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HomeMy WebLinkAbout0046 CEDAR STREET S4, Q ° c` d ,- 0 C o fl ® z r iA LA r. r 3 4 j� i J a y Q � l3 ® / I3 1 4 � r � i '1 F i � It 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel L Application Health Division Date Issued G t L� Conservation Division CAI Application Fee S U Planning Dept.A Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address 6 Village Owner Address - Telephone Permit Request Square feet: 1 st floor: existing Zproposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation G Construction Type IF Lot Size cf- Grandfathered: WYes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: U� Yes ❑ No On Old King's Highway: B es ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq. ) Basem nt Unfinished A a (sq.ft) Number of Baths: Full: existing ew Half: existi g new Number of Bedrooms: isting _new Total Room Count (not including bat : existing new t Floor Room Count Heat Type and Fuel: ❑ Gas Oil Electric ❑ Other ® ~ Central Air: ❑Yes No Fireplaces: Exi g New Existing woo al stove,.'-❑Ye❑ No Detached garage: existing ❑ new size Pool: ❑ existing ❑ new size — Barn: ❑e isting Onew-mize 00 Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: b 1 Zoning Board of Appeals Aut rization ❑ Appeal # Recorded ❑ Commercial ❑Yes o If yes, site plan review # Current Use /347t,1/ Proposed Use 4's' AC APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Z!& 4)T lephone Number � Address iso License # (� f Home Improvement Contractor# I26 2-07 Email-, Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 1 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. 4 ADDRESS ` VILLAGE OWNER t . t • DATE OF INSPECTION: .1AFOUNDATI:OND. FRAME t _=INSULATION;( v, 0:` '" I FIREPLACE s ti ELECTRICAL; , ROUGH FINAL PLUMBING: ROUGH FINAL GAS: T ROUGH FINAL FINAL BUILDING.-` _y f DATE CLOSED OUT ASSOCIATION PLAN NO: �--�-- ,. f' �' � �� ? 1 i � r } 1 { 0 � � `, I , �, f f i 4. e's Gum f Old> r3 the Commm"rwhh ofMmuckuset& Department ofh dus&id AcddwwIr Offi a o,f�fitpesfigafimu .b00 Waslii W=S`bwd -.-- wnrw Workers' Compessafim Ilosurmice Affidavit Bm-M uslConbmc-ftwdEFectnrians nm ers 'cant Ird'ormafim Ple Print: 'h Name Addrew s Cyrsp: °ou SU �� 1540 Am you an emplo3r3 Cheek tare apprG'piste bmu Type of pro] (requir4: 1.❑ I am a employer with _3 _ 4 ❑I am a general contactor and I 6. ❑New construcEon employees(fall anNerpart•fime)_* have hired the sub-camtractcns 2❑ I am a sole proprietor orrpar ins listed on the attached sheet I ❑Remodeling ship and bave no employees These sub-contractors blue g- ❑Demn1'froa woddng for me in any capacity. employees and have wa&s' I ❑BuivIng addition [No undmr8 comp_ins mmce coop.iasuran t 5. ❑ We are a cwrpors6=and its 10�&]et tricot repass or adddi officers have am cised their 1 L❑Plumbing repairs or additions I El I am a hametrvpner doing all work =yseM[No warlcers'camp_' 12❑Boa rqm= insurance required.]I �152,§1(4�and we have no employees_[No vodoe& 13_ @rer comp-msvrance required.] 'AspappH3ai±Owrbe coosp1=stilsoMIandthesecdonbelowsbavem56mirva&E&a mpeassti—paRUmfnonrtiea Home rwnem vdw sabmnt ttis xTuaavic in tia6 they a8 doing am��d tbeah�aatsi@e camtmm�a _b33ir a nem Z idavb iadicatmo sack ICoata�sati�adehecY tlusbax mas<aGached as additiaaal shh�t�boQringthename of 6�e and state t[betLer orncetthase entitieshavr employees. Iftlu sab-cna=a-.bsse-plp)�8iey—cstpaa d&d6r w-ke&comp.poELT=abrr lam an employer thatispmvWrcg nwrkm eompruurlion utsurmrce for my emptayees, Bdow is 8►e pa&cy rend job seta ueforanatiarr. r Insurance Cnmpamyr Name: Policy�or etf--ins Tim / Jo c3 Y F.xpizatiaaDate: Job Site Address ��idtliy = AtUch a copy of the workers'compensation policy d daration page(shvwing the policy member and ezpuitimu date). Failure to secare coverage as required under Section 25A of MtsI.c. 152.can lead to the imposition of criminal peoald of a. fine up to d UOD.00 and/or one-year imprisonment,as well as civA penalties iu$re fb m of a STOP WOR$ORDER and a fine of up