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HomeMy WebLinkAbout0105 LOMBARD AVENUE %per �,�r►��� �.� �► NO.152 W3 ORA N use 1�Min • e • e ILI Application number..... ....../... .. -21�-•1...•• ' l ... ..... ..... ............. Date Issue...........�.1.!?. . HAM i • Building Inspectors Initials. ...... ....•.......•• Map/Parcel.......... 5�... .. .V......... .... ........ ........ JUL 12 2018 Sa 0 � ARNSTABLE 1 EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATIIERIZATION PROPERTY INFORMATION Address of Project: D L.OM 1 A4 NUMBER STREET Phone Number -3 &a — q 7 a Owner's Name: F Fr► LAGE G� Email Address: Cell Phone Number Project cost$ 3, SDD�0 d Check one Residential )0 Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize AVID L C"F- oD ��MODr�G1lJ6¢��SIG-� to make application for a building permit in=ordance with 780 CMR Owner Signature: �, Date: G r v TYPE OF WORK 0 Siding a Windows(no header change)# F-1 Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review 99 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name OW � C0-rro l 1 Home Improvement Contractors Registration(if applicable)# f J ; L (attach copy) Construction Supervisor's License# 0(,0 a(o.!57" (attach copy) V - LL L @ h•afW�1 • c1V�$C hone numbersy,�S&y -7(o- Email of Contractor -0C R ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN. ,.. #ncTn01/' A DDDMIA 1 RFrnRF a PERMIT CAN BE ISSUED. APPLICATION NUMBER.................... 't ........................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am--9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date I All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington-Street Boston,MA 02111 www.mass.gov/dia Workers, Compensation Insurance Affidavit:Builders/Contractors/Elepctriiccianslee �nmbers Legibly A licant Information on/lndhv dual): Name(Business/Organizati _—� Address: e City/State/Zip: 5-C Phone#: Y Type of project(required): Areyouu an employer?Check the appropriate boa: 4. ❑ I am a general contractor and I 6 New construction 1.❑ I am.a employer with have hired the sub-contractors employees(full and/or part-time).* listed on the attached sheet: 7. ❑Remodeling 2 am a sole proprietor or partner- These sub-contractors have . 8. ❑Demolition ship and have no employees employees and have workers' 9. ❑Building addition working for me in any capacity. insurance. o workers'comp•ins ranre We a 10.❑Electrical repairs or additions [N 5. ❑ We are a corporation and its required.] officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work H&of exemption per MGL 12.❑Roof repairs myself[No workers'comp. c.152,§1(4),and we have no 13.0 Other insurancerequn�•]t employees.[No workers' 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 an doing all work and then hire outside contractors must submit a new affidavit indicating such. SContractors that check this box mast attached an addWonal sheet showing the name of the sub-contractors and state whether or not those entities have 1 ,they mast provide their workers'comp.policy number. employees. If the sob-contractors have empees oy I am an employer that is providing roviding workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Expiration Date: Policy#or self-ins,Lic. _ Address:-� �4���`i'U�i -City/State/ZiP:�/` �j�`S l� date). Job Site ss: of the workers compensation policy declaration pages wing the policy number and expiration ) Attach a copy ' osition.of criminal penalties of a Failure to secure coverage as required render Section 25A of MGL c. l can�the form of a STOP WORK ORDER and a fine fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties the violator. Be advised that a copy of this statement may be forwarded to the Office of of up to$250.00 a day against verification. Investigations of the DIA for insurance coverage I do her c e p and penalti f perjury ad the information provided above is true" correct l / a Date: Si afore: Phone#: Offlcid use only. Do not write in this area,to be completed by city or town of'cciaL Permit/License# City or Town: Issuing Authority(circle one): inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical 6.Other . Phone#: Contact Person: 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 id the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partner,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'regnired." 