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0030 ARBOR WAY
f �-=__ - - - �" _ � CONSTRUCTION CO- lic 546A Higgins Crowell Rd,WEST YARMOUTH,MA 02673 PHONE: 508-778-0111 FAX: 508-778-5010 ' VM*.TUPPERCO COti9 Date: 1 - Town of Barnstable �- Thomas Perry CBO 200 Main Street v�P Hyannis, Ma 02601 (508) 790-6230 faxCz m Re: Insulation Permits Dear Mr. Perry This affidavit is to certi that all w' certify.that work completed for errnit`.P a lication permit', # ( � Issued on has been inspected by a certified Building Performance Institute (BPI) inspector. All work performed meets or exceeds Federal and State requirements. I Sincerely, ±Permit Address: ] Richard Tupper License # CS-69058 I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map C D Parcel Application db 1 S-01 3 ;-S Health Division Date Issued 3^ Conservation Division Application Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 3) & o r / )ad Village 1HVaJnV1 Owner I Address3okhoc W&x Telephone Permit Request t 2 11 655 6ard s bd `a 6fuja.(! Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 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 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 19 new First Floor Room Count Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other Central Air: ❑Yes No Fireplaces: Existing New Existing wood' al stove:;❑Yep ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: 0 ,fisting O:new'size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Ln Commercial ❑Yes ❑ No If yes, site plan review# -= Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) (y Name ,Telephone Number 0 b ��1 N Address64(#AC4. #lick-00 0 -6� WYAr wa , IAA 62aC ?5 Horne Improvement Contractor# lls4a+ Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 64�p A WA S Ac.,__ Orowe� I P,4 oJYnan9AJtn Wh A-Wo-T-2) SIGNATURE DATE r• FOR OFFICIAL USE ONLY i APPLICATION# DATE ISSUED a� MAP/PARCEL NO. s ADDRESS VILLAGE t' OWNER DATE OF INSPECTION: FRAME T :x_INSULATION ..ti FIREPLACE S ELECTRICAL: ROUGH FINAL y ` PLUMBING: ROUGH FINAL t _ GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 44 tl OWNER AUTHORIZATION FORM `(Owner's me) * -I - .. ` .. ... _ a,• '. . .fir. _ _ .. owner of the property located at (Property Address) h (Property Address) ti hereby authorize (Subcontrac 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 Sioatilre Date The ConOwnweaith of assach,usetts Department`of-Industrial.r4ceiden s. off ace of Investikations' 06 Washingtoh Street` Boston, MA.02111 xwwwm rss govftt Workers' Compensation Insu °a>E►cc Affidavitta:Buildets/Co cfors/.ElcctiratiEans/Plumbers Applicant Information Please Print Legibl*' Name(Businesslorgaruzatonllndividual) . Tupper Construction Co_ t LLB` Address: 546A Higgins Crowell Fed City/State/Z ; West Yarmouth, Mi*1 0263,Ph #: 5,0$-778.-0111 .Are ou an employer?Check the appropriate boxz, 1 ya �'ype of project(regnaed):;. 4. .1.QX I'am a employer with 4 Q'1 am ageneral contractor.and I 6. Q blew construction` employees(full and/or part=ririme),: !'have hired the sub-contraetors 2.❑'1 am a sole proprietor or partner- listed on theattached sheet..3 Remodeling shipand have no.em lovees These.sub-contractors;have.. 8. Demolition; P ,. 0 . working for me.in any capacity. workem ,comp:insurance,, P ty 9. ❑Building addition [No workers'comp_insurance 5-. [l Ware corporation,and its required.} officers haue:exercised their l Q Electrical repairs or auditions 3.Q I am a homeowner doing all work, right of exemption per MGL 11.❑ Plumbing repairs.br additions myself. [No workers' comp. c. l 52;§1(4),and w.e have nd `12.• $ insurance required_]t employees.[N workers"' ❑Roof repairs: comp..;insurance required:];: 13.[ .OtherWeatherization - *Any applicant that checks bos#r must also:fill out ihe_sectinn iielotiv sta)IN7ng their.worlets coop ensatian Po lick•infoimahon: 7 Momeovvners who submit this afrtdavit indicating they are doing ail work cud then hire outside contractors must suttmit a new off davit indicating such, �Cantiactors that check;this box must attached an additional shut shotiving the name of thesub-cantractors and Their workers`camp,.policy in' rmaUon: I ate an e;~ttploy�er'thgi is providing workers'coMpensation im-urappe.for my employees Below:is the policy and site information. Insurance GompatiyName::. AEIC Policy#or.self.ins;:Lic # , WC 5 0 0 5.5 9 3 O I20I 4A 8xpiralian Date: 10/3115 lob.Site Address: C /State/Zi r �?r----= ty p: Attach a copy of'the workers'.eompensation policy lecIfatio..n page tshowang the pokey nu er and expiration date). Failure to secure coverage as required under Section 2SA of 4 L c. 152`can lead to the irnpostti.on of criminalpenalties:af a fine up to$1,500.{yt?and/or one-year`tmprisonment as well as civil penalties in the form of a ST`.O 1 QRIC ORDE :and a fine of up to$250.00 a day against the violatoe: Be advised thaf°a capy;of this state ix eiit maybe forwarded to the Office of' " Investigations of the'DIA for ift#r rice coGerage verification,. 