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HomeMy WebLinkAbout0056 BISHOPS TERRACE C!/�� . Y/1,�, �_�� 2I � � � 9 % ,� F o . X-PRESS PERMIT o 6 ( 1 Z W Town of Barnstable *Permit# 6 2013 Expires 6 mont om iss date Regulatory Services Fee s �*3ARNSTABI. MAS& Thomas F.Geiler,Director BARNSTABLE Building Division Tom Perry,CBO, Building Commissioner` 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us 0ffice: 508-862-4038 Fax: 508-790-6230 I EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �i Not Valid without Red X-Pres Imprint Map/parcel Number l , Property.Address (5- 6�' t Residential Value of Work DD s Minimum fee of$35.00 or workunder$6000.00 Owner's Name&Address ^64L.4�)610, Contractor's Name Q, �� rLl .� '�o% Telephone Number Home Improvement Contractor License#(if applicable Construction Supervisor's License#(if applicable) L� } 2<dorkman's,Compensation Insurance Check one: ❑ I am a sole proprietor ' a I am the Homeowner I have Worker's Compensation In urance Insurance Company Name �.. Workman's Comp.Policy# C/ V ( I ® 1 Copy of Insurance Compliance Certificate must.accompany each permit. Permit Req st(check box)t ( LRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken tod y5 Pi� ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value -(maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. . Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: . QAWPFILES\FORMS\building permit formsTMRESS.doC Revised 053012. : .- April 9.. 2013 Barnstable Building Dept. The following is a list of our approved sub-contractors for The Home Depot: Ericsson Torres — CSSL # 100546 HIC # 163528 Michael Viola — CSSL #099403 HIC # 140993 Arthur Drougas - CS # 059059 HIC # 165927 Timothy Thomas CS # 51899 HIC# 152121 Ronaldo Solano — CSSL # 101027 HI C C # 152206 Joseph Duarte - CS # 70077. HIC # 132349 Douglas Szynal — CSSL # 103950 HIC # 146142 Brian Laroche — CSSL # 100478 HIC # 152612 Joseph McKeon — CSSL# 98863 HIC # 132614 If you have an questions lease contact Mike Bedard our permit Y any p coordinator at 508-962-6942 or myself at 617-438-9017. Sin Y.* l Br Installation Manager THD At-Home Services,Inc. 908 Boston Turnpike• Unit 1 #Shrewsbury, MA 01545 Phone:774-275-2139•Fax:508-845-6076•Toll Free:800-657-5182 a The Commonwealth of Massachusetts Deparhnent-of-Ind--ustr aI,4c rl t D,,Q°ice.ofInvestigadons 600 Washington Street Boston,M4 42111 . wncw.inass.gmldia Workers' Compensation Insurance ffid2vitr B erslContractors/E•IectiicianstPlumters Apphcant Information Please Print Name{Big4ness/0�6m&&vidaai): Address: C_,�a�- S, City/State/Zip: Phone## Are tau an employer?Check th prapriate box: Type of project(required): 1. I am a employer with lio 4. ❑ I airs a general contractor and I 6. ❑New construction employees(fall and/or part-dime).* have hired the sub-contractors Z..❑ I am a sole proprietor or listed on the attached sheet` 7. ❑Remodeling proms pa d employees an have workers' These sub-contractors have ship and have no employees 8. Elm Deolitioff.t working for me lit any capacity. g ❑Building addition [No workers' comp.insurance comp.mermanre—X required.] ❑ 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[94,00f repairs insurance required.]T C.152,.§1(4),and we have no employees.