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 numbers)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 UP 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 pri ited legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided.to the applicant as proof that a valid affidavit is on file for 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 CommanWealth of 11 =aohusetts Department of Industrial Accidents fie of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-490 ext 406 or 1- -MASSA Revised 4-24-07 Fax#617 727-7749 Www,m Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Irnprovement�Contractor Registration Type: . Individual DAVID A. CARROLL i" ;-;-= - j-�- Registration: 9 123111 12 Frederick B Douglas Rd. i,fi `...........Y' "�` �rrr-- t1 Expiration: 12/09/2018 .Yi... U ' �.. N.Falmouth, MA 02556 SCA 1 C, 20M•05/11 ' `—'` Update Address and,return card.,Mark reason S .. ;off �.e eporrr�uorrciea�//r,o�'C3'rlti�euc/ ' '-� Office of Consumer Affairs&Business Re _ HOME IMPROVEMENT CONTRAC Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 172311=1i; 10 Park Plaza-Suite 5170 DAVID A.CAR ROL 1'='--I�'_ Boston,MA 02116 F D/B/A Cape Cod`Rernodeling;and Design DAVID CARROLLA, 12 Frederick B DOu9'Ias N.Falmouth,MA 02556 Underst Not valid without signature Massachusetts Department of Public Safety ®f Board of Building Regulations and Standards License: CSFA-060265 ., Construction Supervisor 1 & 2 r :. Family DAVID A CARROLL 12 FEDERICK B DOUGLASRD, N FALMOUTH MA 026556 <'� r ' Expi ration:- Commissioher 03108/2019 l A.S. ""` r--�' � 'a,- -• j^ .� ',� �� � a . �+�'t'�",. ' f ,�- ti:.3 Town of Barnstable Final Inspection Affidavit Date: Thomas Perry, CBO Building Division 200 Main Street Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, This affidavit is to certifythat all T�_ k completed at: 1 Street: ' � /' Village: ' e-S k GL! �— has been inspected by a certified Building Performance Institute (BPI) Inspector. All work performed meets or exceeds federal and state requirements. Permit applicatio nu er.2.6 L� Issue date: r 2, L4 Sincerely, n Francis Sheehan c� President Frontier Energy Solutions, Inc. `n r" 502 Harwich Road Brewster, MA 02631 Office: 774-237-0410 Email: fssfrontierenergy@gmail.com TOWN OF BARNSTABL_E BUILDING PERMIT APPLICATION Map Parcel 00 Application #a12 f Z( l Health Division Date Issued 10 a 3> It Conservation Division Application Fee so Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address ikl� Village �[�Sk oSt%l ✓16Cc���' Owner ea % A_ ��X, // Address 16L5 Telephone �d�s 2450 S� b W, arc 66A C1_b Permit Request WeAlAn Vi a. I R G`i t �'h�c. 6 0f, �cl S b Q& eU V 10�C +6 Q 5(:± 6 421�43K k_ tMr, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation . 9166 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure H l H Historic House: ❑Yes ❑ No On Old King's Highway: ❑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 Number 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 Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: 3� Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes Q No If yes, site plan review # Current Use C, c� Proposed Use Re Ce— APPLICANT INFORMATION (BUILDER OR HOMEOWNER) _�� -�^ _ . cm p l-7q- 23- ' aq.I� NameJ;Q5,8k�,dZ � J �U�'1c�.�S 1^ Tele hone Number Address�- q6rW�C,VQ G� License # d� 6 4 ( i G is `3 Home Improvement Contractor# Worker's Compensation #v L` I DU-66�S�i S- 24( ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO o-�cl va!` fit✓\AQ— S SIGNATURE DATE ' I t, FOR OFFICIAL USE ONLY ' APPLICATION# DATE ISSUED I t MAP/PARCEL NO. ADDRESS VILLAGE L , }� OWNER DATE OF INSPECTION: " ,_4 ��FOIJNDA•TI.ON�F�a���ra�rrF ��=ft+�tt> . . ` FRAME tINSULATION.