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HomeMy WebLinkAbout0074 RIDGE ROAD �7W �►ce ��rrQ.. i S M EA® No.53LOR UPC 12543 smead.com • Made in USA ~ FE8t11S�NiM411NOtILT10! SH OF'R*SR " SG G W*MSRPWC V&OW � r �IKE, Town of Barnstable *Permit# J � ( .G Expires 6 mont from issue dat I Regulatory Services Fee C� ` Richard V.Scali,Director l g Division 0 Building , TU � Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 7z/ R/1)%( !18 olzi,5a-P e(4-- ®Residential Value of Work COO& Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address _I911aGI 0 L-0 6 C/44>t C- Contractor's Name S'r'�4� Ci"rl4rP Ir Telephone Number .SD 771r 'Sf F-J Home Improvement Contractor License#(if applicable) 166 6,d ``7 Email: �'�.. C rrr k.r (f6 cc,tf.kr7- Construction Supervisor's License#(if applicable). 79! � ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# W G- 370 Q 9 0 rf 7 Copy of Insurance Compliance Certificate must accompany each permit. , Permit Request(check box) JQ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to_ �'Cy C� y ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side Replacement Windows/doors/sliders.U-Value (maximum.32)#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 Home Improvement Contractors License&Construction Supervisors License is ui SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 Ile Commonwealth of- assachusetts Department o,f 1nd=&ial Acciderd s O}f ce of I£nuestigations 600 Washutgion Street kv- Boston,CIA 02111 fvnn.v mass_govfdia '"corkers' Campensatkn Insurance Affidavit. B:mlders/ContractorslEIecEricianslPlumbers Applicant Infarmation Please Print Ee.Mbly Name(Busmess/OrZmiz3fim n�dcvidad): � �I'Pf ,,L,�•e Address: 14C 5% citylstatt'1 _ C,,47:e ' V �l AA �Phone47 Are you an employer?Check the appropriate box; Type of project(required}: 1.❑ I am a employer with 4. [V I am a general contractor and I T ❑New jestcons(required): employees(full aud!`or part-ime).* have hiredthe sub-contractors 6. tion 2.❑ I am a sole proprietor orpartner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition working for me in any capacity. employees aiLd have wotkess' [No workers'comp.insurance comp.insurance-1 g- ❑Building addition required-] 5- ❑ We area corporation and its 10_❑Electrical repairs or additions exercised 3. f am h,omeoumer doing all work officers have 1 Plumbing repairs or'additions mysel€ [No work ms'camp- right of exemption per their 1.❑MGL 12.8 Roofrepairs insurance required-]F c.152, §1(41 and we have no employees-[No workers' 13.S�Other camp.insurance required_] •Any appticsmd thatchecksbox ffl also filloutthe sectionbeIowshmsing theirwoskere compensatinupolicyiafatmafim fi Homeowners Who submit this d5dm t indicating they are doing all wo*sad then}tire outside umtrnctors om A submit a new affidaw in&cati-sadL fCannactors that check this boot mast attached an additional sheet showing the name of the sub-comuwAm and state whelhec or mat Those entities have employees.If the mib-coatn=rshweemployee%daeynnrstpmvide•their wurkers'comp.porky number- I ant ar eitipiaj-er that is praddig workers'conpeisatiart L-miraace for my employee . Below is the pdiry and job site information. Insurance Company Dame: Policy AL or Self-ins.Lic.4. Expiration Date: Job Site Address City/StatelZp: 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$1,50D OD andror one-Dear imprisonment,as well as civil penabies.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 lavest gations of the DIA for insurance coverage verification. Ida here-by certify a. 0 'is and penalties ofpedary that the informatior>provided abo g is tare acid correct Si Date: �C> Phone 9- 7`ll�`�f�t^S Offidal tree only. Do not write in thb area,to be cannpkted by city or town officiat City or Tome: PerimtlLieense# Lssuit g Aathority(circle one): L Board of Health 2.Building Department 3.Cityfrown Clerk d.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone it: Information and Inst-uefions ' Massachusetts Gd'nmal Laws chapter 152 rmp:r z all employers to provide workers'compensation for their employee. pMM=tto this sfi3t1fr,au..esnployrZ is dewed as."