[No workers' 13,❑Other comp.insurance required.] •Any apphcaw that chedks box Al mast also fill oat the section below showing their workers'cm enssiiaa policy inf notion. Homeoamm who submit this affidavit indicating they ate doing all vn rk and then hire outside contactors must submit a new affidavit indicaaing such. kantractors that check this bmr saust attached an additional sheet showing the name of the sub-coatracton and state whether at not those entities have employees. Lf the sub-contractors have eiaplayees,they nmtst.provide their workers'coup.policy number. I am an empky er that isptvviAWg worlrers'cottgm=atiori inmrarrre,for nzy earploy em Below is thepvdiq and job site iHfortnahan. �l ��- C I LGC,!'""t'�1 � - CO Insurance Company Dame: q GC�q Policy#or Sel€ins.Lie.-9: /t�PV 1. VO 0 0 E.Mcpustioa Date: e Job Site Address. � 1.� i y� l%L f��� ��-� City/state/zip: j Attach a copy of the workers'compensation policy declaration page(showing the policy number a expiration date). Failure to secure coverage as required undo;`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 iinprisomnent,as welt as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a days 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 ver:ffc:atio - I do here by certi nder thepains andpenaities rr.fpednq that the ingot naf en provided above is hwe,and correct. 5i O 7?ei O L5,6 O Date: Phone#: s � 3 $ q3 � ©fidai.arse oniv. Do not write in this area,to be compiete+d by city or totwai official. City or Town: permidUcense it ISgning Authority(circle one): 1..Board,of Health 2.Building Department 3.C ityrrown Clerk d.Electrical Inspector 5.Plumbing lmspector 6.Other Contact Person: Phone#- - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigation.s . 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AvyUcant Information Please Print Le 'bl Name(Business organizationandividual): Address: O-C4&5 Q City/State/Zi : 64- 30-:ug Phone#: 92)V 6,S-" 8�2— Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 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 shipand have no employees These sub-contractors have 8. E] Demolition working for me in any capacity. employees and have workers' 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.❑P umbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.[ oof repairs insurance required.]t c. 152, §1(4),and we have no 3a.❑ I am a homeowner acting as a employees. [No workers' 13.❑Other general contractor(refer to#4) comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensatioAlsolicy 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 sun an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information /J Insurance Company Name: Policy#or Self-ins. Lic.#: V I C- 03 3 9-7S-3 Expiration Date: Job Site Address: P(.5 o-tP City/State/Zip: L Attach a copy of the workers'compensation policy declaration page(showing the policy numbe 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 S250.00 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 a fy er a pains an na of perjury that the information provided above is true and correct ph "(J U P�- — �j 9 one#: Ojj3cial 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 Manachusetts Qeneral Lawn chapter 152 requires all enployrbs to provide workers'compensation for their employeft punuad to this statute,an emplgw is defined as"...every person in the service of anotha under any contract of hits, express or inplied,oral or written" An amVisfer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more Of the forepiof engaged in a joint enterprise,and iwbiding the kpl[epraeatstives of a deceased empkr^or the receiver at it at,e of as individual,partnetsb*associadw or other legal entity,employing employees. However the owner of a dwelling;boric boving not fm , than three apa to ate and who resides-1 , i m.oc the occupant of the dwelling house of another who en4loys Persons to do maintenance,construction or repair wort on such dwelling house or on the gsounde or building appurtenant thereto shall not because of such empbymeat be deemed to be an employer." it3L chapter IA f 25C(6)also states dsat"e M stab sr food 11censf sgeaey shs8 wtthhGM the lsauaaa x renewal s(a Ucenee or permk to operate s badme er to eoastrud boddbW In the eem oawedth for nary appoeaat wbe hoe sot produced swept"eridesee of compltanes with the iasQasa anrap rsgtdrW Additionally,MGL chapter 152,#25g7)states"Neither the coamsenweahh nor any of its political subdivisions shall enter into any conbaat for,the perfinmsaee of public wort until acceptable evidence of compliance with the iaamw@ mgrm mncda of this chapter have bees presented to the cmuncting authority." please f M out the worim 'compensation affidavit completely,by checking the boxes that apply to your situation=4 it necessary,supply suiscontraeto ;)names),addraa(es)and phoms number(s)along with their certificates)of insurance. Limited Liability Campania(LLC)or Limited Liability,parmaWupe(LLP)with no enpbyea other than the members at partners,are not required to carry workers'comrpemadon insurance. If an LLC or UP does have emplo)eea,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for com8rmaebs of insurance coverage: Alse be son to sip mW date the aMoviL The affidavit should be returned to the city or towns that the applicadoe for the permit or license is being requested,sat the Deparunent of Industrial Acsideate. Should you have any questions regarding the lawn or if you aria nquind to obtain a waiters' compensadoa policy,prase call the Department at the number listed below. Self-insured caarI should eats their self-iawranee license mbar on the appeopriats lit ` - i Clty err Taws Ot]ddai i Please be sure that the affidavit is complete and printed legibly. Tbw Department has provided a space at the bottom of the affidavit far you to fill out in the event the Office of Investigations has to contact you regarding the spplicant Please be we to till in the pernmblicense number which will be used as a reference mmnbec it addition,an applicant that mwt submit multiple pere applications in any even year,need only submit one affidavit indicating current policy inkrmados(if necessary)and under"Job Site Addrese"the applicant should write"all locations in (city or town"A copy of the affidavit that bas been officially stamped or marked by the city or tows may be provided to the applicant r proof that a valid affidavit is on file for Mae permits or licensee. A new affidavit moat be filled out each year.Where a home owner or citizen is obtainia;a license at permit not related to say business or conwercial venture (i.e.a dog license or peen it to burn lerm etc.)said person is NOT requred to comptetu this affidavit The Ot&s of Investigations would like to thank you in advance for yaw cooperation and should you have any question. please do mot hesitate to give us a ca1L the Depa ton is address,telephone and fax mmnbw. The Commonwealth of Massachusetts Department of Industrial