�-,. ., FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH .FINAL - - a FINAL BUILDING DATE CLOSED OUT 'k ASSOCIATION PLAN NO. v C r.. e ' OWNER AUTHORIZATION FORM (Owner's Name owner of the property located at (Property Address) (Property Address) hereby authorize t,of t (c)d� C 1--? S (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property.. Owner's Signature Date S C E0 D SEP 21 9 2014 The Commonwealth of Massach.ttsetts Departtherit.of Industirial Accidents ©,ice ofinvestigations 6U0�3'ashinto>r Street.::::.. .. Boston,MA 02I1.1 r+ww mass gov/dia Workers'Compensation Insurance Affidavit;BuUders/Contractors/Electrieians/Plumbers Applicant Infarnmation :: Please Print UWbiv Name MwiwW0rvnizaWn&dividual) G V p ( f� �i1 L ---� Address: Ste . -- `"`- . . r . . Ci /State/Zi : - Phone#: - S Ll: Are you an employer?Check.the appropriafe box:. . .Type of project(required). . . I im a eaeral contractor and.I . 1..�I eta a employer-with 4 �_ . -� . ... g 6: New i:oastrtcton • employees(fills.andlorpom-time).'' bave.hued.the se>�ntractors. Q .2.0 t am.a sole proprietor or partner- l sted.da the attached sheet:. . .. . . .7. U Remodeling:: These sub-contactors have.. ship and have no employees & 0 Demolition working for me in.any capacity. employees and have workers' 9. 0Building addition [No workers.'comp.insurance comp...innlrattce. W e are a corporation and its :'OU EIectrical repairs or additions officeFs Have e�ceieisecl their: . . 1 l. 3. ].i min a homeoyvaei do all wow' . .....,. fl Plilmtiing:repairs or additions serf. . o wor3ceis'.cii right of exemption pei M0.L m5' mp 12.0. oofrepairs. ... . insurance regtr ird].# . ' and we tia�;e.no. _ }. 13. thei jp . .: . �,-7„�d 3a.❑ I eta n homeowner-acting is a eiirployees..[Na workers ' ::_ .. �.��• �,- .. general cantractoa(refer to#4) c0xq?: '�n5'applicant.that checks"AI must also fill out the section below showing thee wodcas w od'ootiry kftmation t Homeowners who submit this ai$davtt indicating they ate doing all wow wtd then hire outside contractors must submit a now al3idnvit indicating Ptah.:. tcouttactars alircheckthis bu�attached an.additiaaal sheet showing.the ueme of the sab.conttacton and state.whether or not those.endties haul:... : i t eu�toyees. If'the sub�actara have. th must . ... .. emyivyees,. ry provtdeatterr.•wotitcrs'.eornpam�Y -::' .. ; I am an employer than is providing.workers'compemadon.insurance for.nry employees. Below i s th policy akjob site . ; irrjornration. . . . Insurance Company Name: . . Policy#or Self-ins L c.*: �/1>J t .. ( :(- 3 }14 Expirzitioii Dale: :. Job site Address: `L G v\,6t �^� ciWIStaWZip:: _ l%w'`/ls ck0� . U�b��W Attach a copy of i ie-werkers"compensatiott poilcy decioratioo page-(shoiviisg the-poliay.namber and expiration dated Failure to.secure 6&erage.as req*ed un&.r_Section 25A of MdLd. 152 can lead 6 ihe.imposition of criminal penalties.of a full:up to SI,504).00 andJor one-year impnsonrizent,•.as well as civil penalties In the form of a STOP WORK ORDER and a fine. of up to V50.00.a day.against the violator...Be:advised that a copy of ibis statement may:tie forwarded to tw Office of Investigations of the DIA for insurance coverage verification. 1 do here crrti under, a auu vnd by fy pertaltres of perjury that the informadon provided move is true and eo� i a Date: Ph 1. 64 t G a,fflcidl use.only.. Do not write in this area,to be conrpleud by city or town official City.or Town: Permit/Lieense# Issuing Authority{circle one}: 2.Board of health 2.8ai1t3ing Department 3.Cityrrows Clerk. 4..EIertrical inspector S,Plumbing Inspector 6.Other Contact Person: Phone* f 3/18/2014 1 : 10 : 10 PM 8740 03/06 a� CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A.MATTER OF INFORMATION ONLY AND CONFERS 140 RIWM 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 HOL.OEFt IMPORTANT:H the certificate holder is an ADDITIONAL INSURED,the poGcy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and condl6ons 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 endorsemernfs). PRODUCER OpSM_Opt 9 Jelhey Fora Rogers 3 Gray Insurance Agency 434 Route 134 - (800)03 180t (608)398 A246 Soulb Dennis,MA OMO RiSURERMAMOMM Via.^Ark/t Mutual insuranceCorrtTsany 33758 INSURED Frontier Energy Solutions lnc 602 Harwioh Road INSURER e Brewstr.MA02Cd1 i COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF-INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE.INSURED NAMED ABOVE FOR Ttd:POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MATH 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. LTR TYPE OF INSURANCE POLICY M M aR Grerrs . G KERALLIABWTY EACRCCCURREWCE E 00VIAERCIAL GENERA=.UABILRY L $ CLAIms4tAm El OCCUR MEDE)fP'(Any onePerwn) _.