to$250-00 a.day against the violator. Be advised that a copy of this statement maybe f yarded to the Office of Ikvesf gatioms of the DIA for insurance coverage verification. Idoherebyeertfyrender arrd thattLeucfarauffanpravidsd'trbovrfstnw and corrm:t tn� D21r- Phone 4- — G O,Di ceaf usa aw1jx Da troE rrrita in tires w-ea,to be caaQpleted by city ar trnm a f frciaL testy or Town: PermitlLicense- Issuing Aatliorky{curie ou* L Board of Health 2.Buulffmg Depw*meut 2.C AYJTvwa Clerk 4 Electrical Inspector S.Plnw a h3pecter 6.Other Gbsrtad Phone 6 �VEA Town of Barnstable Regulatory Services KAMu�, Richard V.Scali,Interim Director i639. ♦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,_ �� tU IL LI—��l C r� ,as Owner of the subject property hereby authorize CO to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms 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. jV Signature of Owner Signature of Ap c 4 Print Name Print Name Date OYORMS:OWNERPERMISSIONPOOL4 10/13 Town of Barnstable Regulatory Services . pUtH Richard V.Scali,Interim Director °-� Building Division seatvsresi.>+. t Tom Perry,Building Commissioner t63Qr ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6250 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB.LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: cityltown state zip code The current exemption for"homeowners"was extended to include owner-occpRied 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. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 JOB - I,JA A-A 3 YC2 TAYLOR DESIGN ASSOC., INC. SHEET NO.._...._ � of P.O. Box 1313 Forestdale, MA 02644 cALcMArec By DATE_fA OF CHECKED BY— C45 SCALE ..........................:.......... .. . . ... . ...... ....`.. _. ....... ...... ..... .... _......_................... ........ .... .........._.....................;.. :_......_ .. .......... ..... .......... . ...... .... .. ..... .......... _.....:_._..._. .. 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'a �i.-......... .........M. 1+.? ,....._...:.......: ........................... .. . ........ . ........:. . : ._ ._... ........ :............{g..�. .. 4, . . ... a .......:....'.... . '. _...................... ........ ............:.._....'._........V ._ ......................... _ ...._............. .. .:..........._.:..:....: .........:..... :..... ... ...._............. .. .......... ... r - Elol �10 NM,01 i 1 AS►e Cape Cod Construction Services 163 tern lane centeiAiille, ma o 02632 telephone +Z fax (508).77$-0897 December 3, 2013 Town of Barnstable Robert McKechnie Building Inspector Re: 46 Cedar Street West Barnstable, MA Dear Robert, Please let this letter serve as notification that the electricity and water are not connected in any way to the barn located at 46 Cedar Street in West Barnstable. Should you have any questions; please do not hesitate to contact me at 774-487-2206 or at davidcccs@comcast.net. Thank you, David Sauro } o r Cape Cod Construction Services, Inc li�s� � CS-072866 St Iva i1. Fe'3+ CERTIFICATE OF LIABILITY INSURANCE DATE�M17/901 YYlt1 TW&GERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS rTo'R ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. HIS CERTIFICATE OF INSURANCE DOES NOT CONSTIME A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE 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 and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: WII.LIAM PALUMBO INS AGCY PHONE FAX 2957 FAL 40UTH ROAD (A/C,No,Ext): (A/C,No): E-MAIL OSTERVIII MA 02655 ADDRESS: 77NHW INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY HAYDEN BUILDING MOVERS INC INSURER B: INSURER C: INSURER D: PO BOX 496 INSURER E: COTUIT,MA 02635 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTMT}iST FIG ANY REGUI RHVIEN T,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCIPA3 TT WITH RESPECT TO WHCH THIS CERMCATE MAY BE EMED OR MAY PERTAIN.TIE INSURANCE AFFORDED BY THE POLICES DESCRI BM HEREIN IS SUBJECT TOALL THE TEMA D(CU ONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOVM MAY HAVE BEI3J RIMUCED 13Y PAID CLAIMS INSR ADD SUB POUCY ETF DATE POLICY E)P DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MuADDYYYY) (MM,DD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE [::]OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 PROJECT F]LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINEDSINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNEDAIJTOS PROPERTY DAMAGE $ (Per acadenl) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ A SLIInON AND WC � OTHER EMPLOYER'S LIABILITY YM UB-4476P341-13 02/06/2013 02/06/2014 UUNM ANY PRCPERITORIPARTNERD(ECUTIVE N/A E.L EACH ACCIDENT . 1 D'0 000 �F (M-datory in NH) E.L.DISEASE-EA EMPLOYE $ 1Q0,000 r describe urdgPTICN OF OPERATIONS below E.L.DISEASE (POLICY LIMIT $ 0,000 DESCRIPTION OF OPERATIONS/LOCATIONSfVEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. N CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE.CANCELLED 200 MAIN STREET BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B,DELIV D IN ACCORDANCE WITH THE POLICY PRO AUTHORIZED REPRESENTATIVE HYANNIS,MA 02601 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD —1988-2010 ACORD CORP rights reserved. w/� ermitmust ipliances from the family apartment, and the ed and placed behind a finished wall a family apartment, the owner of the property the Building Commissioner providing any and pliance.with this section including, but not ling or addition to accommodate the g the names and family relationship among sory use restriction document. y of the family apartment, a certificate of ing Commissioner. No certificate of Commissioner has made a final inspection dwelling for compliance and a copy of the document recorded at the Barnstable ing Division. ily apartment affidavit, reciting the names and ttesting that the property is the year-round d family member(s), shall be signed and I Town of Barnstable *Permit# ? °� OFSHQ TO Eipi 61uondis frain issue date • Regulatory Services Fe Maas. Thomas F.Geiler,Director 9�'prEn��a`0 Building Division . Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 gaX; 508-790-6230 EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Itxprint Map/parcel Number �5 � V 164e, Property Address 17 Value of Work �'<�1OZ70 g,esidential Owner's Name&Address �f �- .3 Contractor's Name_ 212 —J—C- 6i ���� Telephone Number U Improvement Contractor applicable) lob Home Imp tt License# if a( pp ) Construction Sup ervisorIs License#(if applicable) []Workman's Compensation InsuranceSS Check one: /� CC 4C [] I'am a sole proprietor 1 N y 00 � I am the Homeowner have Worker's Compensation Insurance _ Name / -'k / ��G V Insurance Company 0 Workmen's Comp.Policy# v co co Copy of Insurance Compliance Certificate must be on file. v, rn 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) V�Re-side [] Replacement Windows. 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. Home Improvement Contractors License is required. Signature Q:Forms:expmtrg Revise053003 Town of Barnstable p�tHE TOkM .,� o� p egul.atory Services Thomas F.Geiler,Director s + �, q� 16g9• Aim Building Division pTfD � TomPerry, Building Commissioner 200 Main Sheet, Hyanllil,MA 02601 . www,tawn,b arnstable.ma.us Fax: 508-790-6230 OCe; 508-862-4038 property owner Must complete and Sign This Section If Using A Builder as Owner of the subject property to act on mybehalf, hereby authorize in matt en relative to work authorized by this building pest application for. all o ()6 L 6 � t-XeZ� (Address of Job) e-&� ate at print Name � v 92e �o�viiaovz (Il" 8OAgD OF BuU1LDlt(G` Iy` License: CONSTRUCTION SUP EUNIONS i RVISOR Number: CS 074101 ~` 8"thdate :02/24/.1969 ( `1 Expires. 