HomeMy WebLinkAbout0104 CARLOTTA AVENUE F,le�v
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map "t o Parcel 699 Application # 0 b -7 cpc�--
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
t
Historic - OKH _ Preservation / Hyannis
Project Street Address c a.r 10 VP
Village k1 q aLon 13
Owner 'Tcg itk S n a- o. Address S O M E
Telephone 5 $ - -T71 3J 6 4
Permit Request s v_-
1-6 eq t--n a e- V1 11-1 dS - 5)a-A!S-e— %pcL ink &;s e,-20 0-cl-V I rl a _,5je DL-
for orec� ��� ��c���f - S> �' �D�� �3 Gov rl C'ovcc j v1 G�a,y
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation A5,D00 - O f) Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting do�eumentEation.
.w Ca
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) , r"
C
Age of Existing Structure / Historic House: ❑Yes ❑ No On Old King's Highway: O,Yes :0 No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ,
r-D mBasement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) .0
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 Ig 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 Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes �No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name W �I►tA M McCIV'�. So"v`'e, Telephone Number 56 8- 3 qb -0 J q8
,f I
Address +C �_OAA ii m+o n A y2 License # d qL 6
4 Yosm(lik t` ` 6 6 Home Improvement Contractor# M`t J
Worker's Compensation # 7 745 I
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO YCklff\004
SIGNATURE DATE �� � )
FOR OFFICIAL USE ONLY
it} APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
r
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
r
ELECTRICAL: ROUGH FINAL
4
t'
r PLUMBING: ROUGH FINAL 'y
GAS: ROUGH FINAL
,r
FINAL BUILDING
y
DATE CLOSED OUT -
ASSOCIATION PLAN NO.
r
E
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www mass gov/dia
Wor ers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
&Mlicant Information j Please Print Ledbly
Name(Business/Organization/Individual): M 1 C AEL ��,1,�jt _Welk C661;,. SA
Address: '�-C� to u ty m rsi c,n t,3 M,
City/State/Zip: `XZ MOu"I1,i- Ai 6VA Phone#: 3 g' 3
cm
Are you an employer?Check the appropriate box: Type of project(required):
1.El I am a employer with I � 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 8. ❑ Demolition
workingfor me in an capacity. employees and have workers'
y ap ty. 9. ❑ Building addition
[No workers' comp.insurance comp.insurance..*
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
q officers have exercised their 11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work ❑ g
myself o right of exemption per MGL ;
y [N workers'comp. 12.❑ Roof repairs �
insurance required.]+ c. 152,§1(4),and we have no X�sol a
employees. [No workers' 13.®Other t)11
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.
tContractors 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 avid job site
information.
Insurance Company Name:n MZT]S f ALA 9&61 C E
Policy#or Self-ins.Lie.#: C- - 3 • �� Expiration Date: 2
Job Site Address: Carr Nye- City/State/Zip: ann I S I
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 e. 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.
I do hereby certify under the pains d enalties erjury that the information provided above is true and correct
S' lure: fC Date:
Phone#: — F5
Official use only. Do not it 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#:
"" ! '® CERTIFICATE OF LIABILITY INSURANCE ii�`�J1/2010
.;THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsemengs.
PRODUCER IaIAME: Shannon Sperraaza
Risk Strategies Company PHONE , (781)986-4400 FAx .ftl,001)963-a620 �_...._.
15 Pacella Park Drive E-ML .ssparrazzaftisk-strategies.com
gtg 240 PROD p0018476
Pjmdolph NA 02368 INSURE $AFFORDING COVERAGE i NAIC
INSURED hN$URERA:Seneca Specialty Insurance Co
hNsuRERs.Keatina Group Ins Services `
Michael McCluskey, DBA: Cape Save IN RERc Chartis Insurance
7 C Huntington Ave INSURER D:
INSURER E
South Yarmouth MA 02644 INSURER F.
COVERAGES CERTIFICATE NUMBER:CI.i011132675 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERK
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, I
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
i TYPE OF INSURANCE + POLICY NUMBER FF M ODD i LIMITS
GENERAL LIABILITY 1 EACH OCCURRENCE
COMMERCIAL GENERAL LIABILITY !
