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HomeMy WebLinkAbout0099 BACON ROAD q q ����� '��� Application numbe �l Fee UI✓ .................. «....................... NAM 'BuildingIns ectors Initials:..:. sk I Q ..............................................Date Issued:...�R/.7 .� m JUN 06 2019 �3 MapJParcel'' ..... .. . y 30��� t�� 8AHN 1ABL TOWN.OF;BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION.'a 1 PROPERTY INFORMATION Address of Project:2 150-co i P !�� NUIvi+BER STRET VILLAGE Owner's Name: Ste- c rk— al�JClcone Number 7, 2 .. Email Address. Cell.Phone Number Project cost$ Q Check one. -Residential ' Commercial b OWNER'S AUTHORIZATION As owner of the above property I hereby authorize , to make application for a building permit inaccordance with 780 CMR Owner:Signature: Date: TYPE OF WORK- 0 Siding E-1 Windows (no header change)# Q $sulation/Weatherization 0 ,Doors (no header change)# Commercial'Doors require an inspector's review Kr Roof(not applying more than 1 layer of shingles) i Construction Debris will be going to V"j-a 6t, �i CONTRACTOR'S INFORMATION" Contractor's name !ter V Home ImprovementRegistration(if applicable)# / ?Contractors R (attach copy) Construction Supervisor's License# /3 S (attach copy) f Email of Contractor t,Ou1,C� y Phone number-'QP—? '��� �? ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YfARSLOLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ , .` .*For Tents Only* Date Tent�(s) will be erected Removed on number of tents total Does the tent have sides?Yes No ' (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 201bs. or> Yes No ,if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 4�14_er A;qt✓it2 -LO V / Address: 22-011 yl,Pl 04%r&.IA— City/State/Zip: A(I?f�3A, /7Y �� Phone 1 Yu-_ AFan employer?Check the appropriate box. Type of project(required): 1. m a employer,with Pam. 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me-in an capacity. employees and have workers' Y P ty� # 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work, officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of 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 a new affidavit indicating such. $Contractors 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 insur nce for my employees. Below is the policy and job site information. / Insurance Company Name. � � /�/l / �c Policy#or Self-ins.Lic.#: well '��������"d�� Expiration Date: Job Site Address: �P� A>a__CdQL 20 / City/State/Zip: M4 P1 P%r 6 s` Attach a copy of the workers' compensation policy declaration page(showing the policy nu er 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 ins ance coverage verification. I do hereby certify er th ains and pe aloes of perjury that the information provided above is true and correct Signature: Date: ®� so Phone#: 0 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal'entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or 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 Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 446 or 1-877-NIASSAFE Revised 4-24-07 Fax#617-727-7749 www,mass.gov/dia Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standard Constro&iori tilpervisor i - CS-111305 ices:06/0112021 ANDRE YARMALOVIGHi " 204 CINDERELLO MARSTONS MILLS MA 1 !k Commissioner . :fCLIYlf�3F.�.ls ' . Ot6ce of Copau®er ea4 alation T -i72476 HOME lM CONTRACT , . P®: Ems. 7R18 DBA BS MO E IdT ANDREI YARMALO 204 CINDERELLA MARSTONS MILLS, • admit ry ACO® DATE(MM/DD/YYW) CERTIFICATE OF LIABILITY INSURANCE 3/26/2019 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 have ADDITIONAL INSURED provisions or 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 BRYDEN&SULLIVAN INS NAME"" 88 FALMOUTH RD PHONE; FAX No): HYANNIS, MA 02601 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC q INSURERA: LM Insurance Corporation 33600 INSURED r INSURERB: BEL ISLANDS HOME IMPROVEMENT LLC 204 CINDERELLA TERRACE wsuRERc: MARSTONS MILLS MA 02648 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 47733064 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. NOTNTHSTAND114G 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. INSR TYPE OF INSURANCE ADDL LTR wyn POLICYNUMBER MM/DDNYYY MM/DDNYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMTGE.TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea ocwnence $ MED EXP(Any one person) $ PERSONALS ADV INJURY $ GEN'LAGGREGATE LIMIT.APPLIES PER: GENERAL AGGREGATE $ POLICY a PRO- LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: AUTOMOBILE LIABILITY Ea COMBINED SINGLE $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR HOCCUR - EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE -AGGREGATE - $ DED RETENTION$ $ A WORKERS COMPENSATION WC5-31S-615667-019 - 2/11/2019 2/11/2020 ,/ STATUTE EORH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNER/EXECUTIVE ❑N NIA E.L.EACH ACCIDENT $500000 OFFICERIMEMBEREXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500000 If yes,describe under E.L.DISEASE-POI CY LIMIT $500000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ` TOWN OF FALMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 59 TOWN HALL SQUARE ACCORDANCE WITH THE POLICY PROVISIONS. FALMOUTH MA 02540 AUTHORIZED REPRESENTATIVE - (' Jon Smith ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 47733064 1 1-615667 1 19-20 WC 1 n0270258 1 3/26/2019 3:57:58 PM (PDT) I Page 1 of 1 • f Estimate 'BEL ISLANDS Home Improvement 3/24/2019 953 Bel Islands Home Improvement 204 Cinderella Terrace Name Address Marston Mills, Ma ,02648 Louise Kirkpatrick 99 Bacon road, Belislandsroofingandsiding.com Hyannis,Ma 508-280-1794 - 508-364-6909 Terms Project t t l>escnption �' y Qty - t Ratex Y` .:Total� c .4 Permit 250.00 250.00 dumpster 550.00 550.00 --T Total $s,5oo.00 GQ� � b�aD lQ Pa ge 3