Accidents OfYke of INT"dpdons 600 Wmhington Street Boston,MA 02111 -Tel. 617-7274900 ext 406 or 1-377-MASSAFE Fax ll 617-727-7749 Revised 11-224)6 www.mms.gov/dia -0 I0'131201:.1 15.21 F IIiI[IERVIR!TNO 16001;001 SM `dam 31812013 THIS CER WICATE iS ISSUED AS A MATTER OF,INFORMATION ONLY AND CONFERS NO RIGH"UPON-THE CERTiFICAiSMOII DER TNl9 GERTiFICATE DOES NOT NO R ALTER THE COVERAGE:AFFORDED BY t1 m POLICES BELOW.:Ti�11S CER11E{CATE OF INSURANCE DOES ,fs AFFIRMATIVELY OR NEGATIVELY AnAENO, EXTE 0 NOT CONSTITUTE A CONTRACT BETWEEN THE IBSUINO MSURER(S),AUTHORIZED REPRESENTATIVE-OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. il,the cartif"te holder Is an ADDITIONAL INSURED,t1Ta Polkyl(i�s).glusttle endorsed_ ff SUBROGATION IS WAIVED,sublet to the'torms and eondlLlons of the porky,certain Policies s may rvqulR an andon wmenL A StMinent on tthhliss ca tillole does not confer rigor to tho'certlficat-holder In lieu of Such en*Oreement9(el. COwTACT PRODUCER Thomas J.Woods Insurance Agency,Inc. raw i a�. 1 08)755-5944 INC,m i (503)791-98 1 EAWL PO Box 2940 ADDRESS- Worcester.INLA 01613 PRnnorr•R • ? 1FR rj p iNSURERSAFFORDING COVERAGE. NAIL B wsuMR a Atlantic Charter Insurance Company VDAC 29211 c,6dRED - U-1i Rooting R Construction,inc INSURER a: iYSUR�tt C: 1D_\krav erly Street rvSUITER G: Framingham,NIA 01702 INSURERE: — --- — INsuncR F: COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER: tHIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE TOR THE POLICY PERIOD I.SDICATED.NOTNRHSTANDING ANY AEOUIREMENT,T E.l..M OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VATH RESPECT TO WIIICH THIS CEATIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUWECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. wilt TYPE OF II4VRAtrCF ADDL SAAR ! POLCY NUMBER POLICY EF:ECTItiE POLICY EXPIRATION LIMITS LTR iwR LWe i OATE(uMOOMY1 DATE(UhPAN YY) IRIThwes c I GENFRAL-UABUT' _ CGCARREW-E S ('� [ � 4LLKIE TO REYi�'+PnEy,,s:9 :'SMM "vIALOEtv;r✓4.t,4eyT• �� :Et 60awwwt) _ CLANS NA_^C ! I GGCUR .c0EXP&-j,a- H•u^I S `J t 1 DtiK AAD'Y M:-m 9 Sri , .ORAL AC.-alLAXE S .=lIL AG.rtiWi:ULt+T APRIC,7 PEo t. ttYa�:taPA3G S PDu::i ❑F-o CT Lo: AUTOMOWLEiIAMLITY I m PMD Swc-•LE Lim.r A AN AUTO ic3 Atitlni _a0GfLYJWIJRY . ut-%tikD>•.VT03 a:.::•r(JL2R.W:Y. ❑` 1 � bOq YI.YJY,'RV S - OW4 - II ntF.EDA�.._ IFRO?ERry'Gav4G£ S. •azti:.^.E:,wt,•C.. I£A x.,rn?a - - ❑ IU.LWCLLA :,IDiLm ❑ t:ACn 0.^.t1?iaellcE 5 FX..M LIAD CiA%*JAk;E �—'' • -n :iE 9- LJ e �i:TEMtI,,7rJ i A EMPLOVIRS,ulelv-'T10/J AND WCV00990801 02-125i2013 02/25/2014 X ;u 3VTQ Y 9tKER iIVYM17P31E:DnM1•IK7wG.i:-L L;I:r.•E YIN - - 'Dxrl„Eq;yEiteEREx.=u Policy Covcra?c.Stvje!N1A E.�CrA>:cro:I,T .. s 100,000 k.�•yply 11 ra - t~te-e:.eOt.i Lair i3EC4L vltL`r5,6T:i Datl�: IY.sEllu•FCI ,_;LIMY S 500.000 (� if 0wVSr_-EACJiEMF1QVEE s 100,000 OTIqFR D;acR>Pnvv Cr CPlRATICI•A,LDCAr,DNDNF:IaCiEa IA,d:h AC011D iCt,AAtl►Ja,ui a+mA,tt eciiedstlh it ma,i tcttt it ripWntl) Attention: Please note that the Insured has not elected coverage for ttlemselves Bnd there is n-41 ITIJII covt:rcd on this poliev. CER71F1CATE KOI:DER� ��` �.'�{-; '" .�� �i ��r ,; .: ,/• ` ,_ sat.,.,•_._v i....- a....:s:t�,tif i.. � ._ �3 ... ,.`!>•-�r.:°•.:rt ?s. ,.i,"�.1 �� }..u.;.... t:.'�jL'�`T�:1� n���}a y.i� '+Yi .�fichm ..-ry _ ^y..