropriate boa.: Type f project r . uir e l..D5 I am a employer,,S7.th_�. 4. El am a general contractor and 1 }P 'o. P J ( e9 employees(fu.11 and/or part=:time).' have hired the sub-contractors 6. ❑.New constnrctiou 2..❑ I am a sole proprietor orpartaer- listed on the attached sheet. 7. ❑Remodeling ship.and have no employees These sub-contractors have g- ❑.Demolition xrork-ing for me in any capacity. employees and have Zvoricers' IN w'arkers' comp.insurance comp.insurance.. 1 9. ❑.Building addition required.] 5. ❑ We are.a corporation and i.ts 10.❑Electrical repairs or additions 3.❑ '1.am a homeowner doing all work affcers have exercised their 1 l..❑Plumbing repairs or additions thyself [No workers' cornp. right of exemption per MGL 12.0'Roof repairs ins.uratice:required.]:T c. 152, §1(4),aad.rve have no employees.'[No worizers' 13..❑ Other comp.:i=rauuce.requu•ed.] *Any applicant that checks box#1.nuw also fill out the seciian below shooing ih.eir workers'cowpwsa:ti;on policy information- t Honieovvners svbo submit this affdsvit iniH¢ating they are doing 0-wcrk and then him autside contractors mast submit.a mew affidavit indicating scrctL ICarrtractnrs that check this box intnt witached am sddhicasl:she.et sb:owiag the'aame of the sub-contraunrs and state whether or nor(hose entities bave employees. If the sub-contr narslave employees,ihey.nmst provide their wurkus'comp.polio}-number. I our rna employ ar that is prot7dirrg rtrorirars'.contper.tsation irtsrara.Trce for lcry etvrployeas. Below-is the policy- rrnd jo.b site ir�farrrrrrhort, t Insurance Company Name.- Policy#or Self-ins.Lic.#: UU °C _ Q Expiration.Date: F S r) ^ Job Site Addrem: ,r1 City/State/Zip: A \'�� 2Ir 0 Attach a copy of the i`•orkers' compensation policy-declaration page(. hotidng the policy number and eapir•atdon date). Failure to secure coverage as required tinder Section 2.5A of MGL c. 152 can lead to the imposition of cr.ituinal penalties of a fine up to$1.,500.00 and/or one-year imprisonment,as well is 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 st t.ttsmeaat may be forwarded to the Office of Investigations of the D.IA f insurance coverage verification. I ado hereby ti rare er i I aralfies o pevjlity tltat the n.tforrTtatiovt prm�r ed n.bat� rs trite and correct. Si ature.: z7Date: O rJ Phone M O(Iicial use only. Do not ifrite in fins area,fo be couipLeted by cif'or town.ofcial Oty or Tmvn: Permit/License# rssuingAuthwity(circle one): 1.Board of Health 2.Building Department 3.C�ty/roarn Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Outer Contact Person: Phone M op THE rpk Y # + BARNSrA MASS, + 1639. Town of Barnstable j �rFo �A Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder i i as Owner of the subject property hereby authoriz to act on my behalf, in all matters relative to work authorized by this bi. ding permit application for: (Address of Job) G adlc� Signature o wner Date /V C V &I Cl�ld/ Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. QAWPFILESIF0RMSlbui1ding permit formsTXPRESS.doc Revised 072110 r ��o1H�Toys Town of Barnstable ' Regulatory Services * M gqj%IASS. , ` Thomas F. Geiler, Director 4 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 518-862-4038 Fax: 508-790-6230 ------------------------ HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER" name home phone N work phone N CURRENT MAILING ADDRESS: city/town state zip code The current exernplion 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.understan8s�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. 1 HOMEOWNER'S EXEMPTION The Code states[hat: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions orthis 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." '1 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 oRen 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. 'fo ensure[ha[the homeowner is fully aware of his/her responsibilities,many communities require,as par[of the permit application,that the homeowner certify that he/she'understands the responsibilities of Supervisor. On the last page of this issue is a form currently used by several towns. You may care I amend and adopt such a form/certification for use in your community. Q:\WPFILES\F'ORMS\building permit forms\EXPRESS.doc Revised 072110 a CERTIFICATE OF LIABILITY INSURANCE OP ID KG DATE(MM/DD1WW) 09/03 10 \ THIS 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 po cy es must be endorsed ,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). PRODUCER NAME: Northwood Ins. Agency, Inc. (A/C.No,Ext): (ac,No): 540 Main Street, Suite 9 ADDRESS: Hyannis MA 02601 rKVUMMK CUSTOMERID* STANL-1 Phone:508-771-1632 Fax:508-393-2955 INSURER(S)AFFORDING COVERAGE NAICs INSURED INSURER A: Liberty Mutual Ineucanee Co. Dean Stanley Building INSURER B; Contractor nc, 359 Capt. f.i ahs Road INSURER C CenterVille M 02632 INSURER0: 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. UIMK LNWAr LTR TYPE OF INSURANCE MR POLICY NUMBLY (MM/DD/YYYY)rVLMTCrr (MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL.&ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY jEa LOC $ AUTOMOBILE LIADIM COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIM&41ADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ S 08/31 10 08/31/11 TORY LIMITS ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOWPARTNER/EXECUTIVE El E.L.EACH ACCIDENT $100000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100 0 00 If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWNBAR THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF BARNSTABLE AUTHORIZED REPRESENTATIVE 230 MAIN STREET HYANNIS MA 02601 I 01988.2009 ACORD CORPORATION. Ali rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD .,_.. ivlassachusctts- Del). -t'ncnt of public ��" + «ulations and Standards „ Rc�, Board of Building, ervisor License Construction Sup License: CS 35037 . Restricted to: 00 DEAN F STANLEY 359 CAPTAIN LIMA 0 632 CENTERVILLE, Expiration: 111912012 Tr►#: 12334. ('umroisiuncr. Board of Building Regulatio s and Standards License or registration valid for individul use only lug HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registrat on:�132149 One Ashburton Place Rm 1301 Expiration:._11/28/2010 Tr# 278066 . ' Boston,Ma.02108 Type ,:Iridividual DEAN F. STANLEY,- DEAN STANLEY 359 CAPT.LIJAH RD CENTERVILLE,MA 02632Z-" Administrator Not valid without signa ur '