1 do hereby certify rettdeF the paai:ts l€tzrl a calties of perjury that the informtt#i provided above is true and correct Sig r. nature: Dati—, 3A, /1-6 lalione#: (5 0 8} 7 7 Offuial rise only. Do not aur`te .ea t#ais yea,to be.completetd by city ar't©wag offcaal, City,or Town: P rinit/L.ieeatse Issuing Authority(circle one): 1.Board`of Health 2.Building:'Department 3'.G.ty/Town Clerk 4.E'Wtrical Inspeetar 5.Plumbing_Inspeetoe 6.Other Contact Person'. Phone.9: ACOR a ll DATE(MPNDDIYYYY). CERTIFICATE OF LIABILI"I INSURANCE' 1 .12/1/2014 'THIS CERTIFICATE IS ISSUED AS A:MATTER;OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AEF(RNIATIVELY OR NEGATIVELY. AMEND' EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES,NOT CONSTITUTE A CON7RAC t`;BETWEEN THE ISSUING:INStIRER(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 SUBROGATJOWIS.VAIVED;subject to the terms and conditions of the Policy,certain:poticies tray requi►e.an endorseent. A staEement on this certificate does nat tionferrights to the. certificate holder lieu of such endorsement(s);.. m PRODUCER :.. :.CONTACT -. ' :NAAAE: Lori VitZCserald Southeastern Insurance Agency PHONE' (508),997-6061 t FAx }:Ai �.{508)980-2731 939 State Rd. �B�jE 4 zOasoutheasternins•coia P.O. BOX 79398 INSURER S ARORDiNG COVERAGE -NAM 9 North Dartmouth Mk 02747., uasgAERAAAeila .Protection Insurance .. 9136ft I INSURED . . ._ :. :.. iNsuRERs- ssociated 'E la ers T_i3s Co:. .. Tupper Construction. Co LLC -'- ' 79 Mid Tech Drive; Unit B fNSUMEREi .West Yarmouth MA 026i2l rNSURER F. COVERAGES CERTIFICATE NUMBER 2015=I REVISION NUMBER:THIS IS`i0 CERTIFY-THAT THE POLICIESOF iNSLiRANCE:LISTED BELOW, AVVE'BEEN ISSUED:r THE INSURED NAMED ABOVE FOR THE POLICY PERIOD:'. INDICATED. NOTWITHSTANDING ANY REOUIREMENT, T€RM OR'CONDITION OF ANY CONTRACT-OR OTHER R NI DOCUMENT"VcrIT 9 RESPECT TO VNt(tGlj THIS (,CERTIFICATE MAY 8E 1$SUED:OttY PERTAt�l,THE INSURANCe-AFFORDEI3 BY THE:POLICIES DESCRIBED HEREINA' SUS,IECT'-f'r',�.ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF$UCH POLICIES.LlMvtS•SHOWN MAY#NAVE BEEN REDUCED BY PAID CLAIMS: 1TRi TYPE OF_INSURANCE �... POLMVNUMBER EFF I1P9M7DD/YVYV s tJ00.RS. GENERAL LIABILITY - 1 t�E &�0 CURB NCE 1 000r000 X COMMERCIAL GENERAL LIABILITY � L FP ANAUt:& N..cI ere 5 i 'L ' 0' A CLAIMS-MADE f7x1 OCCUR 50000874$ 11/1!'/2014 1/1/.2015 INFO EXP fhny ore Pzr-cr� � D 000 T t_iSERhLGREC4TE €,5. 2,000,000 .. GEN•L A.GYRMA+C OMIT APPLES PER, r PRO- I t PRODI CTS•Cvd1CJP G5)S 2 _000;000 X POLICY LOC -AUTOMOBILE LIABILITY; .. ., S:. .. ...:_ ( m etNEO tP*C+E Llttit tEaetxtient 1 000:000 A ANY AUTO \ + - SODILV NJURY(Far:garsor.'5 i ALL OWNED �y 1 SCHEDtREO (. 1020009389 AUTOS AUTOS _ 2J1J2014 '2/1/2015 80DILY.lN ilRY PLkBec icruyi S t AUT X' HIRED AUTOS X UCaa iED DROPEi2 T`t OAtsaCc i _ .-. lrn:nsu e8+retonsi ES:�n{�Arcv)S: . .256,066 UMBRELLA LIAB t C✓Y-U,< : - .: 1: CH OC+UP.RENCE 5. EA A EXCESS LIAB 1 CLaIMS-MAGE F.Gvk2EGt\TE 8= .. ..-. DEC) RETENTIONS 600058368' 1J:2J2014. N/1/2015 B WORKERS COMPENSATION S. + 'AC'S ATU-.::: IOT�i ., . :AND EMPLOYERS'LIABtIITY _ YIN: - � •�� ., T 7F '' R - ANY PROPR?ETORrpARFAlERtEXc''tjT(yE OFFICERINEAABER EXCLUDED? �'-:NtA r: EL ERCt?ACCiQE,tT .'S' l .QQQ 000.. (Mandator'WNH) --i ) CC5005593012019a + Oj3J2014 '0%3J20E5' }I( as.dascrbotrtltler E' DISEASE, EAE,iP OY 5: 1 000 000 __ DfS� CRIPTfON OFAPERAT4JNS bvitu� 4 i ----' f�. T^�L Os-� E �+�tCY �,,r',s �.:oao 000 ----------------- _ I I DESCRIPTION OF OPERATIONS I LOCA-nf3fJS t VEHfCES(AttaCh:ACDRD 107 Addrhorwi.Remar&s ScAcduf tf-more _. .... �.. e.' space CERTIFICATEHOLDER ' - _.:. • CANCELLATION: SHOULD.ANY OF THE ABOVE'DESCRIEIED POLICIES BE.CANCELLED BEFORE .' THE EXPIRATION :DATE T}iEREOF, iNOTICE WILL bE: DELIVERED- IN IN FORMATION PIIRPi)St~S .ONT;Y ' IT HE POLICY PROVISIONS, TUP.PER CON$TRUCTIONT CO LLC' . . AUTHORIZEOitEPR£SENTATf4E _: :-: . . 545'A FiIGGZt�IS MOWELL. ROAD WEST: YARMOLITH;.I3Fi 026.73' Lora Fi;tzGerald%LHL ACORD 25(2010/05) ©1 68 2010 ACORD CORPORATION Ali'rights;reserved, IN$02$!7¢inO61f1I' Thn iQrhin l m Dam anFYinnn am ra c1oYri :markc pF 6C'G1RI7. , t LarSt rf isfs i on,I ittd h-r: tlt3iritlUt:��tt§ (61ifi'' .. .. Off, e tSt�:nihumt r�€fsin�tNArt s+ltglllq'4( � - EDA#i i(Nt }ttl �I7 CY�fi4taT{3t Jk tuts 4herlit� t� 83fuunc rrtsett � R., JtttraE3eait U 'x }ke �kT{+ct n'� }ittUt tirt�itFi: U�tti.y:'ltcetrt:s4iii� d"�• M irtiatii G!l�F4viti; G - iiF1',a i, ';i7�i i uiti 442it1 -... y3 ry"VRiU�.::k,-H Dt2: tttdr:+�c�st r!° �,vi=t"'wi'rtsa',��ttrittU€si iT�tterc: ' a.UIWIT .nY PEW' sew ; S e i i tW..}Y 4"NIM 363 t 2 a ritcJ—q P vicsi[t+t a i7 a s tub .0 1��� '�``tc�...�r�°; t xlFrte_titsal::P�a�t9i•+`�s.ti#� � '' IM t.a=har;a�t3p�sr '• Heron �tr m. tu � ' ti"iiotl 4 peao'e l}etptng P'w.pto&iAd a Sa€es WN rt d '. • +x�saetextr _ 4 . S.ichafd.TO weer tc on SUrrrnup Safety Pratessfa 61. Pf rrtl 01 #,m 8158119 Exp-,4130/20}5 w F . r s INSULATION 2f�3 F09 15 PM 2 42 MAR GLASS SLAMLSSS SPRAP MAAI SYSPSNDCU • \ASIS GYSLS\S INW AIION SSYYIYS 1-800-696-6611 Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, NIA 02601 I Date: 1 v Dear Building Inspector ' Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements, Property Owner Property! Address I Village r�u�cL1 fi ��� us 30 )k l r Insulation Installed: Fiberglass Cellulose R-Value ' Restricted Unrestricted Ceilings Slopes ( ) { ) ( ) ( ) ( ) cq.,41t Cuttal W CI0) Floors- Walk ( ) ( )' LIV-44 LO 1.%As-4Ctton1 Sincerely k He y E C, sidy J , President Cape Cod nsulation, Inc. G TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION s Map �/ Parcel Application # clu Health Division Date Issued Conservation Division Application Fe U Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis. Project Street ddress k4w bAl Village 14 V41_�) Owner v�l �oaw Address y�L Telephone �� ' 77,6 Permit Request 1 ntu( 6 rx - vS a IV 'ea (' 0119h 1 ID ' m51 Ce(6u t -4 6k c A'6�e t 0 5 h G `` - A� a c��j� -7& e)zc ll Ve Square feet: 1 st floor: existing proposed end floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type! Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. CD Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) N Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: Q:Yes ---M No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other r 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: Zoning Board of Appeals Au horization ❑ Appeal # Recorded ❑ Commercial ❑Yes Q No If �es site plan review# Y Current Use Proposed Use APPLICANT INFORMATION _- (BUILDER ORHOMEOWNER) Name LlWe co 1&:az Id Telephone Number ��� 77� ' 2Z l Address ,Z_E 4 �y C11A License # , e� Home Improvement Contractor# ,/J'_5,3 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE V&V q le I FOR OFFICIAL USE ONLY z APPLICATION# ij DATE ISSUED MAP/PARCEL NO. r r ADDRESS VILLAGE i s OWNER r c DATE OF INSPECTION: `r ? FOUNDATION FRAME INSULATION FIREPLACE 1 ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ' S 1 DATE CLOSED OUT f ASSOCIATION PLAN NO. i JWi c&, MM&W�,&Idd 1! �Opsi 10 Park Plaza - Suite 5170 �.- Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC HENRY CASSIDY ��. _ ..-----.--- - 455 YARMOUTH RD. HYANNIS, MA 02601 -- _.._._- ......- .-.Update Address and return card. Mark reason for change. L Address L_I Renewal Employment .I Lost Card PS-CA) 0 S0M-04.104-(i10i2i6 (triicc.,� "ut uwer Affai �j l3us ue��'Regul rrioa L;iccuse or registration valid for indiaidu! HOME I' 'GV�E ``�CJIV1` AC `W,,M before the expiration date. 11 fonn(d return to: Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 OD INSULATION, INC HENRY CASSIDY 455 YARMOUTH R.D. ���,c� HYANNIS,MA 02601 � -- WiUndersecretary t al } ichusctls-DcI)Illilent of,Public Sat co Boar! of,13 ildin!g Rc!-ulations and Stun(I.u•dx` on$truction Supervisor License iP License: CS 100988 HENRY CASSIDY 8 SHED ROW WEST�ARMOUTH, MA 02673 — ��` Expiration: 11/11/2013 ��` ... The Common l i , ,1/th of Massachusetts G, Departrneru i rl Industrial Accidents - _ oftice , l Investigations a 600 Vl o.j"Wlgton ,Street bos,i,,, . AM 02111 ���`'•C' 'I-"Jug I'V1'I:'II .�;::i.\'.)'.goV/CtiCi Worker's norm isation Insurance Attie;",::;: Builders/Contractors/Electricians/ritrn.tbers 111t>lir�lltt lnfor[n`ttion Please Print l_,egibly our (lit.l,lu�titi/C)rl;aniZLL6011/Incaividutil): c / 17 17 5 - :\re YUU all t'.4IIpIllyCr'J CI►eelc the appropriate box; - —"---- Type of project(reyuirc(l): l I .uu r.nlployc r wide_.. - -- 4.❑ l am a,•,w:,:,I ontractor and I have 6. New construction, cuthlvyres (full anti/or p1 k t-time).;" hired 111 �tdh contractors listed on 7. Remodeling the a[Lldi,d .lice[.:[ st.tic: l.lioprietor or partnership These sui, •.. utractors have 8• ❑ Det'nolitiorl auul have: lio alrtl:,loyres working for eniployt.: :iud have workers' comp. 9. Building, addition ntt: ill ally capacity. [No workers' insuraut' j IQ, Llt.ctcicul rclxtirs ur adtlitiou5 cknnl, in..SUI LInCr, 1r.iluired.] 5. We arc:i;,.,i I;Ol;ition and its El IL Plbi .airs or additions officer,,li:i\, exercised[heir tight of 0umng rc I huuicowucr doing all work exemplitnl p;,t NIGL c. 152§(41),and 12. Roof repairs myscit [No workc4s' comp. we have it,,,iiiployees. [No workers' 1 {, � 13. Ot11artl 1 t~'P1 ZLC1C�t u ISM"Ill Wc re(.Iuirrtl•.) .r comp. intitu:,nte required.] r.gglhr ult that cht-eks bOX #l roust also Fill out the section below shw.t m•+b,it workers'compensation policy information- IL,Inanvucis tvhu subllkil. this iktfitlavir indicating[flay flee doing all lvin l..,,,..i d,;a hike outside coimuc[or 111WA Submit a new affidavit ltll[lcatlng mcll. t ,marl n,that check thls bOX must attach an additional sheet showing th, w.w.:of the sub-contractors and state whether or not those entities have eulpinvar..a if gab,,lluacwrs have:CIIIpIUyCGS, dory [rust provide their wocke4'S'cowl. I—di.�,uumbcr. . I lure an employer that is pro vidiug workers'compensation irisri,auee for my employees.Below is tyie.•poliey and job siteT Itt/irruultiun. 1 / 1—�`� /''� In<urzuic;:-Company Nan"te: A f I a L_��r�V`',( t ���L) 1 (XV1�-e C.--c Poppy li m .sell'-ills. l...ic. k #: � Expiration Date::—...__ loll Jtic Address: . City/S[atelLip: llarh a cupy ur the worlc.ers' compensation policy deel ration pawv isi,,iwmg the policy number and expirati [I date). Ila,lu,r lu sccmc r.uvcraoe its t'CCltllred undoi-Section 25A of MGL c. l).'c.ui hind[0 Ille 1111pO51n.On of climinal pelm tics of a titer Up W 1,500.00 at)(Vul nir year nuprisonnlcnt,as well as civil penalties in the form of a STOP 4\i,I<h ORDER and a fine of up to$250.00 a day against the violator. Be advised Iii.0 a,x,py of dlis statelncut uu, e forwarded to the Office of Llvesti .:,ii,•,ia„f the DIA for insurance coveruge verification, 1 do If ere c if' urtder the P iris and penalties q/pci-olrri,that the information provided above is true and correct. si ,uauut': � Date: llllmle.Ut J Official lose urlly. 1)u .rut write in this area, to be completed bi-efn-or town official City ur'1'uwn: Permit/License# Issuing Authority (circle one): 1.board of hlealth 2. Building Department 3.City,"k,,kil Clerk 4.Electrical Inspector S.Plumburg Inspector o.Other Contact Persotl: ...... Phone#: j . I f l lvl No, 1665 P, I Client#:4597 CCINSUL ACORD,,. CERTIFICATE OF L�AEILITY INSURANCE DATE(MMIDI)LYYYY) THIS CERTIFICATE 1S tSSuED As A MgTTER 07/0212012 QF INFORMATION ONLY AND CONFERS NO RlGHTB UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENLI,EXTEND UR ALTER THE COVERAGE AFFORDED BY THE POLICIES REPRESLOW,ENTATIVE THIS CERTIFICATE OF INSURANCH DOES NOT CONSTIYu"IE A CONTRACT BETWEEN THE ISSUING INSURCR(S),AUTHQRIZLP REPR[$ENTATIVE OR Pf7gDUCER,AND THE CERTIFICATE t1OLDt:R. IMPORTANT:1---f tl)e ca�tjrycala holder is an AbDfTIDNAL INSURED.the flullcy(les)must be endorsed.If SUf3RQGATION 13 WAIVED,suhJurt to the terms and cundltlans of the policy,cnrtBln policies may rnyuh a an endorsamanl.A statement on this cartifiGute doe r not confer ri0111s to the Cortlflcate holder in IieU of such Qndursemenl(s), PRODUCER Rogers&Gray Ins. -So. Dennis NAME: Mar aret Yount) — PHONE 434 Route 134 Arc No Exl:508-760-4602c No. B77-fl'16.2156 EMAIL - ---------- South Dennis, MA 02650-1601 508 398-7980 _ INBUR9R(B)AFFORDING COVERAGE I T NAIC a ----- INSURER A:Peerless Insurance _ '18333 ItJSURED ------- Crape Cod Insulation Inc INSURERS:Evanston Inswanca Company 455 Yarmouth Roatt iNSURERC:Atlantic Charter Insurance Hyannis, MA 02601 x liNjuRERI)..CoMmerce Insurance Company INSURER E: T 1 ___ IN6l1RER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER, rHl9 13 TO CER1lFY THAT' -IHE POLICIES OF INSURANCE LISTED IiCLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAILD. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIt TYPE OF INSURANCE AODL SUER � POLICY EFF POLICY @)r — it� roLlcrNVn+dtR MMIDDIYYYY MM/DDNYYY LIMJY9 A GENBRALLIAHILITY CBP8263063 9410112012 04/01/2011 EACHOCCURRENCE $1 UUU000 X_ COMMERCIAL GENERAL LIABILITY pp MMAAC 77 ENTFQ P�6MIS�S a accu,rcnce $1 UU DUI) CLAIMS-MADE NOCCUR MEDEXP(Any Ono peluoN $SOOU - — PERSONAL,&AUV INJURY $1 000 000 —_T t04101120i RALAGOREGAIE $2,000,000 GEN'L AGGREOAI E LIMIT APPLIC-8 P&R: UCTS GOMPIOP AGG $2 UUU UUU _ POLICY T PRO LOG _ $ AUTOMUHILkL1ABILrrY 12MMBCKVMK 4/0112012INED SINGLE LIMIT cudenl 1,000,000_ ANY AUTO BODILY INJURY(Pcr Pc,.un) :� ALL OWNED X SCHEDULED _— —_ _ AUl'OS AUTOS LY INJURY(Par dccidnnt) S X HIRED AUTOS }( NON-OWNED ERTY DA —'"---"' AUTOS ccltldnllX umeRkLLA uAB OCCUR XONJ453512 4/01/2012 OCCURRENCE $1,000,000 EXCEtiy LIAR CLAIMS-MADEEGATE $1 O l0 000 LARI,)PRI o 5 CONIFENBATION LOYEti3'LIABILITY �/1fCAD052S9U<' 6/3012012 U6/9D/2U1 PRIEry"O PyA'(ME / '�CUTIV&��Y—IN , M� I N I N/A E.L,FaCla ACCIDkNT 1 00U 000 ry in and ' E.L.DISEASE-CAE P V1 404 0(0:noa unary M tovEE 1TION OF OPCRATIONS Unluw __ _ E.L.DISEASE,POLICY LIMIT t1,000,000 UEBChIP TION OF OPERATIONS I LOCATI0NS I VEHICLES(ALlanh AC ORD 101,Addhlww Renmrks Sch@dulR,IL m9re 8pRco IB(BNglrRd) "Workers Comp Information°^ Included Officers or Proprietors Certlticate Holder is included as an additional insured undur General Liability when required by Written contract or agreement. CERTIFICATE HOLDER CANCELLATION T Cape Cod Insulation,inc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES tat CANCkLLf-0 PEFURL• THE EXPIRATION DATE THEREOF, NOTICE_ WILL BE DELIVERLU IN ACCORDANCE WITH THE POLICY PROV131UNS. AU[HORIZED REPRESENTATIVE 0188 -2D10 ACORD CORPORATION,All f(ght9 mioryod. ACOHD zg U5) 1 of 1 The ACORD name and logo aro rogls(ered marks of ACORD#5938491491M83fl4U MAY Friday, November 02,2012 8:50 PM Richard J. Murphy Sr.508-775-7218 p.01 OWNER AUTHORIZATION FORM -J (Owner's Name) owner of the property located at (Property Address) (Property Address) r herebyauthorize `e d (Subco ctor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my pro rty. Owner's Signature Date D NOV 5` 2012 } t. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application #1:609 6 s cool Health Division .3 l� Date Issued lot -Edocl Conservation Division Application Fee Planning Dept. Permit Fee �n Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation /Hyannis Project Street Address 30 4 Rhe k G('4 Y Village A/S/AMIS I/ Owner � AAA✓ /'�U��1 Address SXNA. Telephone S09- 7 7 — 7�Z� Permit Request e !ST/A)G becleo /�LCo�cJ�lG U .E. STi�/�25 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation L Construction Type_ ���pe,Q�r� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Sr'— Two Family ❑ Multi-Family (# units) Age of Existing Structure 4Z 4 WS Historic House: ❑Yes 3<o- On Old King's Highway: ❑Yes &M Basement Type: mull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing J? 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 3<iI ❑ Electric ❑Other Central Air: ❑Yes Alqo— Fireplaces: Existing New Existing wood/coal stove: ❑Yes UH56 Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: U o Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# N ao Current Use Proposed Use APPLICANT INFORMATION rn (BUILDER OR HOMEOWNER) Name !G° iQ/� T• IVIMAIV SR. Telephone Number 6-09-776 -73Z� Address License # I%IIV A)Ai/l S Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO /_'3i4"S97R- 8(dr_ SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ` ADDRESS , VILLAGE OWNER DATE OF INSPECTION: r' FOUNDATION F FRAME INSULATION FIREPLACE i N ELECTRICAL: ROUGH : FINAL- , PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT v ASSOCIATION PLAN NO. r 3 AN The Commonwealth of Massachusetts Department of Industrial Accidents j- Office of Investigations I� 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `� Q Please Print Legibly Name (Business/Organization/Individual): � 0-Y/C 4 de� �' M(�F� set Address: .3� �IQBG�Z 604V City/State/Zip: A1Y,4A)A16 NW ago Phone #: 609,-176-7.325 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 I *` have hired the sub-contractors 6. ❑ New construction employees (full and/or part-time). ' 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ re d.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0'6her�LPiQ/R comp. insurance required.] .S(JP 0.2TS /�/QS *Any applicant that checks box 41 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. tCon[ractors 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 andjob site information. Insurance Company Name: Policy#or Self-ins,Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby ce under the i�s nd penalties of p r.ury that the information provided above is true and correct. Si nature: AM Date: Z Zoo Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: r 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,constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." . Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable 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 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 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 burn 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 Industrial Accidents d Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Rev Fax # 617-727-7749 ised 4-24-07 www.mass.gov/dia Town of Barnstable y��of zrtt:r�y� Regulatory Services BA STAB Thomas F. Geiler,Director LY- 1'� 6 Building Division Tom Perry,Building Commissioner 200 Mairi Street,.-Hyannis,MA 02601 vcww.town.barastable.ma.us Office: 508-862-403 8 Fax: 509-790-6230 HOMEOWNER LICENSE EXEMPTION / Please Print DATE: JOB LOCATION: number str=t `7 village name home phyo�nei#/ work.pbonc# CURRENT MAILING ADDRESS: � Ah ctttawo state np 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- superyisor. DEFINMON OF HOMEOWNER Persons)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/sbe understands the Town of Barnstable Building Department . minimum inspection p occdures and requirements and that he/sbe will comply with said procedures and re en F Signature of Homeowner A Approval of Building Official Note: Three-fam.Uy 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 pernrit is required shall be exempt from the provisions of this sccdon.(Sectian 1 D9.1.1 -Licensing of construction Supervisors);provided that if the homcowncr engages a parson(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(sec 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 responstble. To ensure that the homeowner is fully aware of his/ha 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 forn-Jccnifi cation for use in your community. Q:forms:homccxcmpt � r Town of Barnstable 0 Regulatory Services F `raAxxsg Thomas F_Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 `vww.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder as Owner of the subject.property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete.the Homeowners License Exemption Form on the reverse side. P } , `if �� .! ' ' �- - .. .. �. � ,; "" '� ` ..a �y, ,� — __ — _---_ __ _ 0 �__..__ _... _ a� _ ._ ..._._ ... _�....__ti,Y • P C T T 7"1 9 XN «c . r 4 .t } ON S E W R IN.I T Q 14 V1LL`AGE t1�ST""A tl'rER'S NAME w ADDRE:S'S _o rIG 66�ya j�� xis t C�l�Ee OS 142 .Car rafiiatt-77 .Sfi�efi OIOVRERA <�k �• 4;y®nr�Es, i�cass: 77'S a �.0AT`E PIA M 14 "ISSD°ED +�ek SAT E COLrl1_ANCE = ISSUED , �r " a, Fi"' .,3' i-a.,,.• a +/z.. �'' .�Wr,V: a - I If,�,jy�p� �i+S ".� :e t,k r°�'N z '�1 " � slag VX MN low - y',5nyk-^at.e,�g - 3.Y'��" .� ! € ri�� #�r „S # $ ,� a � .a t y t mass44 `tsh.e'' "� t.,za &5Ll i otiYKEr ` own of Barnstable *Permit# Expires 6 ararrlis from issue At atxNsrAs[E Regulatory Services Fee i��S hta Thomas F. Geiler, Director lFo �� Building Division dm Perry, CBO, Building Commissioner SEP _. 8 2009 y �.0� g 0 200 Main Street, Hyannis, MA 02601 OF www.town.barnstable.ma.us Office: 508-862-4038 AR�ST�B�� Fax: 509-790-6230 EXPRESS PERMIT APPLICATION - RE,SIDENTIAL ONLY y t Valid without Red X-Press Imprint Map/parcel Number 2 1F20 W Property Address 3 M /`7�/,t/� ❑ Residential Value of Work JJ19O, 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address �P)cf7T� 3 Q Contractor's Name Telephone Number(,!a ���3�3G oT T Home Improvement Contractor License 9(if applicable) l�� /6 Construction Supervisor's License#(if applicable) 2 J{// ❑Workman's Compensation Insurance C�h k one: LL/J t am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name - Workman's Comp. Policy# Copy of Tnsurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles)- All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of room ❑ Re-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. "Note: Property Owner must sign Property-Owner Letter of Permission. Hom I7 v e C ntractors License& Construct Supervisors License is required. SIGNATURE: y7 " The Cotn>nonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street Boston, MA 02111 �•�`'� wwminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele'etricians/Plumbers Applicant Information PIease Print Lefxibly Name(Business/Organization/Individual): dz, Address: City/State/Zip: �' •l�S�/�jJ� SJfi�{� Phone.#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction mployees(full and/or part-tim.el.* have hired the sttb-contractors 2. I am a sole proprietor or partner-' listed on the attached sheet. 7.. 0 Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and Have workers' 9 E]Building addition [No workers'comp. insurance comp. insurance.$ required.] 5. We area corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 / Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant.thatchecks 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. xContractors 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 andjob site information. Insurance Company Name: Policy#or Self-.ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 cri_muial penalties of a fine rip to$1,500.00 and/or one-year iWrisorunent, 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 DIA for insurance coverage verification. I do hereby ce i under the pains and penatti s ofperjury that the information provided above is true and correct Signature: Date: Ald — Phone Offccial use only. Do not write in this area, to be completed by city or town official .City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Information and Instructions employers to provide workers' compensation for their employees. Massachusetts General Laws chapter 152 requires all 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, §2SC(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), addresses)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 permiUlicense 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 Sile Address" Lhe applicant should write"all locations iu__(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. ue^ffice cfInvestigations ,voimld 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 Departrnent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSATE Fax# 617-727-.7749 Revised 11-22-06 www.mass.gov(dia Town of Barn-stable Regulatory Services Thomas F. Geiler,Director Fo Building Division Tom Perry, Building Commissioner o 200 Main Street, Hyannis, MA 02601 W)VW.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790- Propel Owner Must Complete and Sign This Section If Us ing A B under () ug , as Owner of the subject property hereby authorize '0A-u 1 d /0 ,S�y ��y to act oa my behalf, is aff matters relative to work authorized by this building permit application for. 30 .(Address of fob O Signature of er Print Name If Pro erty Owner is applying for permit please complete the Homeovmers License Exemption Form on the reverse side. Town of Barnstable Regulatory Services t Thomas F. Geiler,Director stixt�rsr.�at-E. Building Division Tom Perry,Building Commissioner 200 Main:Street,—Hyazmis,NfA-0250 www.town.barnstabla-ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Plcasc Print DATE: JOB LOCATION: number street village ".HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: cityhown state zip code The current exemption for"homeowners"was extended to include o�cner-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- superyisor. DEYgi-MON 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 dwcuing,.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.be/she understands the Town of Barnstable.Building Departrnent rrrinirnum inspectio cedures and re ircmrnts and that he/sbe wi11 comply with said procedures and re Cmen r Si afar of Horn."'c:r 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 Tbc Code statrs that: "Any bomcowocr performing work for which a building permit is rcquircd shall be exempt from the provisions of this section(Section 1D9.1.1 -Licensing of con=ction Supervisors);provided chat if the homcowncr angages a person(s)for hire to do such work,that such homeowner shall act is supa-visor." Many homcowncrs who use this rxcrrgtimi are unaware thatthcy arc assurrung the msponsibilitics ofa supervisor(seeAppcndix Q, Rules&Regulations for Licensing conshvction Supervisors,Scction 2.15) This lack of awareness often results in serious probicros,particularly when the homcowna hires unlicc sad persons. In this cast,our Board cannot proceed against the unlicensed parson'as it would with a licensed Supervisor. The homcowncr acting as Supervisor is ultimately responsible. To ensure that the bomcowncr is fully aware of his/her rrspmE bilitirs,many communibes require,as part of the permit application, that the homcowna certify thkt hclshe undcrstands the resporunbili6cs of a Supervisor. On the last page of this issue is it form currently used by several towns. You may care t amend and adopt such a fom>/certifi cation.for use in your community. t�L c '•3• Board of Buddt� Construction Supervtsor.Licen standards t w `. r h License Cs r . • Btrthdate 95114 3/7/1956 Expiration 3/7/,2010 Tr# 95114 Restriction 00. DAVID ASHLEY 1 4' ARSTON MILLS AMA 02648E Coromissioncw . t ' ,y -�l f2C ZJO�I7Y/72(Y)ZLU�Q�GiL.Q�✓[�Gt�:A6QC>`Zlld�Gtb- - - '; . rl c t Ititildi,ib Regulations uI ata?.tt tr,is License or r—istration v alul far iuciiviti t`:<..mtt ,- HOME IMPROVEMENT CONTRACTOF i before the e%piration(late. If fourd rein ' to Re�tstratt '"8o n 1361u4 Po trd of Building Regulations and Si;u, d � G,. Ashburton Place Rm7301 Ex iratton 6/19/2010 Tr# 2 v23 z T e Boston,)1a.02108 Type Individual `1 �G,9ViD ASHLEY•,y Lp i- ARSTuN MILLS,MA"0264'8 4chninistrat�,= f Not valid tt ithout signac,,,, 1 Town of Barnstable *Permit#,20o�6 /� Expires 6 months from issue date Regulatory Services Fee 60 Thomas F,Geiler,Director Biiilding Division �- Tom Perry,CBO, Building Commissioner 200"Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY. Not Valid without Red X-Press Imprint Map/parcel Number 2 Property Address 30 am �y44A)l - [jjlesidential Value of Work 00 Minimum fee of S25.00 for work under$6000.00 Owner's Name&Address 30 0460k WA Ve ,y,)i._q Contractor's Name Zd NiQ/Q_ /I z),P 'q Telephone Number__-'T4Y-779 7.3ZS Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance . Check one: ❑ I am a sole proprietor [P 'am the Homeowner X-PRESS P E 'T ❑ 1 have Worker's Compensation Insurance Nov ® 9 2007 Insurance Company Name TOWN OF BARNSTABLE Workman s Comp.Policy# Copy of Insurance.Compliance Certificate must be.on file. Permit Request(check box) ["Re-roof(stripping old shingles) All construction debris will betaken to ZAA).