_.every person in the service of another ender any contract of hire, express or implied,oral or vn itt en." An employer is defraed as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint a turprise,and including the legal representatives of a deceased employes,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;occapant of the - dweIIurg house of another who employs persons to do man,t mance,construction or repair work on such dwelling house or on the grounds or building appmtanaut thereto shaR not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also stains that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a busin ess_%r to construct buildings in the commonwealth for any . applicant who has not produced acceptable evidence,of compfianm with the insurance.coverage required." Addit onally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor arty of its political subdivisions shall enter min any contract for the pe$uimance ofpublic work until acceptable evidence of compliance with the fimm: „ce. requnmments of this chapter have.been presented to the contracting authority_" Applicauts Please fill out the workers'compensation affidavit completely,by checking the boxes mat 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-Part amships(LLP)withno employees other than the members or partners,are not rbquimd to taffy workers' compensation ins¢rance. If an LLC or LLP does have employees, apolicy is required. Be advised that this affdavrt may be stibmittrd to the Department of Industrial Accidents for confrmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be mtemme:d to the city or town that the application for the permit or license is being requested,not the Department of Ladustial Accidents.,Should you have any gnesdons regarding the law or if you are repaired to obtain a workers' compensation policy,please call the Department at the number list d below, Se1&insirced companies should enter their self-insm-ance license number on the appropriate line. City or Town Officials . t - Please be sine 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 pen�itllicrose number which will be used as a reference number. In addition, an applicant that must submit multiple permit icanse applications in any given year,need only submit one affidavit indicating current policy it l ration(if necessaiy)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 maikedby 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 obtdoing 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 lilt a to thank you is advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Departmenfs address,telephone and fax number. The C 10awealt3E of Massachusetts_ ' Depadment of ludntial Accidents Off ice of Igve&tgatlo.� �Q4�ashin�tan Sfr� � . . Boston,IAA 02111 T(,-1.#617 727-4g00 cmt 4-06 or 1_97 SA� Fax#617-727-7749 Revised 4-24-07 In gavI Ia OFIKE I • Baxxsrnsie. MASS. Town of Barnstable ArEO�► Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO 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 ,as Owner of the subject property hereby authorize �r���srti ��'� �� to act on ray behalf, in all matters relative to work authorized by this building permit application for: x0, Rd to, BaVK4 h( (Address of Job) Signature of Owner Date Pant Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 Town of Barnstable Regulatory Services oFs miry Richard.V.Scali,Director ~o Building Division e w RAURWNST'ALF. Tom Perry;Building Commissioner .a� �� 200 Main Street, Hyannis,MA 02601 e ArEo 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-occurred 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 r quire Ltsandthat he/she will comply with said procedures and requirements. 97ignalure of Hdmeowner 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 040215 Massachusetts Department of Public Safety Board of Building Regulations and Standards ----� License: CS-076536 Construction Supervisor STEPHEN WCRESWELL— ill"� 195 PINE STREET CENTERVILLE IVIA 02632; 33 1 U's ,(�=/l^^K C, Expiration: Commissioner 08/27/2017 �— ve-s� "A8 e`;axng nggnd to Waw1J!?d9fl- s 4asn'yaesss"V! _�. Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 160627 Type: Individual Expiration: 8/8/2016 Tr# 253341 STEPHEN W. CRESWELL STEPHEN CRESWELL 195 PINE ST CENTERVILLE, MA 02632 - -- Update Address and return card.Mark reason for change. Address F, Renewal ❑ Employment Lost Card SCA1 0 20M-65/11 ate'_. Office or Consumer affairs&Business Regulation License or registration valid for individul use only ✓� sOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ' — egistretion: 16p627 Type: Office of Consumer Affairs and Business Regulation individual 10 Park Plaza—Suite 5170 y Expiration 8/8/2016 Boston,MA 02116 STEPHEN W.CRESWELL STEPHEN CRESWELL- �/c 195 PINE ST L CENTERVILLE,MA 02632 Undersecretary _ Not valid without signature i AC�® DATE(MWDDNYYY) �y CERTIFICATE OF LIABILITY INSURANCE 03/02/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: W.Scoff Kerry KERRY INSURANCE AGENCY ac°NN Ext: (508)255-8000 arc No: E- scoft@keriyinsurance.com @nYMAIL AD ke Insurance.Com P O BOX 1945 INSURERS AFFORDING COVERAGE NAIC# N.EASTHAM MA 02651 INSURERA: LIBERTY MUTUAL FIRE INS CO 23035 INSURED INSURER B: S CRES INC INSURERC: INSURER D: 195 PINE STREET INSURERE: CENTERVILLE MA 02632 INSURERF: COVERAGES CERTIFICATE NUMBER: 34451 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I�TSRR TYPE OF INSURANCE ADDL SUER pOUCY NUMBER MMLICIDI) EFF POLIO(MMIDDI EXP OMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ TO CLAIMS-MADE OCCUR DAMAGES(RENTED PREMISES Ea occurrence $ 4 MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMPlOPAGG $ JECT OTHER: $ AUTOMOBILELIABIUTY COMBINEDSINGLELIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION x1 STATUTE ERH AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? NIA NIA NIA WC231S610224015 04/19/2015 04/19/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Addltional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-compensationAnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St. AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel Cro y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 0 ACOR" CERTIFICATE OF LIABILITY INSURANCE CATE(`AID°"�""' 03/Ol/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CEATIPICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL. INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement 1 A statement on this certificate does not confer rights to the I certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jim hindman Schlegel & Schlegel Ins Broker PHONE -F X — - - 34 Main Street • (508) 771-8381 / No: (508) 771-0663 West Yarmouth, MA 02673 aDDD ESS: schlegelinsurance@qmail.com INSURE S AFFORDING COVERAGE j NAIC k INSURER A:NGM INSURANCE COMPANY INSURED INSURERS:PROGRESSIVE — - I---- ._ . MT CONSTRUCTION -- I------- - INSURER C: AIM MUTUAL 2 ahab roadINSURER D: yarmouthport, MA 02675 - -- --- INSURER E: INSURER F: � 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 THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ! CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR I TYPE OF INSURANCE IAODL!WVD POUCY NUMBER POLICY i PO/DDI�Y LIMITS A GENERALLIABIUTY MPP0601V 05/18/2015 05/18/2016 EACH OCCURRENCE is 1 000 000.. X COhAA LJ ERCIALGENERALLIABILITY DAN TO RENTED ` $ _ 500 D_O_O CLAINISMADE OCCUR ME EXP(Any ore person) $ 10 000 I-- 1-- PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $I 2,-000 000 �-GEN'LAGGREGATEL9vtITAPPLIESPER PRODUCTS-COMP/OPAGG $ 2,000_j000 I POLICY f 1 PRO- Loc i I $ B AUTOMOBILE 04287439 03/28/2015 , 03/28/2016,I EOaa1Hciden NGL IhIR $ 250 000 ANY AUTO I BODILY INJURY(Per person) $ j ALL OWNED X SCHEDULED -------. I AUTOS AUTOS I BODILY INJURY(Per accident). $ 5500,000 I N ED I PROPERTY DAMAGE HIRED AUTOS _AUTOSUTOS Poraccident $ 100,000 UMBRELLA LIAB OCCUR i EACH OCCURRENCE — I —jl EXCESSLIAB L$ CLAIMS-MADE I AGGREGATE Is — DED RETENTION$ i WORKERS COMPENSATION WC-37892097 10/07/2015 10/07/2016 WC STATU- LOTH-I C I AND EMPLOYERS'LIABILI TY _ 0 ICERANEIN ANYPROPRIMBER EXCLUDED?�CU YTIVE 'NI A E.L.EACH ACGDEM $ 100,000 (flies,describe cry in and I E.L.DISEASE-EA EMPLOYE $ 100,000 ItySCRIPTIONO O 500 000 DESCRIPTION OF OPERATIONS below ! E L.DISEASE-POLICY LIM , I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is regUred) CERTIFICATE HOLDER CANCELLATION BREAKWATER CONSTRUCTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BREWSTER MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE'POLICY PROVISIONS. AUTHORIZED REPRESENT E ©198 -201 ACOR CORPORATION. All rights reserved. ACORO 25(2010/OS) The ACORD name and logo are registered marks AC RD Phone: Fax: E-Mail: