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Home My WebLink About1825 MAIN ST./RTE 6A(W.BARN.) A7 uu k UPC 12543 % Q Now 53LO R star NASTINGB,,YN ND _ J �j[� G M .� /(/y � , �oFT � ti Town of.Barnstable *Permit = �6 v,P G Expires 6 months from issue date y Regulatory Services . Fee ' ' + BARNSfAB� MAss'�U 0` RESs �� Thomas F.Geiler,Director �p 1639. ♦0 MAC& 1-Building Division . O C.j 2 9 2008 . (1 Tom Petry;-Building Commissioner V T.0Wfq OF,B,q.RNS - 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 LE Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address `� chi o\ ❑Residential Value of Work U`7 Owner's Name&Address ' Contractor's Name etc �� lo�.� Sn��^c�a ,��. TelephoneNumber SyrS aIAD �� ( Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) i ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ,® I have Worker's Compensation Insurance Insurance Company Name 1 t b`�' y v'T vn Workman's Comp.Policy# 7' '-31 S 3 is actq`j� d I�,s �,�� j(I look, ; Permit Request(check box) `FAI Re-roof(stripping old shingles) All construction debris will be taken to .__X�KOA 0-15 JZQC_' \,,.,..rNJ ❑Re-roof(not'stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.historic,Conservation,etc. I. ***Note: Property Owner must sign Property Owner Letter of Permission. Signature Q:Forms:expmtrg Revised121901 f Massachusetts -Department of Public SllfeTC* A Board of Buildim� Re�-ulations and Standards ' Construction Supervisor Specialty License License: CS SL 101185 Restricted to: RF,WS,DM MARK NICKERSON Irv, 321 RED TOP ROAD BREWSTER, MA 02631 Expiration: 10/26/2011 s (' nuni �incr Tr#: 101185 4 c Town of Barnstable Regulatory Services Thomas F.Geiler,Director MASS. 9`b %63 ,.�6. Building Division •�O Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 L Property Owner Must Complete and Sign This Section If Using ABuilder t I, YG as Owner of the subject property hereby authorize ty! L4.{ r 5��^ �On�vo�� to act on my behalf, 4 in all matters relative to work authorized by this building permit application for. t 4s a6- XNN^,v% r (Address of Job) S#ature of Owner Date = I a C" t Print Name QTORM&OWNERPERMLSSION Liberty Liberty.Mutual Group P.O.Box 9090 mu[tuo. Dover,N1103921-9090 Teleph6ne(800)653-7893 Fax(603)-245-5330 March 10,2008 TOWN OF BARNSTABLE ATTh1:BLDG DEPT 200 MAIN STREET HYANNIS, MA 02601- RE: Certificate of Workers Compensation Insurance Insured: MCAS LLC DBA NICIERSON HOME IMPROVEMENT PO BOX 2476 ORLEANS, MA 02653 / \\ Policy Number: WC2-31S-360989-018 Effective: 3 1 2008 / / T apiration 3/1 /2009 Coverage afforded under Workers Compensation Law of the following state(s): MA Employers Liability(Li Sole Proprietor/Partner Coverage Election Bodily Injury By Accident. $100,000 Each Accident Bodily Injury by Disease:. $ I00,000 Each Person Bodily Injury by Disease: $500,000 Policy limits As of this.date,the above-referenced policyholder is insuredby Liberty Mutual Fire Insurance Co under the policy' listed above. . The insurance afforded by the listed polity is subject to all the terns,exclusions and conditions,and is not altered by any requirement; term or condition of any or ocher docureenis with respect to Which tl-tis cer6 cate may be issued. Tlus.certificate is issued as-a matter of information obly and confers no right upon you,the certificate holder. This certificate is not an insurance policy and does not amend, extend,or alter the coverage afforded by the policy listed above If this policy is cancelled before the stated expiration date;Liberty Mutual will endeavor to notify you of such ca.ncellatiop. jf s AUTHORIZED MRES NENTTATNE LJBERTY MUIUAT,[T SURANCE GROUP •this CertiECeje is executed by LMERTY KU'IUAL INSUA C&GROUP as respects sucb iasuratice as is afforded try those companics. cc. Insured: Producer of Record: AiCAS LLC v ROGERS&GRAY INS AGCY INC DBA NICKERSON HOME IMPROVEMENT PO BOX 3700 PO BOXY 2476 ORLEANS, MA• 02653 PLYMOUTH, NfA 02361 3/10/2008 ,per The Commonwealth of Massachusetts '\ Department of Industrial Accidents Office of Investigations a 600 Washington Street �< Boston,MA 02111' ww'Mmass.gov/dia Workers}Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le;;ibly Name(Business/Organization/Individual): °/.5 'W11_ yvn Address: iz Go City/State/Zip: Or 1 Qtiv s M Phonet so a4 o 72045 1 Are.you an employer? Check the appropriate bog: :Type of project(required):. i.❑ I am a employer with 4. [] I am a general contractor and I * have hired the sub-contractors 6. ❑New construction . employees(full and/or part-time). Remodeling 2.❑ I am a'sole proprietor or partner- listed on the'attached sheet ❑ g ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition comp. insurance. - [No workers comp.insurance 10. Electrica rep airs or additions required.] 5. ❑ We are a corporation and its p. •3.❑ I am a homeowner doing all work . officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers' comp. right 6f exemption per MGL 12.❑Roof repairs insurance.required.]t c. 152, §1(4), and we have no 13.❑ Other 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: W�'Z 31 5 (C)9. `6 Q 0 I `� Expiration Date: 3 (o �� Job Site Address: 46 S'r r City/State/Zip: kl-p,r h S to�10 Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00.and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK:ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains•and penalties of perjury that the information provided above is true and correct. Si afore: Date: Phone# . Official use only. Do not write in this area, to be completed by.city or town offcciaL City or Town: Permit[License# Issuing Authority(circle one): .-1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: r� Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee-of an individual,partnership,association or other legal entity,employing employees..However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to•operate a business or to construct buildings in the commonwealth for any applicant who has not produced,acceptable evidence of compliance with the insurance coverage required." Additionally,MGL ehapter..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-comp ance wit:h:tlie 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-confractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members•or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their seU-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 necessafy)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 maybe 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.. ne Commonwealth of Massachmetts (Department of laftstdal Acoidents Office of Investigations 600 Washington S.trcet Boston,_MA 02111 TO. #6.17-727 45Q.0 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 � - www.mass.gov/dia