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HomeMy WebLinkAbout0114 KETTLEHOLE ROAD UPC 12543 No. co HASTINGS,MN Alt Town of Barnstable *Permit o� .� RVirm 6 mont n'su at Regulatory Services Fee • BAWMABM • MARL g' Thomas F.Geiler,Director 639 " Building Division Tom Perry,CBO, Building Commissioner .200 Main Street,Hyannis,MA 02601 www.townbnrnqtab1e.mz.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Dq/0 Not Valid without Red X-Press Imprint Map/parcel Number Property Address J 14 C`ZTLt k o l-E 12b W. ,AP,,•S,-j14 31.L Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address LA �A Contractor's Name .xO)t A) ;SV OM A I A Telephone Number .S-0 7.5:'s 3 Home Improvement Contractor License#(if applicable) O 2,5- Email: -1-5 V oM ALA Ca CDk%C AS r-- Nc`T Construction Supervisor's License#(if applicable) m ®�a. ❑Workman's Compensation Insurance PR Check one: SEP 1 `� 2013 ❑ I am a sole proprietor ❑ I am the Homeowner []'fhave Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name t'S50C(AZT l N IAM, LAA&A,)L Workman's Comp.Policy# LA) CC- - 5-00 -- .5-0090,2 4 AQ Ll 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) �� ��� ❑ Re- W i i✓j 94a S eplacement Windows/doors/sliders.U-Value o 0 (maximum.35)#of windows C1 1VNVtc 041- SwAD j #of doors: -5 - ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and required. Separate Electrical&Fire Permits required. �� S "where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. .***Note: Property Owner must si operty Owner Letter of Permission. A copy of the ome I vement Contractors License&Construction Supervisors License is required. QAWPFIIM\FORMS\building pernrit \02RESS.doc Revised 060513 oFE T Town of Barnstable Regulatory Services 9 iE� Thomas F.Geiler,Director �p s6gq. �0 r 6.19 a 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, &&A ,�AsJe& , as Owner of the subject property hereby authorize �( IQ AI SU014i A 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. 6U,J, Signature of Owner 7 Ilatute o pp cant Print Name Print Name I I Date QTORM&OWNERPERMISSIONPOOLS 6/2012 °41K Town of Barnstable Regulatory Services 933ARNSMABI.F.nr.+ss. S Thomas F.Geiler,Director 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: cityltown 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. C:\Users\dmolldcWppData\I.ocal\Microsoft\Windows\Temporary Internet Files\ContentOudook\QRE6ZUBN\EXPRESS.doc Revised 053012 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Superviair License: C"82712 JOHN E SUOMAIJA .r 4 WOLF H LL E SANDWICH KA 0253 s Expiration Jam~ 09/21/2014 commissioner ,G ���.f::...lCrjva472n7up��r//�n/i^� .n:Jcrr Ur4c;. �:•'. t\. Office of Consumer Affairs&Business Regulation: ; OME IMPROVEMENT CONTRACTOR Type:. egistration: 160825 , Expiration: 8126/2014: Private Corporatia ENGINEERED HOME SOCCJTIONS INC. JOHN SUOMALA 4 WOLF HILL g E.•SANDWICH,MA 02537 Undersecretary Ie t(�arrunza�aeuea/G1 o�� aeiaclucae(rt�, . License or regis} ation vaiid for individul use only i .Office of Consumer Affairs&Business,Regulatidp, s before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation egistration: ,Ab0.825 Type: l Private Cor oratir.;i 10 Park Plaza-Suite 51 xpiration: 8(26/2014; p Boston,MA 02116 ENGINEERED HOMEtS,OLUTIONS INC. - ;�,. JOHN SUOMALA 4 WOLF HILL E.SANDWICH,MA Undersecretary vali without signature , .. i .% i Tire t;omrt ompealth qfMassaehuset#s Dejriment of IisIrsbial Accidents Office of imestigadons 600 Washington Street Boston,MA 02HI wn m ynass govldia Workers' CompensationInsurauceAffidavit-Bydlders/C:onh-acturs/Flectricians/Plumbers Applicant Information Tease Print Lezitbly Na=(Busmessl0aganization/In&vi&4: )4 A) .Stl OMA e A Address: (z City/State/Zip: L - .3 Nb L Phone g- L"vf3-Z — 7 �J Are you an employer?Check the appropriatae box: Type of, •o ect r 4. I am a contractor and I YID Pa' 3 (required): 1.❑ I am a employer with ❑ 6. ❑New construction ,employees(full andlorpart4ime.}* have hied the sub-contractors 1 a sole proprietor orpartner- listed on the attached sheet 7• ❑Remodeling ship and have,no employees These sub-contractors have g_ ❑Demolition w for me in an capacity. employees and have workers' working Y � {Y• 9_ ❑Building addition [No workers' comp.inwranre Comp-insurance.1 required] 5..❑ ate area 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 em tioa per MGL 12_❑Roof repairs insurance regaired.]I c.152,§1(4} and we have no employees-[No workers'comp- Other 0t A/1�t�+t.,S lr- comp-insurance required-I.- 5 *Any appli ant tbat checks boa#1 nmst also fM out the section below showing-&&wodcers'compensation policy mfh ntation_ T Hameawuers who submit this afadrvit iDd k3fmg they are doing sIh wmI wad then hue outside contractors—submit a new afdarit indicating suds_ =Cantmcmrs that check this two must attached as additional sheet d urming the name of the sort-co=2ction and state whether ornot those entities have. employees. If the sob-contractors love employees,they must provide their workers'comp.policy number. lam an employer ihat isprm icing it�orke.rs'congmnsation insurance for my employees Below is Sre policy and job site information. Insurance Company Name: A SSaC/tar tit=7 I N( AN7 MV�4 wJ e Policy#or self-ins-Lic Lj CC - Sex) - , -oo ?014 ExpirationDate: :!e"��f Job Site Address: 11-4 kg- L.t-kol.e- 126 City/State/Zip: lJ_ ���e✓ Attach a copy of the workers'compensation policy declaration page(showing the police number and expiration date). Failure to secure coverage as reguiredunder Section 25A o€MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.0D and/or one-year imprison as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250-DO a.day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Im-estigations of the DIA for insurance cov Wrifieation- I do hereby certify a pains and p 'es ofpetjury that the informalien provided above fs true and correct Si Lure: Date: U 13 Phone z O - - .SS Ofc&l use only. Do not write in this area,to be caalnpleted by tafy or town officraL QLty or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CiVrown Clerk 4.Electrical Inspector S.P'lnmbing Inspector 6.Oth•er Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 Iocal 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 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 pemiitllicense 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 fide 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 Commonwealth of Massachusetts Depaz$nent of Industdal Accidents Office of lmvestigations 600 washington Street Boston,IAA 02111 ToI.#617-727-4900 ext 446 or I 477-MASSAFE Revised 4-24-07 Fax#617-727-7749 wwv.massmgov/dia 06-03-'13 10:23 FROM-G. H.Dunn Ins, B.B. 508-759-7177 T-289 P0001/0001 F-292 ACU1R 7" nW CERTIFICATE OF LIABILITY INSURANCE GATE (LI1 OB/03120132013YY) THIS CERTIFICATE 18 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollw(ies) must be endorsed. It SUBROGATION IS WANED, subject to the terms and conditions of the polity,certain policies may require an endorsement.A Statement Oh this certificate does not confer rights to the certificate holder In Ileu of such Ondorsemcnt(s). PRODUCER Phone:(608)70-3122 Fax SQ&759-717r uONfAcT Deborah Hathaway G H DUNN INSURANCE AGENCY,INC. FHONE t3oe 298+0008 A71 8oe-286 0360 P O BOX 330 216 MAIN STREET ao RF deborah@ghdunn.com BUZZARDS BAY MA 02532 INSURER(S)AFFORDING GOVERAGF NAIL# INSIRERA : MAIN STREET AMERICA GROUP INSURED ENGINEERED HOME SOLUTIONS INC INSURER a Associated Inland Marine CIO JOHN SUOMALA 1Ksuaenc 4 WOLF HILL RD EAST SANDWICH MA 02537 INSURER0: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 19861 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 RFQUIREMENT, 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 SU13JFCT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEeN RE DU ED BY PAIID CLAIMS. IILTR TYPE OF INSURANCE Imp �yya,� POLICY NUMBER POLICYEff POLICYEXP LIMRB A GENEML LWILIYY MPT2927H =20113 02/26/14 FACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO READ g 500,000 PAUmsPs vaomnnce CLAIMSJMOE a OCCUR MEO,FXP(Any ono Person) S 0,00 PERSONAL&AOV INJURY $ I,O0O,000 GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY CT LOC S AUTDleOelle LIA111LnY 0010e114Ep e1NCl@.WIT Ia 600dmq J ANYAUTO BODILY INJURY(For parson) $ ALL OWNEDLNUOTr1J`.:0*W LED AUTOS BODILY INJURY(Par awdenq $ HIREDAUTOSNED PROPERTY DAMAGE(per amamty S UNbkdLLA LIM OCCUR EACH OCCURRENCE S extass Llae CLAIMS4AADE AGGREGATE 3 DED I IRETENTION$ $ B WORKEAB COMPENSAVOR WCC-SOM009026-2013 04/25/13 0412S/14 AND EMPLOYERS' LIARILITY TO"LIMIT$ ER $ ANY PRDPRICTORUPARINERICXEQftNE YUN E.L.EACH ACCIDENT $ 500,000 OFFICERUMERMER EMIPED7 N/A (M.rd.1oy In WK) E.L.DISEASEEA EMPLOYEE $ 600.000 99dwaftuiw RIPTIONOF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTioN OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks 809dule,it more space Is rvqulred) John Suomala is excluded from coverage for workers comp as a corporate officer CERTIFICATE HOLDER CANCELLATION 7hp Town of Falmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AVMD S VE Attention: IL ACORD 25(2010105) 0 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Door Qo Map Parcel:'." .Application F/ Health`Division Date Issued Conservation Division ',Application F Planning'.Dept: Permit Fee' Date Definitive,Plan Approved by Planning Board Historic _ OKH Preservation / Hyannis . Project Street Address _ �r —C°T ���� Q_3ZyA,4�:�� Village Owner ' Q)Q Address Telephone �� 734.'Z-- Permit Request r Square.feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District. Flood Plain Groundwater Overlay Project Valuatio iF °� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family l] Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: 0 Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.). Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new umber of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other I Central Air: 0 Yes ❑ No : Fireplaces: Existing New Existing wood/coal stove: ❑Yes 0 No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing 0 new size _Shed: 0 existing ❑ new size _ Other: c-7 m � o Z Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ o 0 Commercial ❑Yes ❑ No If yes, site plan review# w Current Use Proposed Use W APPLICANT INFORMATION rn (BUILD�HOMEOWNER) Name Telephone Number Address Z . Z xa c c>, L�A License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO __K m - e SIGNATUR of DATE 'Z--� o- FOR OFFICIAL USE ONLY APPLICATION# DATEISSUED MAP/PARCEL NO. ADDRESS �` - VILLAGE OWNER 1 � .DATE OF INSPECTION: -, FOUNDATION • - FRAME ,. 'INSULATION .FIREPLACE ' ELECTRICAL: ROUGH l FINAL R PLUMBING: ROUGH FINAL GAS: ROUGH t FINAL FINAL BUILDING DATE CLOSED OUT » Ilk ASSOCIATION PLAN NO. , The Commonwealth of Massachusetts ,Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston, MA 02111 i, wwlv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumberg '_Applicant Information Please Print LeiblY Name(Bus iness/Organization/lndividual):C>n, \ S�Wmht zxz Address: City/State/Zip LJotV, Phone.#: `Z Sk Are you an employer? Check the appropriate box: Type of project(required): 1.LvJ I am a employer with 3 . 4• ❑ 1 am a general contractor and 1 6 Q New construction employees (full and/or part-time).* have hired the sub-contractors listed on the-attached sheet. T. Q Remodeling 2.❑ I am a sole proprietor or'partfter- These sub-contractors have ship and have no employees employees and have workers' 8. Q Demolition ' working ,for me in any capacity. 9. Q Building addition workers'•co insurance comp• insurance. ' [No �' - 5. Q ts Electrical repairs or additions required.] We are a corporation and i 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.Q Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.Q OtherIDv.�Q comp, insurance required.] L1n�•�v\ *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 anew affidavit indicating such. lContractors 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 providb their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: CL.Dte S .��.Y�c� ' Policy#or Self-ins.Lic. Expiration Date: Job Site Address: e �Qlz 'Qs V4Ct4%,Z -Q" V City/State/Zip.�os Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure fo secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimixi4l penalties of a fine tip 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 1 A for insurance coverage verification. I do hereby cerii under the pains-and penalties of perjury that the infornrtation provided above is true and correct Si a.ture: ' Date: Phone#: 71 `6 Z 3 Offccial use only. Do not write in this area, to be completed by city or town offcciat City or`fawn: Permit/License# [6. ssuing Authority(circle one): .Board of Health 1.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector Other Informationand I.nst ct ®ems Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, ekpress 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 dwell(ng 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 1 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�Rth 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-contiactor(s)name(s),address(es)and.phone number(s) along with their certificates)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 applica#ion 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 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" Ilie 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 Commonwealth of Massachusetts Department of ladustrial Accidents Office of InvesiigadQ-ns. 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MA.S.SAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia �YHE, Town of Barnstable Regulatory Services i 1AMMULE, Thomas V. Geiler,Director KA S. 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 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized bythis building permit application for, • +',,ems . � (A dress of Job) O � � Signature of Elate Print Name If Properly Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. +`' Town of Barnstable Regulatory Services Thomas F. Geiler,Director BAANSTABLE, 9�A ' A9. �m� Building Division Tfo � 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: village number - street "HOMEOWNER": hone# name home phone# . workp 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 period shall not be considered a homeowner. Such es` "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 performedrunder the,buildine permit. (Section 109.L 1) r' 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 t minimum inspection procedures and requirements and that he/she witl comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubicifeet or,larger will be required to comply with the t 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 t 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) Thus 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. F To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit applicatiori, 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. 0:\WPFI LES\FORM S\homeexempt.DOC f - . - .�-. ;�ia.�ictiu`oertc=b'cliu.rtnunt ut;�ubnz'S'tici�i "'< Board of Building Re! ulat�ons�und Stundai Construction.'Supervisor Specialty License.' License- CS SL 102689, Restricted to SF DAVID KOPEC P, 188 PARK PLACE .'_.Z A-WOONSOCKET, RI',02896 ��- Expiration 11/15/2012 ;: i ('umm issiuncr Tr#: 102689 Office of Cousumerr Affairs Beiness e u a e License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration:-,`6�167 10 Park Plaza-Suite 5170 Expiration 9/29/2010 Boston,MA 02116 `1 ggType;.S:uppfement Card IF r I��^ I• BEANTOWN CHIM-NE.Y•�« S1W_EEP'.. DAVID KOPE&_ 12 REBECCA RD Fc�f fig, CANTON,MA 020 — t Undersecretary Not valid without signature ■ OCT-07-2009 (WED) 13: 06 MALCOLM & PARSONS INSURANCE (FAX) 17813441425 P. 001/002 ACORD. CERTIFICATE OF LIABILITY INSURANCE ioio jio 9 PRODUCER 7 1)344-3200 FAX (781)344-1425 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Malcolm & Parsons Ins. Agcy. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6 Freeman St. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 527 Stoughton, MA 02072 INSURERS AFFORDING COVERAGE NAIC# INSURED Beantown Chimney Sweep, LLC INSURERA: Hermitage Insurance Company DBA: Jean Donahue / Gary Desmond INSURERS: Massachusetts Bay Insurance Co 22306 _ 12 Rebecca Road INSURERC: Canton, MA 02021-3416 INSURERD: 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. INSR ADO'L TYPE OF INSURANCE POLICY NUMBER POLICY DATIFfmim POLICY EXPIRATION DATFtmminniYYi - LIMITS GENERAL LIABILITY HGL-523710-08 11/27/2008 I1/27/2009 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S 100,000 • CLAIMS MADE Q OCCUR MED EXP(Any one person) S 5,000 A PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S include X POLICY ECT LOC AUTOMOBILE LIABILITY AUN866674202 03/24/2009 03/24/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S ALL OWNED AUTOS -. BODILY INJURY S X B SCHEDULED AUTOS (Per person) 50,000 X HIRED AUTOS BODILY INJURY S X NON-OWNED AUTOS (Per accident) 100,000 PROPERTY DAMAGE S (Per accident) 100,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS/U IdBR ELLA LIABILITY EACH OCCURRENCE S OCCUR ❑CLAIMS MADE AGGREGATE S S DEDUCTIBLE S RETENTION $ S WORKERS COMPENSATION AND WC STATU• OTH- TORY EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACFI NT S N � OFFICERIMEMBER EXCLUDED? E.L.DISEASE eMPLOYEF S If yes,describe under s.,. SPECIAL PROVISIONS below E.L.DISEASE--,�,p„Q,C),CY LIMIT 5 OTHER v-r „e- v y. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS himney Sweep r~n orkers Comlpensation, w/Granite_State_pol.icy:#WC4.404268 eff 10/25/08-09, cerfificate�has=bee -__y —e— equested from the=carrier;as=required'by MA state law;and will'lie forwarded=upon=receipt. T — _ -------- _ —� CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Town of Hyannis OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Attn: Ernie AUTHORIZED REPRESENTATIVE David Parsons -- ` ACORD 25(2001lo8) FAX: (508)790-6230 ©ACORD CORPORATION 1988 -- I TOWN OF BARNSTABLE Permit No. __20192 ` 1 NUISTAU i Building Inspector Cash -----_^—_-- OCCUPANCY PERMIT Bond _ X-- 2018 "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to John & Denise McAlpine Address 66 Outpost Lane, Centervi�le lot #19 114 Kettlehole Road, West Barnstable Wiring Inspector �- Inspection date Plumbing Inspector ° Inspection date Gras Inspector ' ^ Inspection date ,i/Engineering Department � � Inspection date THIS PERMIT WILL NOT BE-VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. If�le;() ....._. �9 fit- ...........I....................._... , .........._.1..../........................................ ._....- v1 Building Inspector G�0 ♦ o ' a - 4 u3 M F� v- Ig • �c�-rAA�, • . A. RAXTE R !lu 2 r�4a - C-aZTir-AaM PL07' c ��= �O BATE= Sh 1 G6tZTtFV T"AT' TNE. 9V1JDA'T1Q'h� St3o�i►.1 i � Z E t�►�1 GavLPL�IS W 1 TI-i TtaE 51 D�•Li►-IEr LOT � AWD sET$AGIL VC-QuIQEAAF--►-ITS QF TNT Tow►J of '$AQy;A TQ At �ViuEJ P .-rE 1 �.I � a 4 i3Q.X�-EiZ u�E Ic- ^ REGISt'cAcD 1.A1.4� Suevc.YoczS TV-A IS t3�-A i-t t S +J oT 12A4se`t7 o►.,i A.W os?uzv%LLE o MASS. irJst'pcJ�E�.tT 5uevcY J T►-la oFcS rS SI.1Owu-> APPLt CA," T- ( E f bT 8E usmo To DLTCQM�►J� �T' l_rN�S dot-4►..1 44,�,P Uc. d Assessor's map and lot number ..�0.9...�,�1 .r?.� SEPTIC SYSTEM MUST•BE =, o k .�� y-�o — 71 WITH INSTALLED IN COMPLIANCE" `.; l f�3. ARTICLE II .........:.............. .; SANITgRY STATE a -� Sewa a 2ermit number ................................. CODE AND N r, � g .. REGULATIONS TOW BARNSTABILE N Q�0`THE T��.r. . :• 1-3TOWN _ O F ,� t' ` Z BABBSTGBLE, : o; M6 9 •`� 3 DUiLDIHG% INSPECTOR _y 20 W iV w <1 1Pc r APPLICATION FOR rPERMIT TO �L . ,+ ( 4�* , /TYPE OF CONSTRUCTION ...........;--�./.At CL..� ..'.�.1.:/./...� ( ...... .�L,L�/!� �.... I °04 .....................t9.,?� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............!C.QT..../. . f !;lX ...... ..........rt�. 5 ........... ' ProposedUse ............... ./ LLI .............................................................................................................................. --'' �.! Zoning District ...............�.1//:'.............................................Fire District ..�r.J..£5.7.......�19�/�S'.�.f.�.......F�. ........... Name of Owner Address ......46-J.7�.,e.(r �� Nameof Builder ......t. v ............................................Address .................................................................................... Name of Architect E'• l�O.( ../...1.T...................Address .................................................................................... ..................... Number of Rooms ............../.. ...................................Foundation ........ �ti.C.!� '.1.. ........................................... ....... Exterior ...C.A.��0.40.,q ... !! ..<C,9�C,9............. .............. ..............................� ...................... Floors /g�... ...CWPO .T....................Interior ./ L��. � .......... //�� ,,// 01 Heating ...0.e.A.►........IC !'+�. .......................................Plumbing 2 U�.,WS. ............................................................ Fireplace ..................................................................................Approximate Cost ..............?:..ft..QQ0............... ........ Definitive Plan Approved by Planning Board _______3 _ •3------19_/,g. Area .....Al.zZ. .....:.......... Diagram of Lot and Building with Dimensions Fee �a SUBJECT TO APP OVAL OF BOARD OF HEALTH 01 1 3 2 L/ regarding I herebY agree to conform to all the Rules and Regulations of the Town of Barnstable the above construction. o Name %%���.v' l .....1....... McAlpine, John & Denise 0 . . ........... . Permit for ..... ........... t 0 1; 2 192 . ...........s.i.n&l.e...f .................... Location ......... ............. ........................V e bIX..bams.tablp....................... Owner ...........�. se..14 r.41 V.in e....... Type of Construction ...............ftalom............... .......................................................................w......... # Plot ............................ Lot ..........19.................. May 9 78 P6rmit Granted ........ ............................19 Date of Inspection 74-.:51.761.........19 Date Completed ....19 PERMIT REFUSED ................................................................ 19 ....... .. . �.......... .................. .. ..... .. . .......................................... ............................................................................... Approved ........................................ ....... .19 ................. ............................................................. ............................................................................... Assessor's map and lot number........ ! ` .. .^.%...:.`•` :� 77 Sewage Permit number .......................................................... °`7NEr° TOWN OF BARNSTABLE Z HASBST" AMLE, i ° 9 BUILDING INSPECTOR o► i0rt'o yar°'' APPLICATION FOR PERMIT TO .:-.......................................................................,......... ........................ ......... TYPEOF CONSTRUCTION ......................................... ............:.:.........:........c....-................................... \� ' 1 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............^.....�.'.� ....�....................... ".........- ......-............: ....................................... .......�: r.. `�. �............... ' Proposed Use .................„!.... .. Zoning District f,, �...................................................Fire District .................................................. Name of Owner .\/.-�i:/..) .� i,.'_ /i_'r...� ����i X' Address ./�( r7 r�iF':��� .................................................` .....c _ y Nameof Builder ..�,,I, )r).�:..........................................Address ........................................................................:........... Name of Architect .... ..:...................... /.. .............................Address .................................................................................... r Number of Rooms ................................................Foundation ........ tea. Exterior ... ..:......Fib ?�/ �.!�......:r/�i�a (.'-1 . .. .r/ -s..'....!�� .................................... :..............Roofing ............................... Floors !./'� ;' �f .................�.':!:......f.....`...............................................Interior ........:...'.... .:............................................................... Heating ..........-:. ;'. T�{ f ���` .................................................Plumbing ................? ..f...... ........................................... �- . 4 �10 Fireplace ..................................................................................Approximate Cost .................................................................. Definitive Plan Approved by Planning Board �� __ �-_____ 19_ Area ..... ............... , -:f Diagram of Lot and Building with Dimensions Fee . SUBJECT TO APPROVAL OF BOARD OF HEALTH Al Or f Jrr 'w I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name. 't +7 : ....... ......................................... ...... McAlpine, John & Denise A=109-34- 20192 two story No ................. Permit for .................................... single family dwelling 114 Kettlehole Road Location ................................................................ West Varnstable John Denise McAlpine Owner ...................) ............................................... C r(c ion frame Type of onst t .......................................... ................................................................................ Plot .................... #19.......................... Ma 9 78 Permit Granted ...........A.........................19 Date of Inspection ..................19 Date Complet d ......................................19 \ERMIT REFUSED ......................... . ..... ..... 19 .. .. ........... ........... . ...................... ..... .. ............... .. ..................................... ..................... Approved ................................................ 19 ............................................................................... ...............................................................................