62/24/2005 Tr.no: 10195 I Restricted; .00 SEWE ANDERSON 50 TROWBRIDGE PATH WEST YARMOUTH, Mq 02673 Adrtiinistrator � � ... ✓/te i�omvnamuve� a�'✓Gt!Cratiaclu�la Board of Building Regulations and Standards U91HOM l�IMPROVEMENT CONTRACTOR Regis''6ation: 128778 6 a Expiration: 5/16/2005 Type: Individual SEAN E.ANDERSON r SEAN ANDERSON i 50 TROWBRIDGE PATHS - fu✓ W.YARTiv10UTH,,,AA 02673 Administrator Application' to. � `"`'- OId King s Highway Regioliial Hisic District Committee in the Town of Barnstable for a CERTIFICATION.OF EXEMPTION 4pplication is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7-of-Chapter 470. kcts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans,drawings,or photo- paphs accompanying this application. . TYPE OR PRINT LEGIBLY DATE 2 G c � J O ADDRESS OF PROPOSED WORK �� ... ASSESSORS MAR N•-. OWNER / y l /T S_ .7� � ASSESSORS LOT NO, y5� HOME ADDRES TEL. NO. AGENT OR CONTRACTOR ADDRESS LGy i -`C c>r�i� �GA_(.0 F- Y"d4eZ TEL.NO. U7/e`�l_ � �Z This application is for exemption of proposed exterior construction on the ground that: ❑ (1) it will not be visible from any way or public place. ©�- (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission. (Check applicable box) PROPOSED WORK: Describe and furnish plan of proposed work,showing location on lot, and, if an addition Is involved, show• ing location of existing building. M . SIGNED Owner-Contrector-Agent Space below line for Committee use. . Received by H.D.C. The Certificate is hereby Date Time I By Date l Annrnyari ® The categories of work entitled to exemption are listed on Town -of Barnstable ' Regulatory Services �ee 6h'°l' slm� RIRNCT1Rj$, s / MAS =cb 1YJS �b� ThomasF. Geiler,Director X_PRESS PERMIT A {. . Building Division Tom Perry, CBO, Building Commissioner O C T - 5 2012 200 Main Street,Hyannis,MA 02601 ' www.town.barnstable ma_us - Office: 508-862-4038 TOWN OF B41&N 30 EXPRESS PERNTr APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ' ;3�j0 Property.Address �1P (�G�GI/ RResidential Value of Work eo0 Minimum fee of$35.00 for work under.$6000.00 Owner's'Name&Address 1 . / ���� Contractor's Namedv. �� �`7?,,T-�; Telephone Number Home Improvement Contractor License#(if Wlicable)_I�7 16 :5 Construction Supervisor's License#(if applicable) 4�� 11) ❑workman's Compensation Insurance Check one: ❑ I am a sole proprietor �❑-,�am the Homeowner ,'have Worker's Com ensation Insurance Insurance Company Name // G A-60-- fZ--(4 v, Worlsman's Comp.Policy# �Q S e ��B Lf 7 �j� P J�d — a f µlb �.pya Copy of Insurance Compliance Certificate must accompany each permit. ' Permit Reques�check box) /J /! / Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to / ZW/4-2^�( 6✓� ;4 ❑Re-roof(hurricane nailed)(not stripping. Going over exisimg-layers ofroof) ®-�3Ze�side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt'compliance with other town department regulations,i.e.Historic,Conservation,etc Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&,Construction Supervisors License is j required SIGNATURE: Q:IWPF=\F9RMS\building permit formsTMESS.doc Rightfax N2-2 10/5/2012 5 : 42 : 06 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) T IFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PAUL PETERS AGENCY INC PHONE FAX 680 FALMOUTH ROAD (A/C,No,EXt): (A/C,No): E-MAIL MASHPEE,MA 02649 ADDRESS: 28LBR INSURER(S)AFFORDING COVERAGE NAIC 9 INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY MACKEY,THOMAS P DBA TOM MACKEY FRAMING INSURER B: INSURER C: INSURER D: 135 CEDAR STREET INSURER E: WEST BARNSTABLE,MA 02668 + INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS.TO CERTIFY A E 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 PAm CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MWDD\YYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE [::]OCCUR. REMISES(Ea occurrence) VIED EXP(Anyone person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY PROJECT a LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO '. LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB r7 CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-4774P983-12 07/27/2012 07/27/2013 LIMITS ANY PROPERITORIPARTNER/EXECUTIVE El OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100.000 If yes•describe under •. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR MACKEY.THOMAS P. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE-BLDG.DEPT. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEL 200 MAIN ST., IN ACCORDANCE WITH THE POLICY PROW �+ AUTHORIZED REPRESENTATIVE HYANMS,MA 02601 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPO •rlgh s reserved. Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-094616��� THOMAS P MACYEY. - 135 CEDAR ST - G W BARNSTABLE Expiration , J 08/3112014 Commissioner I ✓fie Vom��zan�uea�C�t a�-✓vGad6ac�iciael7a office r•f Cons umer Affairs&Blfsiness Regulation License or registration valid for individul use only before the expiration date. If found return to: HuMr-IMP ROVEMENT.CONTRACTOR i Office of Consumer Affairs and Business Regulation y kegistration:.;-.-1.57t65 Type' 10 park Plaza-Suite 5170 i I-'P'•Expiration 1t1=15%2J1.3 DBA Boston,MA 02116 TO MACKEY FRAMWG0 /THOMAS MAChtY,, __- ", 'J i ✓/iGu�rt'� JJ// [�//////J 135 CEDAR STREET,. W.BARNSTAKE,MA\0266i3.;;' 55� pndersecretary Not valid without signature = < • .. a •, - ' t I A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston,MA 02111 s�•° www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Orgaaization/Individual): . Address: 1 zzd,-r- 4 �- City/State/Zip: gar-K 5 �� Phone.#: S Are yo4 an employer? Check the appropriate bog: Type of project(required):_ 1. I am a employ _with 4. ❑ I am a general contractor and I mP Y er 6. ❑New construction . employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY• mp �' 9. ❑Building addition [No workers' comp.insurance co insurance. 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 M❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.Q 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: G Policy#or Self-ins. Lic.#: /� 7 7 y i a A). Expiration Date: —7—;?— /3 Job Site Address: y� t IX�l 11r--C-r_oL City/State/Zip: �G•:—h4, G/�/� 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 bIA for insurance coverage verification. I do hereby certify under the pain/sfand pe allies of perjury that the information provided above is true and correct Simature: Date: 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): .4.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i 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:,vidence of compliance with the imsiu ance 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-contiactor(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 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 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 CommonwWth of Massachusetts Department of fndustrial Accidents Office of l avestigations 600 WashingtQn Street Boston, MA 02111 Tel. ##617-727-4900 ext 406 or 1-977-MASSAFE Revised 11-22-06 Fax 4 617-727-7749 www.mass.govldia °FZHE rqf, Town of Barnstable ti ` Regulatory Services 9 IE� Thomas F.Geiler,Director i639� �0 1D�F1639.�1. Building Division Tom Perry.,Building Commissioner'. 200 Main Street,Hyannis,Iva 02601 www:t o w n.b a rn s to b l e.ni a.u s Office: 508-862-403 8. Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property herebyauthorize to act on my behalf, in all matters relative to work authorized,by this building permit (Addtesg of Job) **Pool fences and alarms 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 Signature of Applic Print Name Print Name U l� Date Q:FORM&OWNERPEPMISSIONPOOLS 62012 Town of Barnstable of THE Tp� Regulatory Services anxxsresri Thomas F.Geiler,Director r Muss. 163y. .�� Building Division . TFD MA't A 1 Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.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 forimacceptable to the Building Official, that he/she shall be responsible for all such work performed under the building n rmit (Section 109.1:11)•., r The undersigned"homeowner"assumes responsibility for compliance with.the State Building Code and o&r. applicable codes,bylaws,rules and regulations. �i 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 s, 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, Z 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:fo" :homeexempt A