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HomeMy WebLinkAbout0184 WEST STREET G7 perm Town of Barnstable *Permit# Expires 6 months�rom issue date Regulatory Services Fees . 5� • anxrrsresi.a. - MASS. Thomas F.Geiler,Director i639 �� Building Division C IZ2 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 PERNUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number t Property Address I V 7 ljj CS 'F 5 T O ,S TC2 U I L6 67 Residential Value of Work q (� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address i Contractor's Name y"1 (-M p Telephone Number 5 © � ,S a• 3 L Home Improvement Contractor License#(if applicable) CD 9 2 q` Construction Supervisor's License#(if applicable) �S ! ,5-'7 'D Z q_R 0" M Imo' ❑Workman's Compensation Insurance NOV 17 2011 Check one: ❑ I am a proprietor ❑ 1 the Homeowner � 0VVN OF BARNSTABLE have Worker's Compensation Insurance - Insurance Company Name 04q-C L Workman's Comp. Policy# 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 Ho provement Contractors License&Construction Supervisors License is required. . SIGNATURE: Q:\WPFILES \building permit forms\EXPRESS.doc Revised 0 0 r The Commonwealth of Massachuseift Department of Industrial Accidents Offwe.of Investigadons i 600 Washington Street _ Boston,MA 02111 . tia►c*ty mru&gov/dia Workers' Compensation Insurance Affidavit: Bml+ders/Contractors/Elects*leians/Phgmbers Applicant Information Please Print Legibh Name dnai):VrMI C5- ^ 0 d,6 E C ARI e evi, /c' Address: / S G o C(_C-l7,-9 O-e �' FA o���� 'loll V S� C City/State/Zip: Phone# Are yo employer?Check the appropriate box: Type of project(required): 1. I am a employer with 3 4• ❑ I am a general contractor and i employees(all and/or f s have hired the sub-contractors 6. ❑New construction P�-�)- 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and bane no employees Tie sub-contractors have g_ ❑Demolition wmking .for me m any capacity, employees and have wodo rs' [To worlmrs'comp.incrxanre comp.insurance.1 9. ❑Building addition 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 1 l_❑Plumbing repairs or additions myself [No workers'comp- right of exemption per MGL 12.❑ repai rs irs insurance required.]' c. 152, §1(4),and we have no employees.[No workers' 13.ErOther E S(p comp msuraznce required.] 'Any applicant that checks boot#1 must also fill out the section below shoeing their workers'compensation policy information I Homeowners who submit this affidavit indicating they are dating all west and then hie outsuk cohrto mrs most submit anew affidavit indicating such- FContrnctars that check this boot mast attached an additiooai sheet showing the name of the sub-cmis p actors and stare whether or not those en.:ts hate earph"es. If the ob-cantmaors hale emplcyees,they mssst.provide then workers'comp.policy nmaber. I am an employer that is prov ng workers'conTensysrion iusanmee for my enzplePyee% Bdow is thepoilicy and job site iufortgration. � � �� Insurance Company Maine: y Policy*'or Self-ins.Uc.#. 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 Imestigations of the.DIA for insurance coverage verification- I do hereb}h ce nder the pain id penalties ofper,jury that the iuformafian prm►ided/above is bw and correct Si Date: i Phone#: OBk al use only. Do not sprite in this area,to be coi npleted by city or Mow'i ofrcia! City or Town: PermitUcense# Timing Authority(circle one): 1.Board:of Health ?.Budding Department 3.C ty/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 w oFt"e�ti. • ■nxrrsraars, ,0� Town of Barnstable Regulatory Services Thomas F. Geiler,Director . Building Division Thomas Perry,CBO Building Commissioner 200 Main.Street, Hyannis, MA 02601 www.town.ba rnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I,- Y W CA 1A "\ C , as Owner of the subject ro er P P tY hereby authorize �NANS S ° c to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date kQ-Y tnn A. ti t, Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on-the reverse side. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 N , t Town of Barnstable . Regulatory Services ' BARNSr'ABLE, ' Thomas F. Geiler, Director ArF�A`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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# 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: 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. i Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 t Of Public SOON ivlassachusetts- Del)l i�)ns an Standards �• Re'rul Board of Buil(lm, ervisor License Construction S F milt' Dwellings One- and Two- License: CS 45959 v, DAMES S MOORE 4 15 GOELETTA DR 02536 E FALMOUTH, MA Expiration: 11/2412012 Tr#: 6209 ('ummissiuner �! Qa /, -Office of of Cotisume.r.Affairs&Business RegulaF-0�, HOME IMPROVEIy ENT CO r l License orregistration va-nd for mdiyYdul.i Registration s NT !4CTOR before tne.expiration date. If fobnd return 120592 E9) xpiration Office of Consumer Affairs:and .. /5%20,12 B Type;,� Y y T►#-* 2 15 3 lop Plaza'= Business R Indwiu Suite 5170 . MOORE CARP �++1 Boston Mq 02116 JAMES MOORE`T . —� -� r4r 15.G0ELETTA g BAST FALMOUTH�Mq`02536` '.— `��— Under secrete y ,* ANoa[id witho ntsibna re ACOR,O® CERTIFICATE-OF LIABILITY � INSURANCE THIS CERTIFICATE IS ISSUED AS A IYIATTER OF INFORMATION ONLY AND CONFE SN a°�f�"'�Dp''^''�'1 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, 11 17 11 BELOW, THIS CERTIFCATE OF INSURANCE DOES NOT c'.ONSEND- I A CO O RIGHTS UPON THE CERTIFCATE HOLDER THIS EXTEND OR ALTER THE COVERAGE AFFORDED 9Y THE POL1gES REPRESENTATIVE OR PRODUCER,AND THE:CERTIFCATE HOLDER. T BETWEIvN THE ISSUING INSURER(S), AUTHOli IMPORrAM; If the cert flcate holder is an ADDITIONAL INSURED, the policypes the items and c011dlfaOng of the policy,certain policies rrlay re�Iira an endorserlT®n Assta�m®rl�en t If�eUit'I�F,r��dce$ a�D,subject to certificate holder in lieu of such end orag�q PRODUCER rights t0 the United Insurance ON r 199 Main Street �®ncy, Inc. P►qN 508 759-6595 FAX „ (SOB) 759-3822 P•0• $ox 1013 ORD s; Buzzards Bay, MA 02532 �. 8216 f RED ------ INSURERV APFORDINl2 COVERAGE _ INSIIRERAtI-1—V�9 London _NAICR James MCiOr9 2 15 GOGIetta Dr INSURt?,:Ill — E Falmouth INeuRetc; MA 02536 I NSU Rt�D INSURER EI COVERAGEg CERTIFICATE NUMBER: INBUR FI REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES UI fNSURANCE LISTED BELOW HAV@ BEEN ISSUED TO THE RVSURED NAM®ggOyE FOR THE POLICY PERIOD INDICATED- NMA BE S SU 0"G ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICFI 7}a� CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURgNCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT E ALL THE TERM EXCLUSIONS AND CONDITIONS OF SUCH H POLICIES.L IMI7'S SNOVVN MAY HAVE BEEN REDUCED BY PAID CLAIMS R $ LTR TYPE OF INSURANCE A U -- GENOtALLIA91UTY UCY w M ----- -- ulllTs A X COMMERCIAL GE NEPAL LIABILITY 11MAOO2O8$ DA EACH OCCURRENCE RR�p i 1 %OOO CLAM-MADE 6/14/11 6/14/12GE X occuR LB�s�Es.. D� a 100,000 MEDEJtp Anyom wacrl s 5 000 PERSONAL&ADVIN,IURY S 1 0O0 000 GEN•L AGGREGATE LIMITAPPUESPER OENERALAGGREGATE $ 2 000 000 X POLICY PRO' PRODUCTS-COIu�/OP AGG $ LOC 2,000.000 AUT'OMOBII„E UAJ3ILIiY S — ANY AUTO CONE INEO SINGLE LIMIT ALLOWNIEaoc000l S SCHEDULED D AUTOS BODILY INJURY(Par Pelson) g SCHEDULED AUrOg HIRED AUTOS BODILY INJURY(Par oWdam) S PROPERTY DAMAG£ NONOWNEDAUTOS (Per a ocident) 3 3 U&MRELL%LIAB OCCUR I S E)tcESBUA9 CLAIMS EACH OCCURRENCE 3 DEDUCTIBLE AGGREGATE L RETENTION S $ WORKERS COMPENSATION AND HNPLOYERS'LIABILDY WC STATU. OYIi- E OFFICE PROPRtET°RMAR NEReXECUTIvE YIN WCC5o101240i2011 s/14/�1 6/14 12 X MandaRMIInIl EXCLUDED? NIA / IMandatAry In NH) E.L.EACH ACgCENi tl 100 OOO tt os undar OrO D RIPTIOIPnON OF OPERATION EL,018 EASE-EAEMPLOYIl S 100 000 �B� S be E.L.DISEASE-POLICY LIMIT $ 500 000 ESCRIPTION OF OPERATIONS/LpOgTIDNS/VEHICLES (Aleeeh ACORD tot,Adm"wad Rertetto School If Moro slam to it emodelincT contractor ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIEa 9E CANCELLED B�OIi£ Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept Fax no, (508)790-6230 All PRES'EN TLV Barnstable, ma aL ®1988-2009 ACORD CORPORATION. All rights reserved. CORD 25(2009/09) The ACORD name and logo are registered marks of ACORD I