�/ lLL ❑Re-roof(not stripping. Going over existing layers of roof) i ❑ Re-side ❑Y Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,_Canservation,etc. ***Note: Property Owner t sign Property Owner Letter of Per A c y of th om Improvement retractors License is�required. SIGNATURE_ QTon, mtr:ez r. p g " Revise061306 f - " The Commonwealth of Massachusetts Department oflndustrial Accidents r Office pf Investigations • 600 Washington Street Boston,AM 02111 , www.m ass.gov/dia Workers" Compensation lasurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizotion/Individual):. Address: �vD4 13d it— Gf'/q City/State/Zip: �y`Q�Iy S ' Phone.#: 73 Z 5 Are you an employer? Check the appropriate box: 'Ty pe of project(required):, 1.❑ I am a employer with 4. ❑ I am a general contractor and I have hired the sub-contractors 6 ❑New construction . . employees (full and/orpart;time). � 2.❑ I am a'sole pioprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees 'These sub-contractors have g, [j Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers'comp.insurance comp.insurance. •$ re d] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.EZPTam.a homeowner doing all work officers have exercised their 11.[:]Plumbing repairs or additions rnysel£ [No workers' comp, right of exemption per MGL 12.❑Roof repairs insurance required.]t C. 152, §1(4),and we have no employees. [No workers' •13.[] Other comp,insurance required.] , 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet sbowing the name of the sub-contractors and state whether ornotthose entities have employees. If the sub-contractors Izve employees,they must providb their workers'comp.policy number, lam an employer that isprovlding workers'compensation insurance for my employees Below is the policy and fob site information Insurance Company Name: Policy#or Self-ins;Lic.#: Expiration Date: . • r v Job Site Address: City/State/Zip: Attach a copy.of the workers' compensation policy declaration page(showing the policy number and expiration date), Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the tIA for insurance coverage verification. I do hereby ce ;cnd the p and penalties o per' +that the information provided ab ve is a and correct: Sienature: Date: Phone#: Official use only. Do.not write in this area,'fo be completed by city or town aIcial . City or Town: � Permit/License# T Issuing Authority(circle one): .1.Board ofHealth 2.Buff ding Department 3.City/Town CIerk 4.Electrical Inspector 5.?lambing Inspector 6. Other Contact Person: Phone#: � f Town of Barnstable Regulatory Services • BARNSTABLE, MASS. �, Thomas F.Geiler,Director Qjo 0g9. �0 . lFowa+" 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 Mu Complete and Sign`This' ectiori si A. . .TM� ,If LJ 'ng -Buil er 1 � -.t -, # ,,. ` .. ..,' ,. .. tip•, .+E, y�.: N., i - as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work`authorize by this building permit application for: (A dress of Job) Signature of Owner Date F , Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. " Q:FORM&OWNERPERMISSION Op 1HE Town of Barnstable � Tp�� y�P Regulatory Services ► BARNSTABLE, « Thomas F.Geiler,Director MASS. i639• A,0 Building Division lFn � 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 DATE: Please Print � D Q Q 1 / ,/ �q JOB LOCATION: 3D �IC(JD Y 0411A (/ z number y� street ` village ,.HOMEOWNER': C dl2l ly,A QA/V� ",0 7 7�'7ZI9 J a-774"7.3ZC name n Q home phone# work phone# CURRENT MAILING ADDRESS: 30 kAok a)A ) A/YAx IS xM oZdai c /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 mini inspection p cedures and re uirements and that he/she will comply with said procedures and req men . Sigr�a—ture_ol Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1,1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forrms:homeexempt E-migineering Dept. Ord floor) Map a 8 Parcel Permit# - House# -3 (' Pis Date Issued /0 ''�—�� Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Ml�l�, �e ee r Conservation Office(4th floor)(8:30-9:30/1:00-2:00) SEPTIC STEM NPRAS T BE msTALLED 19 '_D TOWN OF BARNSTABLE ' Building Permit Application sect Street dress � J Village Owner • Address Telephone — 02/S" Permit Req est Gil - - � t First Floor square feet Seco d Floor square feet Construction Type Estimated Project Cost $ a. O d Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family p'___f Two Family ❑ Multi-Family(# •nits) Age of Existing Structure 3Q Historic House ❑Yes L.m o On Old King's Highway ❑Yes a eo Basement Type: ❑Full ❑Crawl alkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing Yy New No.of Bedrooms: Existing New Total Room Count(not including bath , Existing New First Floor Room Count 67— Heat Type and Fuel: Li Gas , Oil ❑Electric ❑Other Central Air ❑Yes , l<O Fireplaces: Existing New Existing wood/coal stove ❑Yes ONO Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Attached(size) ` d4-A, - ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# . Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO C SIGNATURE r DATE BUILDING PERMIT DENIED FOR HE FOLLO *G-REASON(S) r FOR OFFICIAL USE ONLY � 1 PERMIT NO. t� DATE ISSUED MAP/PARCEL'NO. ADDRESS VILLAGE .. OWNER '} 1 j r . DATE OF INSPECTION: 4 i FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: - ROUGH FINAL GAS: �:a ROUGH FINALc FINAL BUIL'DING' • � � J t DATE CLOSED OUT t r ASSOCIATION PLAN NO. / lit- Department of ludzurrial Accidents ,,, �\- ;Y _"�� 0>fceollayestigatloas . _ j. 6110 ff avhhigronr Strci t Bucum.Alas 92111 Workers' Compensation insurance'Affidavit w ane I am a hom wner performing all work myself. I am a sole proprietor and have no one working in any capacity �,�,�_,_��• �] 1 am an employer providing workers' compensation for my employees working on this job. enmainy cih Mont.