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HomeMy WebLinkAbout0135 WATERFIELD ROAD ToWn of Barnstable *Permit 06�; " Expires 6 m hs from issue date X-PRESS PERNI Regulatory Services Fee 'Thomas F. Geiler,Director SEP 0 7 .2006. Building DivisiongfJe°6 TOWN OF Perry,CBO, Building Commissioner QAIL OF BARNSTABLE200 Main Street,Hyannis,MA 02601 www.town.barmtable.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 Property Address Qjt�esidential Value of Work LO, 00ol• ay Minimum fee of$25.00 for'work under$6000.00 Owner's Name&Address Ina r y t/a lei Way!i�v 49P1� .410, I�(���9B�l�Te'fe" Xne'Num er Contractor's Name ((JJ P HomejImprovement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance .Insurance Company Name "��r�Q /—tom /l/Y Gli Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) nn LJ Ke-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side replacement Windows/doors/sliders. U-Value (maximum.44) *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 a Improvement Contractors License is required. SIGNATURE: .Q:Foims:expmtrg Revise061306 - Department oflndiistiialAccidents ' Office of Investigations: 600 Washington Street r Boston,MA 02111'. www.mass.gov/dia - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kpplicant Information Please Print Legibly 01 Vame (Business/Organization/Individual)'�,!/G2 �/ /� (1�' �/�N ��� ®of Udress' yG City/State/Zip: ee4 Phone 12 .Ar y u an employer? Check the-appropriate box:: Type of project(required):- , 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 ❑ I am a sole proprietor or p artner listed on the attached sheet t 7. []JRemodeling ship and have no employees These sub-contractors have 8. [] Demolition Working for me in any capacity. workers' comp.insurance: g, ❑ Building addition [No workers' comp. insurance 5. ❑ We area corporation and its officers have exercised their 10.❑ Electrical repairs or.additions • required.] . . ❑ I am a.homeowner doing all work right of exemption per MGL ME] Phunbing repairs or additions ' 1 'myself.•[No workers' c. 152, orkers' comp.' • � � § (4),and we have no 12.[2400frepairs insurance requited.]t employees. [No workers` . comp.incr,rance required.] 13.❑ Other �,i rtQ�ti( oy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: IN ' tomeowners who submitthis affidavit indicating they an doing an-work and then hire outside contractors must submit a new affidavit indicating such ontmactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy iafor nztion. . vn an employer that is providing oviding workers'compensation insurance for my employees'Below is the policy and job site formation. ,urande•CompanyName: >Ll� t lkellt--w'11e, zjJ rivr�� licy'#or Self-ins.Lie.#: at Expiration Date•• j b Site Address: IiS. NQ �!�l/ X �S�f��i/� � �/l� City/State/Zip: tack a copy of the workers' compensation policy declaration page(showing the policy number and txpiz;a#on date). lure to.secure coverage as required under Section 25A of MGL e. 152 cam lead to the imposition of criminalpenadties of a ,e up to$.1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOYWORK ORDER and a ime• up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of restigations of the DIA for insurance coverage verification. `o hereby certo under the pains d penalties of perjury that the information provided above is true and correct Date: de. one#: 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 !..Building Department 3.'City/Town Clerk 4.Electrical Inspector"5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and. Instructions : L. fassachusetts Gcneral Laws chapter 152 requires all'employers to provide workers' compensation for their employees. ursnant to this statute;an employee is defined is"...every person in the service of another under any contract of hire, rpress or implied,oral or written." association,-corporation or other legal entity,.or any two or more �n employer is defined a�.:"aa?mdivid�al,:p���P,: • . - � • f the foregoing-engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the eceiver or trustee of an individual,partnership, association or other legal entity,employing employees. Howev..er;t�e- er of adwelling house having not more than three apartments and who resides therein, or.the occupant of the •ceiv .ywellinghouse of another who employs pions to do maintenance, construction orrepaa woiY on such dwelling house Ir on the grounds or building appurtenant thereto shall not because of such employment b e deemed to be an employer." vIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or •enewal of a license or.permit to operates 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 .nter into any contract for the perfonnance of public work until acceptable.'evidence.of compliance with the insurance -equiremeats of this chapter have been presented to the contracting authority. 4pplicants Please fill out the workers' com ensation affidavit completely,by checldng the boxes that apply to your situation and,if necessary,supply sub-contractor(s)narne(s),addresses) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or United Liability Partnerships CLEF)with no employees other than the members orpartners; 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 Deparfinent 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 lime. 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;fixture permits.or-licesases.•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 p ermit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office.of Investigations would tilde to thank you in advance for your cooperation and should you have any questions, please do not hesitate t6 give us a call. The Department's address,telephone and fax number: ' The Commonwealth of Massachusetts . Department of Indi}striaLAccidents . . . . .. .. >: .Office of Invest igations •b00-Washingfon Spreet . • V Boston,MA 0211L Tel #617-727-4900 ext 40.6 or'1-877-MASSAFE Fax#617-727,7749 . Msed 5-26.05 Wwy,mass.gov/din ACORD CERTIFICATE OF LIABILITY INSURANCE WARROP ID S DATE(MM/DD/YYYI) WA2 06 21 06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HUB 'International New England HOLDER.THIS CERTIFICATE DOES.NOT AMEND,EXTEND OR 437 Station Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. So.Yarmouth MA 02664 Phone: 508-394-0946 Fax:508-760-1407 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual Ins. Co INSURER B: Mass Workers Compensation Walter R. Warren INSURERC: 40 Alexander Drive INSURERD: Yamouthport MA 02675 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N POLICY EFFECTIVE POLICY EXPIRATION Lb 'UTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 A X COMMERCIAL GENERAL LIABILITY BINDER 05/15/06 05/15/07 PREMISES(Ea ocrurence) $ 50000 CLAIMS MADE 7 OCCUR MED EXP(Any one person) $ 50 00 X Owner/Cont Prot. PERSONAL BADVINJURY $ 1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2000000 POLICY JEa F LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ - H AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ S DEDUCTIBLE $ RETENTION $ _ $ WORKERS COMPENSATION AND X TORY LIMITS ER B EMPLOYERS'LABILITY APPS 05/19/06 05/19/07 E.L.EACH ACCIDENT $ 100000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $100000 IfyE6 describe under E.L.DISEASE-POLICY LIMIT $500000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ------1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL For File Purposes Only IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTH PRI_ IVE`� ACORD 25(2001/08) ©ACORD CORPORATION 1988 f i t ' ✓. fLD.I���REAITIO,N�S �. L►cen"sez 60 STRUCT.IONSI�JP-ER ISO`R y ^ r F Nur 091 riber � 653 r B►rtndateo34��sss T Ex ►res Og. '' �:� 2,008 r Trrno 99653 x Restr----- p a ' ,1NALTER-R .;1NA - _ y Yam' Board of Building Regula ons and Standards One Ashburton 'lace - Room 1301 Boston. Massachusetts 02108 Home Improvemenr;� o. .tractor Registration A Reqistration: 145832 Type: DBA z ( r Expiration: 3/4/2007 u r NORTH SIDE HOME IMPROVEMC WALTER WARREN JR. a 40 ALEXANDER DR. YARMOUTHPORT, MA 02675 r s-4 s Update Address and return card.Mark reason for change. DPS-CA1 0 SOM-0004G101216 Ej Address Renewal Employment Lost Card �0*1KE � Town of Barnstable Regulatory Services BARNWAB1 E ' Thomas F.Geiler,Director' �:..P 1659. rEo►�,+ Building Division Tom Perry, Building Commissioner. 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I a r r a-l , as Owner of the subject property hereby authorize �'l�I�� GU 1' o act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) - Signatur of Owner Date . riot Nam I Q:FORMS:OWNERPERMISSION