--_•- _.�— PERSONAL B ADV INJURY S I 'r Ge&=RAL AGGREGATE S BVLAGGR_GATELIMITAPPLIEDPER: PRODUCTS-COMP'OPAGG 5 ( tK�ucy FIM Floc AUTOMOSILE LIAERM TMBKED e SINGLE S ANY AUTO BODILY INJURY(Par p=4 S ALL OWNED SCMULED AUTOS AUTOS $DOILY 6YJURY(Pet atadmq S- t-0RBIAUraS NON-ONiM PROP AUTOS (Plasoddero UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 'EXCESSIJAB HCLAIMSMADE 'AGGREGATE S om RETEIrTION a s ' X ��..{V�tN� El..EACH ACCIDENT S 1,000,M 00 A X .cL I ` 1 NIAJ VWC-100401531E-2814A 311412014 3/14/2016 .............____ IMandeoorylnNlq EL.DISCASC-r-ADAPLO. - 4 1.000100OA0. .. PEtAT1ONSbebwEL DISEASE-POUCYUMR S 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS IVEMC£SlAttNA ACORD 40t.Addi;brmlRemarKsBchedtde.A mom speeeisre ImQ CERTIFICATE HOLDER CANCELLATION Town of Sandwlch 130111a n Street SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE San41MCh,MA02663 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVE"D IN ACCORDANCE WITH THE POLICY PROVISIONS.. AUTHOR®REPRESENrATNE ®1888-2010 ACORD CORPORATION.Ailrlghts ceserved.: ACORD 25 tM8165) The ACORD name and logo aTe registeTed mafks of ACORD 3201 i �lG/.�'YGrauzaiec,.aeFr&o�:G{ �az;�relrrJcfls Office of Consumer Affairs&.Busin[ss Regulation License or regtsh'ution valid for individui use only j - ME H UMVE MENf CONMCTOR before the expiration date.If found refiam to: istratiore UbI154 Type: Office of Censnmer Affairs and Business Regatation iradon :91@Y016 , 1LG.. -Suite 53?0 Boston.MA02116 FRONTIER ENERGY SOlffltONS FRANCIS SHEEHAN 502 HARWICH RDA _ BREWST€R,MA 02631 Undersecretary with signature I F31as aehusel?ts-Z3e sT 9nerft of?S bi 'S3f Restricted To_CM4C-insulation Contractor Board of Building-'Pegulatians.and S=tan.dards. COni ink� rrs isn�S;srci: € ;�: :" "s i�se CSSL-105941 t`> 502> f�IBl1 BrewAerlV 'y F-Atureto possess a atmet*ed-idon of tote Massadwsetts State Building Code is causeforrevocation of this license. J.�ir+ 1: A• For DOS ioensingi &onv www161ast. /DPS .�PT3LsG+tS I I f I ~ ao/ 30Ga90 Town of Barnstable *Permit# Fapires 6 months from issue dote Regulatory Services Fee '"W ' r X PRESS PERMIT �>�. Thomas F.Geller,Director Ep Mlle Building Division Tom Perry,CBO, Building Commissioner SEP 10 2013 A^, 200 Main Street,Hyannis,MA 02601 p VY- www.town.barnstable.ma.us TOWN OF f Office: 508-862-4038 F EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY _ Not Valid without Red X-Press Imprint Map/parcel Number Property Address J�,Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 O wner's Name&Address aJ- / h � . Contractor's Name 1 / Ol 1/� J /'L IO/J Telephone Number r q S 7i Home Improvement Contractor License#(if applicable) L.3 /) 3 �� Eta: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Ch k one: 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) ,� h u410U-e /Poll4a!e r�'lf9 4'-Of^e 11f G El Re-roof(hurricane nailed)(stripping old shingles) All construction debris tv: be taken to Re-roof(hurricane nailed) (not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ 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. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the ome Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: QAWPFILMPORMSbuilding permit forms\EXPRESS.doc Revised 060513 e t The Commonwealth ofMassachuseas Depa'tment of Industrial Accr.dents Office of II mfigations 600 Washington Street Boston,MA 02L11 wnnv.inass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Etectricians/Rumbers Applicant Information Please Print Leeibly d Name(BasroesaldFganization&diAdnaq: D14yJ 2Z 1 a�2eshie2� LiItcl� City/State/Zip: Y%ho. �• 7 g / �D�s'� 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 1 6- ❑New constriction loyees(full and/or part4ime)* 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 g_ ❑Demolition working for me many capacity- employees and have workers' 9 ❑Building addition [No wormers' comp-insurance Comp_inset ac T required] 5. ❑ We are a corporation and its 10..