#• , inmir•Ince co Holley a'f I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: om anv na e• •Iddr cit nhone f#- incur•Ince co policy 0 �� �. _• - .. — -•- -• ,•en• .a��es -,�. -arm•—.+.vc.' -cT.��s�. _ __�_a�_ r+s•-.-w _-fie-:.�:.j cnm am•n•tme• nddre c- rit nhone!i- i curan c nolicy N Attach additional sheet if tiecess + -e,_:,•..,ic css,es -..:. :•r.:...,- ...,77•...,. � tr�<��+'—_.,-•_.. Failure to secure coverage as required under Section 25A of 1%IGL IS3 can lead to the imposition of criminal penalties of a fine up to SI.500.00 and:o- unc scars'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and aline of 5100.00 a day against me. I understand that copy of this statement may be forwarded to the Otftec of investigations of the DIA for coverage verification. ' I do 1 ebr cerr'. under t re pal Is' n penalties ojpe ' n•1l the information Prodded above is true and correct. ianatum Date Print name Phone 'oMcial use only do not write in this area to be completed by city or town oMcial city or town: permitAicense# nlluilding Department Licensing Board check if.immediate response is required C3Sclectmen's Office C3Heallh Department contact person: phonefl; rtOther uerucd 1'15 P/A 1 r Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for employcrs. As quoted i1rom the "taw", an emphgiwe is defined as even,person in the service of another under anN contract of hire, express or implied, oral or written. An enrplorcr is defined as an individual, partnership, association. corporation or other legal entity, or ally two or r the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased emplover, or the _ rccciver or trustee of an individual , partnership, association or other legal entity, employing employees. Howeve. owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwclling house of another who employs persons to do maintenance, construction or repair work on such dwelling_ or on tite :rounds or building appurtenant thereto shall not because of such employment be deemed to be an empic MGL chapter 152 section '_5 also states that every state or local licensing ngency shall withhold the issuance of renewal of a license or permit to operate a business or to construct buildings in the commonwealth for an• applicant who has not Produced acceptable evidence of compliance with the in coverage required. Additionally. 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 chaps. been presented to the contracting authority. Applicants Please full in the workers' compensation affidavit completely, by checking the boa that applies to;your situation at- supplying company names. address and phone numbers as all affidavits 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,tlte application for the permit or license is being requested. not the Department of Industrial Accidents. Should ydtt have any questions regarding the "law''or if you are requi to obtain a workers' compensation policy, please call the Department at the number listed below. '.•r L,.`.y`,. :tip,a.,..iar •:i• Cin- or ll oiwns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bortorr the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returne the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questi please do not hesitate to give us a call. The Department's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston,Ma. 02111 A ` of VE ri The Town of Barnstable K" Department of Health Safety and Environmental Services 6139- Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-790-6227 Building Commissioner Fax: 508-790-6230 r For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing t not more than four owner occupied building containingsuch at least one residence or buuildiag be done by registered cong units ractors or to with structures which are adjacent to certain exceptions long with other re uirements. Type of Work: _ Est.Cost Address of Work: �d Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. QB '!ding not owner-occupied wwner pulling own permit Notice is hereby given that: PERMIT OR DEALING WITH UNREGISTERED OWNERS PULLING HEIR OABI E HOME avROVEMENT WORK DO NOT HAVE CONTRACTORS FOR ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. .Date Contractor Name Registration No. OR " �,�� 04-9 4 6wN�R ` TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE ) JOB LOCATION W Number Street 4dress Sec on of town "HOMEOWNER" S--^ Name Home phone Work phone PRESENT 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 such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one to six 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 Officia- 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 Stat Building Code and other applicable codes, by-laws, 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 comp ith sai r ced res a d r uirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. At HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 Home Owner engages a person(s) for hire to do such work, that such Home Ownei shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for licensing Construction Supervisors, Section 2. 15) . This lack of awarene: often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home "Ciwner- actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, . mar communities require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community.