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HomeMy WebLinkAbout0183 WEST STREET ^ ° ✓ ° ^ o a °,,o p s- ° - yr. - 0 n e ° p. o �o o m - v ^ v o o a 0 x 0 a n u ^ u v • i� r v .,. 1. „' ,. • _ f �� _ ° , .. ., ° o.. ^ o a � o ° ° n ' ^' c A' r , r ° ^ P 0 0 p n v 0 r- e a i 0 t, ° ° ° r ao P ^ u ^ ^ r , ° a n, n 0 0 0 n� Il a °-.: .. .;° °- � .'. ,9 '..^,° ' ,. - � °•� � � O�^ ° °^.. ° ' °°.: � �n � ,°, �•.°r � roe �. ° ^ p ° ^ ° a ^ a" �o ^ 0 ° 0 r U ° ° ° •� ��, $ r ° - mod'° �4 , ° u, F ,. `cs3R� ..-9� ,�..,,+rT+iR.. �•�.r... °. -�;-`,R'++!;+*�..,. °. . _ r- kV, _�- �:r."a�R''.'�4�^"-`�"�r`�,^^Tm,t,,,r,�.4�,...a•....:n�.°.,,,,,,:,,,.�;r� ,^..-r,,.�-:: e- 4,-, %A n Town f B rn 1 *Permit ow o a sta e �CBO Building Departm wee 6►,►onths from issue date Brian Florence T .max �. s639. 1 Building Commissioner p Fp I�pr 200 Main Street Hyannis, �Q 601 �C 1 www.town barnstable.ma��i /! � ©J',� Office: 508-862-4038 8jf�UnY�, Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL 0N1Y p Map/parcel Number �d Not Valid without Red X-Press Imprint � -{ � �J Property Address Residential Value of Work$A; �,�,-„,— Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �6( I�A p—zi", k--60 P—` �z:5 (,i>.M -'42 I Wfon,�, ► t ram° Contractor's Name 4�CA,4,n D4p,_^ Telephone Number 7-24/-3/3- 7?c2c�— Home Improvement Contractor License#(if applicable) Z?(,, :2 g�4� Email: Q Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Che,pk one: [J l am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 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 ❑ roof(hurricane nailed)(not stripping. Going over existing layers of roof) [►� Re-side ReplacementWindows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *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. C:\Users\decollikWppData\Local\Microsoft\W indows\INetCache\Content.Outlook\9NNOKXYW\RESIDENTI ONLYEXPRESS.doc 09/26/17 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): �IQ r Address: T/J„ 24A4 o y�1 City/State/Zip: 3 Phone#: _ — -7o6 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 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. ❑New construction 2.91 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• $ 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g P • 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. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 under thepains andpenalties ofperjury that the information provided above is true and correct Sierra E�r'� Date: � /7z rI Phone#: 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#: 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, ed, oral or written." express or impli 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-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 cant'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 permittlicense 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 maybe 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 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 luvestigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#61.7-727-7749 Revised 4-24-07 www.mass.gav/dia Town of Barnstable Building Department Services a"B AS ' Brian Florence,CBO n�►saL . M�� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstablemaus Office: 508-962-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section - If Using A Builder I SC.G'TI 02-fZ-�Sa%�f ,as Owner of the subject property hereby authorize�f� r !v�-4 +4- to act on my bebA in all matters relative to work authorized by this building permit application for. �y, I (Address of Job) **Pool fences and slams are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner SigSature of Applicant Print Name Print Name k-9: 9' Date Q:FORMS:OWNMPMuV MsI0NP00LS Rev:08/16/17 'C and of Building Regulations and Standards ' •- '����icen e`C$-002187' � �- �'�'• Construction Supervisor GERALD T DINEEN PO BOX 844 = s MONUMENT BEAC 0.2 63 a l.J, Expiration: Commissioner 09/02/2017 �e rcoarc»�a�uucall�o`Qb�ga/yu Office of Consumer AfTairs&,Busines s Regulation }r HOME IMPROVEMENT CONTRACTOR, Registration:I,'7.6745 Type: Expiration:==9%20/2p7 Individual + GERALD T.DINEEN3Y y h 4 -- GERALD DINEEN :a . 5 CARL GARDNER RD. Z'* MONUMENT BEACH,MA 02553 Undersecretary aarUeu$is;no„i,b pgen;ou • " a9TTZO VAT`uo;sag LU0113131nft ssanisn OLIS a;!nS-:mIj 311ed01 gPue si[e]Jd jautnsuoD JO aaiw0 :o;a�n;aa Puno33I .081)ao13w!dxa aq;alo;aq. o asn V1PUrpur lo;P11eA 110l;er;s?28l Jo asuaa17. Assessor's map and lot number .../ ...:..... EPTfiC SYST "IUST INSTALLED lim rC�-�'w(, ;CE -. �..._ ( STATE Sewage Permit number .....,.. ./.......:-.......:....... -SK 1 TARP CODE AND TOWN � J W ATIOS. �PO.THETO T ,WN- OF BARNSTABLE � L 99sBSTSBLE,MAM i oho YpY a�0 BUILDING INSPECTOR APPLICATION FOR PERMIT TO �- TYPEOF CONSTRUCTION ................ ....................................................................................... ................2...........................19...?14— TO THE INSPECTOR OF BUILDINGS: - The undersigned hereby applies for a permit according to the following information: Location 7 . ...........�..�3........��c,�� ........��.................... ................. .............................................................. f n ProposedUse .................... t.......�I��%4.........G�I:................ � ...................................................................................... ZoningDistrict .........'� .. �.................................................Fire District ...................................................................... .... Name of Owner ..9_.dvu.' j...... ....!.................Address ..../............. ..............................:::............................... Name of Builder 119...............Address ...: 0 5 '2..1..�� - ...F!....'4.`�-;�. t.'.`..� '•• l.... ........ .... .......... . Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ...................................................................Foundation ............................................................................... Exterior ..........1. leeg-................................................Roofing ............. ::... ........................................... hInterior ...............Floors .................. " r.............................,..... ..................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace .I..........................Approximate Cost ,. ��- v ...................................................... ............ .. ......................... .................. Definitive Plan Approved by Planning Board -----------_______-----------19________. Area . �'... ....`..�.............. Diagram of Lot and Building with Dimensions Fee ! 0 SUBJECT TO APPROVAL OF BOARD OF HEALTH c-- ------------------------------- J ,o I hereby agree to conform to all.the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..................... ....... ..................... ...................... � ` � ' . � 6��� Garage No ' - Permit for .. �� ( � ! ' ------------------ .—.. � ' � Location —_l��..���b...St..............| ................ ` ] --����������.---------------- . l�roId OIaeo Owner --------------''-------' � . � Type of Construction -------------- ` --------------------------' ' Plot ....�����.---- �» ----------' / / Feb. 2l �� Permit Granted lV " ' � -------------. Dote of Inspection ..... ........lA | ` � 'Date Comp�he6 ..��..��'..—^�-----lg � ' . � PERMIT REFUSED � ` / l�| ................................................... --------------------------. . /� ~._---------------.-------... x | � ~^------_----........................................ \ � ...--------.^-----.~----.—.--.—. � , � ^ Approved ................................................ 19 � � . --------------------------'' | ' ' ~ ----------''-----------'—'^^—' < | ` Y gineering Dept. (3rd floor) Map Parcel Permit# 'Sc-2 House# Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00 � Fee.- ` —ate--�—_ 8:30- 9:30/1:00:2:00) ldg.) THE Thy; oard 19 BARNSTABLE. 1639, TOWN OF BARNSTABLE. Building Permit Application Project Street Address Village _a:4� Owner ,-C2w �w�.c� Address Telephone Permit Request �� First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure ,2$-,tW..A-- Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: Zf ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) 9 Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. 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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) -A Attached(size) ❑Barn(size) ��❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes If yes, site plan review# Current Use Proposed Use Builder Information Name �.��//� �iil//Y� /�or Telephone Number Address License# c:�P s.Q7"' Home Improvement Contractor# Worker's Compensation# C✓C NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) L i FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. t� ADDRESS VILLAGE "I OWNER - DATE OF;INSPECTION:• ; FOUNDATION c i FRAME ` INSULATION —' FIREPLACE ELECTRICAL: ROUGH r FINAL PLUMBING: ROUGH FINAL r , GAS: ROUGH FINAL J FINAL BUILDING - DATE CLOSED OUT , ASSOCIATION PLAN NO. = The Town of Barnstable �g Department of HeuIth Safety and Environmental Services Building Dlvm *on 367 Main Street,Hyannis MA M601 Ralph Crosson Ofll= 509-790-6=7 Building Commissic::: Fax: SOS-790.4WO t For oince use only Permit na Oau AFFIDAVIT . SOME zWROVEMENT*CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION NIGL a 142A requires that the "reeonstracdon, alterations, renovadon. repair, moderniotiM conversion. improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than lbur dwelling Waits or to structures which are adjacent to such residence or building be done by registered contractors, with certain c=ptions,along with other requirements Type of work• Fat.Cost Address of Work: Owner's Ham U " 2 Date of Permit App licatlon• �— y I hereby certify that: Registration is not required for the following renson(s): Work ezciuded by law _Job under SI.001L Building not owner ocenpied —Owner pulling own permit NW is hereb �NG O THEIROWN PERMIT OR DEALING WrM UNREGISTERED ORK Do CONTRACTORS FOR APPLICABLE WROGRAM OR GUARANTY FUND UNDER MGLO 142A � AC TO-ME ARBITRATION SIGNED UNDER PENALTIES OF PERJURY I hereby fly{bra permit as the agent of the owner. 5,� v itiZ, eft Darr Contractor Hame Registration 1`la OR Owners Nurne Date Tile Commonwealth: of Massachusetts Department of Industri&I Accidents HUYOffice allnaesti0ations 600 Washington Street Boston,Mass. 02111 Workers' CoTyensation Insurance Affidavit M name: location: city phone 0 ,C] I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any 'a' tv am an employer gF r/F -r providing workers compensation for my employees working on this job. I comnnnv name: Z� address: city- X>C725, phone#- insurance CO. A,41 pniicv# .............. ...... ❑ I am a sole proprictor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: .... .. compativ name- address- phone dtr. .............. in s arnnce cm com anv name: address: M city: phone x insuran cc CO. ev to mom of Min e uptosi moo and/or Failure to secure coverage 22 required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties .5 one years,imprisonment as well as civil Penalties in the form of a STOP WORK ORDER and a fine of3100-00 a day against me. I understand that a copy of this statement may be forwarded to the omce of investigations of the DIA for coverage verification. I do hereby carjo under the pains and penalties opf Perj that the information provided above is true and correct Signature---- _Pate Prizitname Phone# official use only do not write in this area to be completed by city or town offi-4-1 dtyortawn: permitilicense 0 MuildLng Department OLAcensing Board [3 checkffimmediate response is required MelectmCn'2 Office CU31Hlealth Deparuattent contact person:---------------------, phone C30ther_ ..................... ........... ............ ...... (mmua9/95PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any cots : of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or anv two or more of die foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receive: . trustee of as 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 or . ,6^A..,.,igvrc to do maintenance , construction or repair work on such dwelling house or on the grounds o building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who ha. not produced acceptable evidence of compliance with the insurance coverage required. Additionally,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 in the workers' compensation affidavit completely, by checking the box that applies s to affidavits may situatz be - nd supplying company names, address and phone numbers along with a certificate of insurance e submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the davit. '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. City or Towns I Please be sure that the affidavit is complete and printed legibly. The Department has Provided a space at the bottom of the the Office of Investigations has to contact you regarding the applicant- Please affidavit for you to fill out is the event be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would Iike to thank you in advance for you cooperation and should you have any questions. please .io not hesitate to give us a call. WINE: The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Invesugadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 eat. 406, 409 or 375 DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Number-.4!2—_ ,,,Expires: Restricted To. 16 DAVID`J-L'INNELL JR 59 FREEBOARD LN YARMOUTHPORT, NA 02675 .t,r��,�`�b� 1c ��cy,y'����pantmei�iea�a�y�aaad�uraelld , +" �;AOME IMPROVEMENT;CONTRACT7;OR . 4J, M1 ra RegiStTatl0n' t20659 �.�t T:YPe � . 02/14/00 ' UEzpliation fixLINNELI ENTERPRISES FREE r �gpM1N1�.l!yTOR YARMoU HPORT MA.02675 1 p. T TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 13�f Parcel 003 � ��� ` Application # Health-Divisions ��- �' Date Issued Conservation Division 9F�O D 'Application Fee Planning Dept. , Permit Fee. �.576 Date Definitive Plan Approved by Planning Board ` /` � �� I Historic - OKH _ Preservation/ Hyannis hub 4*0 Project Street Address 1 EST S T xtk-T ,Village aS�I a 1 vL.(,, Owner ez)(%a_ Sz orr �o a1l i5.�� Address 25 6R JA+A L44 40 11000E i KiSCO Telephone n Permit Request _Drv^'\o rY ys-r(MGt- Poa.?_4 A& t 6aWI_Q . C-owsric,r Nr"o 000G 6p aoaz4 1 ti S,+mr,1 LoCA-I o tJ Square feet: 1 st floor: existing 2953 proposed 2nd floor: existing _proposed Total new Zoning District - ( Flood Plain Groundwater Overlay Project Valuation 21�000 '00 Construction Type wouD Lot Size o•4(o Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family g Two Family ❑ Multi-Family (# units) Age of Existing Structure 5 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: 0 Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) -1ab Basement Unfinished Area (sq.ft) 2253 Number of Baths: Full: existing Z of new Half: existing new Number of Bedrooms: 3 existing 4 new Total Room Count (not including baths): existing to new First Floor Room Count Heat Type and Fuel: U Gas ❑ Oil ❑ Electric ❑ Other Central Air: � Yes ❑ No Fireplaces: Existing I New Existing wood/coal stove: ❑Yes �d 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 j No If yes, site plan review # Current Use 1010 Proposed Use 1010 .APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ko&-6aS A.-D MARN(�j ��� 23 Telephone Number 609, 4-2_,� a Address Fa gDX 310 License # C S- 101 9 MA Home Improvement Contractor# Email Worker's Compensation # I-S�DU'644PP25lIG ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO ► SIGNATURE DATE I � FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. - ADDRESS VILLAGE + i OWNER 4 - 7 DATE OF INSPECTION: .FOUNDATION ;! FRAME INSULATIONS FIREPLACE ELECTRICAL: ROUGH FINAL ` PLUMBING: ROUGH FINAL ' GAS: ROUGH FINAL FINAL BUILDING ' DATE CLOSED OUT ' ASSOCIATION PLAN NO. - , f 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 ��,Aq � n Please Print Legibly Name (Business/Organization/Individual): R0&rbfLS An3� ►�tA",C y 10j' 01LI 6n•-S Address: i?0 6ox 310 City/State/Zip: DS-VaVI�� 4A 02�, 5 S' Phone #: SOS 422 to 4 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. X I am a general contractor and I 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.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. Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. Other i�oa_uN 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. , 1 Insurance Company Name: 0Aa-r�� Vn)b6au)ct,iTC-4-S Policy#or Self-ins. Lic.#: Expiration Date: 1 1 Job Site Address: M; W rSt S-aP T City/State/Zip:Osrt wia6 r OA O 7/6 f� 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 a pains an naltie of er ry that the information provided above is true and correct. Signature: Date: Phone#: 5.0 10106 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#: ROGERS & MARNEY, INC. Subcontractor Workers Compensation Page 1 Insurance,Policy Report System Date: 04-06-16 Vendor Name WC Insurance Co. Policy Period 256 BAY COLONY CONCRETE FORMS, INC ACE EMPLOYERS ASSOCIATED INS. 03-31-2016 - 03-31-2017 WC-500-5013138-201 268 TIMOTHY D. BRENNAN TRAVELERS PROPERTY CASUALTY 03-07-2016 - 03-07-2017 7PJUB2E77221816 336 CAPE COD INSULATION, INC ATLANTIC CHARTER INSURANCE 06-30-2015 - 06-30-2016 WCE00431901 395 DAVID COX, INC. TRAVELERS INSURANCE COMPANY 07-16-2015 - 07-16-2016 UB910X7422-15 414 JD CUSTOM BUILDING, INC FARM FAMILY CASUALTY INS 09-17-2015 - 09-17-2016 2001W7511 820 ELITE WOOD FLOORING INC HARTFORD UNDERWRITERS INSURANC 02-01-2016 - 02-01-2017 08WECEI0807 860 DAVID HOLCOMB PLUMBING & HEATI MERCHANTS INSURANCE GROUP 01-03-2016 - 01-03-2017 WCA9098376 940 JOYCE LANDSCAPING, INC. HARTFORD UNDERWRITERS INSURANC 04-07-2016 - 04-07-2017 UB-5B916249-16 1012 R&S LAFLEUR, LLC MERCHANTS INSURANCE GROUP 07-09-2015 - 07-09-2016 WCA9097899 1093 MALFY ALARM, INC HARTFORD FIRE INSURANCE 10-06-2015 - 10-06-2016 08WECCK7161 1632 SOUTH SHORE HEATING & COOLING GERLING AMERICA INSURANCE 07-01-2015 - 07-01-2016 EWGCD000093015 1. a :eta Town of Barnstable Regulatory Services Richard V.Sall,Interim Director Building Division Thomas Perry*CBO Building Commissioner 200 Main Stre►st, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 509-862.4038 Fax: 508-770-6230 Property Owner Must Complete and Sign This Section If Using A.Builder T. SGO 1 AIZ.r2-Iij&q ,7s Owner of the subject prx)perty hereby authorize Roqers and Marney Builders to act on ray behalf., in all matters relative to work authorised by this building permit application for. !83 orosr (Address of Job) of gwner bar Print Nameerly If Prop Owoer h applying for permit,please complete the ruverse side Homeowners License Exemption i orra on the i i Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-102999 GARY J SOUZA P.O.BOX 310 ; Osterydie MA 02355 Expiration Commissioner 08/16/2016 QZ 7-�e Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 -ZF Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164688 Type: Private Corporation Expiration: 10/30/2017 Trtt 272021 ROGERS AND MARNEY, INC. GARY SOUZA P.O. BOX 310 OSTERVILLE, MA 02655 - Update Address and return card.Mark reason for change. S 20M-05/11 Address ❑ Renewal Employment ❑ Lost Card �e�a-nzrraarrcueultl e�C�/Cla:teac/ccretf Office of Consumer Affairs&Business Regulation License or registration valid for individul use only fp -. tl-IOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _FRegistration: 164688 Type: Office of Consumer Affairs and Business Regulation e)Expiration:.: 10/30/20.17 Private Corporation 10 Park Plaza-Suite 5170 --`- Boston,MA 02116 ROGERS AND MARNEY;_.INC.' GARY SOUZA _ =- 445 WEST BARNSTABLE,RD. `" ._ r OSTERVILLE,MA 02655 Undersecretary Not val' witho signature AC"Ra CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.� 01/08/2016 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 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). PRODUCER CONTACT NAME; Rogers and Gray Processing ROGERS & GRAY INSURANCE AGENCY, INC. PHONE , (508)398-7980 (FAA/C.No: 1 ADDRESS: mail@rogersgray.com 434 RT. 134 INSURERS AFFORDING COVERAGE NAIC N SOUTH DENNIS MA 02660 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B ROGERS & MARNEY INC INSURER C: INSURER D: PO BOX 310 INSURER E: OSTERVILLE MA 02655 INSURER F: COVERAGES CERTIFICATE NUMBER: 22766 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MMIDD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE PREMISES OCCUR DAMAGE (Ea occurreRENTED nce) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ M.L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 PRO ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY CEa OMBINED SINGLE LIMIT $ accident ANY AUTO BODILY INJURY(Per person) $ I ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ I NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A 'OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S60UB4977P25216 01/01/2016 01/01/2017 I (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Barnstable Bldg. Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 `_`, Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Town of Barnstable Geographic Information System April 14,2016 139042 #144 139005002 #131 CA?rSr44�KE/PD 139004 #145 to 1 H 139059 #184 139003 115022 3 139058 9379 #157 139002 #173 139060' 139092 #84 0 21 Feet #150 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:139 Parcel:003 boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:MORRISON,ROBERT SCOTT& Total Assessed Value:$736700 Selected Parcel 1'=100'may not meet established map accuracy standards. The parcel lines on this map are only graphic representations of Assessols tax parcels. They are not true property Co-Owner: Acreage:0.46 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:183 WEST STREET ` such as building locations. Buffer i j Al _ �I o ?7' I)Ut-V- ZAQC� ,t�3 oP ��►��.. �r..i L.P_.D,�. II ~ 1 ' 3 r S,E P ALL---, .J I lO FT (3]-o K1NQx—"Yf I2i3 6-6 P-r �b �-/7ye t x I o��lsn @ 16.0 C , T/P- ZX M ZM Ay, 1< ,.1 .L- - J! ►L_ ..1 t Js� _J 1 �_ J� L - :L -- , t' (� '` � �.r. �05� I� Z Iwo x --,-i-I 7 it 1�_ _—� ��_----- � ;r -► i �osrSl: ON L _- J fL L -J I �� 1 _ - . ANJ nAAX S-r QPT ( L J IL Jr J! 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