- SHOULD A.YY OF THE A8(1Vt;DESCAtBEO P01JC E8 BE C,irvCELlE08EfORETt�. THD At Notate Services, Inc.and The.Home Depot ExrlRAroN QATE TFit REOF,THE ISSUING COLIPANY 1h1LL ENDIcRVAR TD A1All 2690 Cumberland Rwy,Suite 300 i DAl'S.VtSiITIEN I:OTICE TOTHE C_ERTiFfu�TE FIaLD£R NAAI Tp3}IE i�T. Atlanta,GA 30339, 3UTFAILURE TO OO SO'SH:.LL iM E NO Ct3UGATtON DR t vLA1UTY ..OF ANY KIND UPON THE INSU r S AGENI'S OR REP td,-aTtyES 4Un+DRirfD RfPRE&EltTAi?5r' � ACORO 21(2000.0) na All tt�wv rvevtvod, Page 1 Dt T CUTIFICATE HOLDER cork 1' DATE(MM/DDrfYYY) CERTIFICATE OF LIABILITY INSURANCE 02/27/2013 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 I BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME- MARSH USA,INC. PHO F TWO ALLIANCE CENTER Alc No Eat): Arc No: 3560 LENOX ROAD,SUITE 2400 E-MAIL ADDRESS: ATIANTA.CA 30326 INSURER S AFFORDING COVERAGE NAIC q 10004_92-Hom_e_D_-GAW13-14 _ INSURER A: Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Cc 1 - 16535 THE HOME DEPOT,INC. N Hampshire Ins Co 23841 HOME DEPOT U.S.A.,INC. INSURER C: ew am p 2455 PACES FERRY ROAD,NW INSURER D:Illinois National Ins Cc 23817 BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003159545-04 REVISION NUMBER:7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LIMITS LTR ` TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD1YYYYl MMIDD/YYYY A GENERAL LIABILITY GL04887714-03 03/0112013 03/0112014 EACH OCCURRENCE $ 9,000.000 DAMAGE TO RENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY,LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE L OCCUR LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL&ADV INJURY. $ 9,000,000 GENERAL AGGREGATE $ 9.000,000 GENT AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ 9,000,000 X POLICY PEO LOC $ B AUTOMOBILE LIABILITY BAP 2938863-10 03/01/2013 03/01/2014 COMBINED SINGLE LIMIT 1,000,000 Ea accident I ANY AUTO BODILY INJURY(Per person) $ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOSNON-OWNED - PROPERTY DAMAGE $ HIRED AUTOS AUTOS - Per accident ---- $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION$ - $ D WORKERS COMPENSATION WC033575314(ADS) 03/01/2013 03/0112014 X WC STATU- O D CRY LIMTH- 'AND EMPLOYERS'LIABILITY WC033575315(AK,AZ) 0310112013 0310112014 1,000,000 ANY PROPRIETOR/PARTNERIEXECUTIVE YIN / - E.L.EACH ACCIDENT $ D OFFICERIMEMBER EXCLUDED NA WC033575316(FL) 03/0112013 03101/2014 E.L.DISEASE-EA EMPLOYE $ 1,000,000 (Mandatory in NH) - If yes.describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C WORKERS COMPENSAI ION WC033575317(KY,NC,NH,VT) 03/0112013 03/01/2014 (EL)LIMIT 1,000,000 C I WC033575318(NJ) 03/01/2013 03/01/2014 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FER11Y ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS. BIILDING C-20 ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjeeaupo►� .�rL+tidtn e a ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD , �+1; r = a Office of Consumer A.ffai and Business Regulation 10 Park Plaza - Suite 5170 _- Boston, Massachusetts 02.116 Dome Improve Contractor.Registration z r Registration: 126893 Type: Supplement Card l j 4 la i'r Expiration: 8/3/2014 ' The Home Depot At-Home Services MICHAEL BEDARD 2690 CUMBERLAND PARKWAY 'SUI,TE300 ATLANTA, GA 30339 ; { Update Address and return card.Mark reason for change. Address Renewal ❑ Employment Ej Lost Card nPS-C<•.i 50rn-oa04-6101216 .,. �%�ie ��vm��zoozcuea/,Cl a�'✓�ac�uaeC7a . Office of Consumer Affairs&Business Regulation License or registration valid for indiretul use only OfV{E IMPROVEMENT CONTRACTOR before the expiration date. If found return to: office of Consumer Affairs and Business Regulation. a 4— Registration 126893 Type: 10 Park Plaza-Suite 5170 Expiration;"8/3/2014_ Supplement Card Boston,MA 02116 The Home Depot:'At=Home:_Seni�ices C MICHAEL BEDARD LAND P" RKWAY S � �� (/�� f T.1f 2690 CUMBER A_ .. �—'— "l A'ITLr ffA,GA 30339'` ;`.: Undersecretary Not va 'd without signature _ 5 `� FW��j .�;^fi���� r:�..v� f'�`. ^'c� � ,.�. � ls: k -,�,�r mot. � a t �L '+z"�, at" S`krt� ,jy.� �•$�4°,�.+r-• ff k�v� - �s' C f - ' P6t �5.onsntnerA�ttairs}."sc tiu�=Qes� �Qu€ to ° v+ �L.r a^'p 4 a� s •a .•.. + R7 s 3 .: r.:.. : ys,#"f`-��„ti '. ,� z kc-: r A` ad "",' .t y '7; err.ei��r:. `' .�,�k' t•� t HOiViEpIMPR, VEMENT'CONTRAQTOR.', j W Fteistratcon»` j52206 n. Tx ` p T.'tn Expiration , j� >� r ve t'�?3+''�.�..- t .._. 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Y'.�tr"'> _�,y,,�y� xY...n�,p�'s'� •,t+j:, 'JM�� tg': i.�,> t - 5 ! i �t .',.+p^�,"" �"`.x`' p,t �, � 9 � Y - � ,.R- �t - P'� � _ r �'�� '�'�,•-k+�ad`ya�'rsn.+r,� ::.. ,. ..� r.` t .� tis'C�C��y7 '�r��i�a K k , f� �i' � ��� ` �fi �" - ?rt t r %; �`t+4 �i"�'.• C� -C � `.Vfi '� �li II 241 �^ t �� . i v „r- EngineerYng De�t.(3rd floor) Map Parcel Permit# aZ/ 6 House Date Issued V NO n4dih roams � L/ Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee U%�6,C� Conservation.Office(4th floor)(8:30-9:30/1:00-2:00) Planning De pi, t floor/School Admin. Bldg.) of1ME, Definiti4treetAddress owed by Planning Board 19 aTOWN OF BARNSTABLEBuilding Permit Application •-/Projec '5 �o r g yo 5 /�.iZ ,� . Village ✓V S Owner 28 4,Cov -�`A ddress 3,15 YO 7 '.S` ZTelephone `- •are,�� = s ., , .`,permit Request 7�uest i t (o r✓ `� 8eD! ©c) M w o� First Floor square feet Second Floor square feet Construction Type OQt2,6 _E R AA-I F, VIIE"stimated.Project Cost $ e 400 Zoning District Flood Plain Water Protection Lot Size 7, -Y -2� Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 7220 x 20 Historic House ❑Yes Eklgo On Old King's Highway ❑Yes tj"No Basement Type: ["Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Alo Basement Unfinished Area(sq.ft) 3 4 X 2. S' Number of Baths: Full: Existing ✓ New Half: Existing New No.of Bedrooms: Existing New �— Total Room Count(not including baths): Existing New First Floor Room Count 'T Heat Type and Fuel: p'Gas ❑Oil ❑Electric ❑Other Central Air ®'Yes ❑No Fireplaces: Existing ✓ New Existing wood/coal stove ❑Yes LWNo Garage: �J Detached(size) X Z Y Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None kShed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial 0 Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information v Name l�0� ?'K 9�(�, yQ�',� t _ Telephone Number -7 75- - --7;3,? Address S t0,00S-- '7 F9 R . License# Home Improvement Contractor# - //� / 1V /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 SIGNATURE DATE BUILDING PERMI DENIED FOR TH ALLOWING REASON(S) ' I FOR OFFICIAL USE ONLY w PERMIT NO. (✓ ' DATE ISSUED ` MAP/PARCEL NO. + ADDRESS VILLAGE ' OWNER DATE OF INSPECTION: " FOUNDATION �L�'� FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING :31�'-'_��-7 ?,4- DATE CLOSED OUT ASSOCIATION PLAN NO. r" • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE , JOB_ LOCATION - Number Stree address Secti of town "HOMEOWNER" 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(s)' 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 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 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 comply with said procedures and requirements. 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. HOME OWNER'S EXEMPTION ter=. 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 Owne2 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 "dwner, actir 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. 1 The Town of Barnstable 94, 6 ,e�' Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissio; 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 owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with hoother requirements. Type of Work: 0= Cd i l ►o or Est. Cost $" O lz� Address of Work: hn nc —TZt 2A Owner's Name�� " _ 2A2'f'► LL Date of Permit Application: '2- i D I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law Job under S1,000. _Building not owner-occupied " Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE 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�oe owner. Date Contractor Name Registration No. OR -- t FILE # C2928 CENSUS TRACT # CLIENT: Attorneys Hoag & Sullivan DEED BOOK PAGE 18 OWNER : Olyon & Lorraine Far. ul,ar� PLAN BOOK PAGE LOT APPLICANT: Robert & Barbara Ball ASSESSORS PLAN PLOT MORTGAGE INSPECTION PLAN OF LAND I I N B A R N S T A B L E SCALE: 1"= 40' NOVEMBER 20, 1984 NSF BEA4SE 142, 03' LOT 36 DECK 1z I� 3ro 00 LOT 35 #56 '�° Cr LOT 37 1 STORY �t * 4811 i I ' i 1 142.00' BISHOPS TERRACE I CERTIFY TO ATTORNEYS HOAG & SULLIVAN , WHITMAN SAVINGS BANK AND ITS TITLE INSURANCE COMPANY , THAT THERE ARE NO VISIBLE ENCROACHMENTS OR EASEMENTS EXCEPT AS SHOWN AND THAT THIS PLAN WAS PREPARED UNDER MY IMMEDIATE SUPERVISION , THE LOCATION OF THE DWELLING AS SHOWN HEREON IS IN COMPLIANCE WITH THE LOCAL APPLICABLE ZONING BYLA14S WITH RESPECT. TO HORIZONTAL !01 DIMENSIONAL REQUIREMENTS , THE DWELLING SHOWN HERE _DOES NOT FALL., WITHIN I TH I N KrtvRr_.TH. L A SPECIAL FLOOD HAZARD ZONE AS DELINEATED cvi FRREIIRA ON A MAP OF COMMUNITY #250001 DATED 10/1/'83No.28716 BY THE F , I , A , SIJR� ; Land Surveyore CIA1 Engineers . U�Ia¢ �astart '�inrca �6urbc� fQa., �1TC. 2G1 �.Inion �t s Nefu �eafora, cp 02740 GENERAL NOTES: (1) The declarations made above are on the basis of my knowledge, information, and belief as the result of a mortgage plot plan tape survey inspection made to the normal standard of care of registered land surveyors practicing in Massachusetts. (2) Declarations are made to the above named client only as of this date. (3) This plan was not made for recording purposes, for use in preparing deed descriptions or for con— structions. (4) Verifications of property line dimensions, building offsets, fences, or lot configuration may be accomplished only by an accurate instrument survey. The Town of Barnstable �n+E Permit# a� k 7 9 Massachusetts Date 11& SOLID-FUEL STOVE PERMIT o Fee � O d This constitutes an official stove permit after inspection and approval by the building inspector. Owner?3 y Z ii K , 1:b A �` L` '-Telephone no. 77 7 3 ,-"Address of of Property i to S 'Z 'Z /Z Village V/ Location and Stove Type , vU Date: r Building Insp t The solid fuel burning stove at the above location passed: failed: inspection. III ,%f` ', y. t � a, ``k i (i� _.. .. �. _ _ _ ,� _ b ..� 6 1 1} .` l ��. .. l '� �� To Date Time WHILE U vv E OUT G M of Phone Area Code Numb? 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