❑El,ectrical repairs or additions 3111 am a homeowner doing all work officers have exercised their l l-❑Plumbing repairs or additions myself [No workers'comp- right of exemption per MGL 12_❑Roof repairs insurance mod]3 c- 152,§1(4�and we have no employees_[No workers' 13-❑Other comp_insurance required.] *Any appUc mt that checks boa 91 mast also fill out the section below showing their woikers'compensation policy informatian. T Homeowners who submit this affidavit mdicstimg they ue doing all wordk and&en hire outside contractors mast submit a new affidavit indicating mcb. TConttactors thst check this bank must attached an additional sheet showing the name of the sub-comitsctm and state whether or not those modties have employees. Ifthe suit- tractors have employees,they mast provide their warkers'comp.policy number. I am an employer that is prodding workers'compensation insurancefor my amplayeas. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins-Uc-#: Expiration Date: Job Site Address: City/State/Zip: Af#ach 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 c riminal penalties of a fine up to S 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification- I do hereby net fy render the pains enalfies ofperjury that the information prmzded above is taw and correct igna titre: Date: ° �V / 3 Plume#: J 2.9/ •0 $�S Z O2ci.al use ally. Do not write in this area,to be completed by city or town officiat City or Town: PermitUcense# Issue Authority(tdrele one): 1.Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 9: s; 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 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-contractor(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 retumed to the city or town that the application for the permit or license is being requested,not the Depar rent 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"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 Commonwealth of Massachusetts Depaitment of Industrial Accidents Office of kivestigatiens 600 Washington Street Boston,MA 02111 Tol.#617-727-49(}0 ext 406 or 1-977-MASS.A'E Revised 4-24-07 Fax# 617-727-7749 www.mass_gov/dia i oFz►+E r Town of Barnstable Regulatory Services BAMMASS. E Thomas F.Geiler,Director jDr 639. 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 eir , as Owner of the subject property hereby authorize (5i to act on my behalf, in all mattets relative to work authorized by this building permit ON- Z-ot-t? 6 4 e-a(A-a f 4q 6 0- (Address of Job) 17,14 102�6� **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 Applicant Print Name Print Name � 0 Date Q:FORM&OWNERPERMISSIONPOOLS 62012 J 0 �j► Town of Barnstable Regulatory Services '"ter M Thomas F.Geiler,Director 94'�Eo;��►`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 persons)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%decollikVlppData\Local\Microsoft\Windows\Temporary Internet Files\ContentOutlook\QRE6ZUBN\EXPRESS.doc Revised 053012 4 _— 77: ` License or registration valid for individul`>use:enly. f before,the expiration date. If found return to: 1 Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170.. Boston,NIA 02116• !� Not valid w' out signatu e Offse . Ee of CQ=usume uecclC/ CpR7ralrs& � ROME IMpV u ; e9t EMENB gualact% TIsratiori: .CONTRA13302xplraton 3 5:; T11201DA TYPieou:LVq �s VID Individual :; AVID.S1LVq ---` -_ .22HE 1 C f.: i SHIRE CIRCLE,."A W. WAREHgM.MA 02575 ilndersecretary- 8Oarsachusetts _ _ d of a Builgjrj partment of p LicensehCSSu 9ndt)ons and Standarety . -078670 ds CIO 221 sr SSE C reb L We a MA 25E 76 _ Co �riti 1a mmissloner E _ '2 pir4tion 07/Z014 The Town of Barnstable Permit#_ _5� — , '' Massachusetts Date 3122-IC7,S— SOLID FUEL STOVE PERMIT Fee CS , lu►s cuusututes au tulivai stove permit after inspection anti approval by the builaing inspector. Owner z Telephone no. -?6 2 — 7 �' Address of Property S /—p 66 Gt AVz Village t-J I UCf 61-7 S,/� Location and Stove Type ll (, !-I G Coo Date: oil mg Inspector The solid fuel burning stove at the above locatio ass failed: inspection. gwoM r The Town of Barnstable Permit# — , ' Massachusetts • A. sauvsrestZ Date MAS& SOLID FUEL STOVE PERMIT Fee au u►uciai stun c -rwit a►ter inspection anu approval ny the n uw, inspector. Owner l Telephone no. Address of Property�'lG �G�L�. i 4-< < G(/V �{!,%� , Village (, ��S✓� C� (;; Location and Stove Type Date: Building Inspector The solid fuel burning stove at the above location passed: failed: inspection. gwood