DAMAGE T61MR7915—
PREMISES oomwerr4s) $ 50,000
A CLARASaMIADE IX;:000UR ARG1002608 '10/16/2010'i10/16/2011!MEOEXP(Ay oneperson) $^� 10,000
PERSONAL&ADV INJURY !$ 1,000,000
} ?GENERAL AGGREGATE is 11000,000
iGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG ;$ 11000,000
X ?POLICY F 7 PRO- LOC
i AUTOMOBILE LIABILITY icOMBINED SINGLE LIMIT $ 1,000,000
�•:ANY AUTO 208200 11/6/2010 11/6/2011 (Ea accident) _
1 BODILY INJURY(PerPe�rsj S
L- ALL OWVPIED AUTOS { 4 BODILY INJURY(Per sccidem)":$
X SCHEDULED AUTOS ( :PROPERTY DAMAGE ;5
X HIRED AUTOS !(Per sw4erd)
}X NON-OWNED AUTOS
f X °UYLLA UIlB �*OCCUR ( I EACH OCCURRENCE $ 1,000,000
EXCE58UAB +CtA1MS-ulADE� AGGREGATE _rS 1,000,000
I
DEDUCTIBLE
B i RETENTION $ j 23579601 �0/16/201010/16/2011 $
C i WORKENSCOMPEN$ATI t i *chael McGluskey X! WC STATU i01H•
AND EMPLOYERS'LtAaLITY Y YIN' I TORY LIMITS —
;ANY PRDPRtETORMARTNER/EXECUTIVE I i is excluded from coverage E.L.EACH ACCIDENT ;$ 500,000
i OFFICER/NJIEMSER EXCLUDED? j N I A I t
(Mandatory in NH) 1 �9930981 10/21/20100/21/2011 E.L.DISEASE-EA EMPLOYEE$ 500,000
P s�aaees,describe urder I E.L.DISEASE-POLICY LIMIT.$ 500,000
DESCRIPTION OF OPERATIONS hefow €
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101,Addilional Remarks Schedule,it more space is required)
Issued as evidence of insurance. Contractors-Executive Supervisors or
Executive Superintendents.
CERTIFICATE HOLDER CANCELLATION
(508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Ruth
460 !Rest Main Street AUTHORIZED REPRESENTATIVE
Hyannis, MA 02601-3698
chael Christian/SMS
ACORD 26(2009f09) 01988-2009 ACORD CORPORATION. All rights reserved
INS025(2oow% The ACORD name and logo are registered marks of ACORD
f 9.4e
epmmpwawa&X
Office of Consumer Affa' s and Business'Regulation
Q110 10 Park Plaza - Suite 5170 ,
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 164432
Type: Supplement Card
CAPE SAVE Expiration: 10/6/2011
WILLIAM MUCCLUSLEY
8201 S. HOURD CT
CHAPEL HILL, NC 27516
Update Address and return card.Mark reason for change.
OPS-CAI 0 5om-04104-GlOI216 J Address Renewal Employment C host Card
yq; �� �llY/l2Q9¢UJP,Il'.�LlL 6�•6' �,[l.�J - . ...
r ^Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
f `,NQq�HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
�V- y y Registration 16443g Type: 10 Park Plaza-Suite 5170
Explrat♦on 10l6/2011 Supplement Card Boston,MA 02116
CAPE SAVE
WILLIAM MUCCLUSLEY'
7C HUNTING AVE..S.YARMOUTH,MA 02664 Undersecretary Not valid wi ou signature
1lassachusetts- Department Irr Public Sareo
Beard of Building; Re;ulations uutlStandards,
Construction Supervisor Specialty License
License: CS SL 102776
Restricted to: IC
WILLIAM MC CLUSKY
37 NAUSET ROAD
WEST YARMOUTH, MA 02673 "
Expiration: 6/28/2013
C+i�nuisi+�Frr Tr»: 102776
t
�� rr r++rr ww•�w J1 rJ..ir JJJ "r'(� i91/dl
CME! SAVE
Weatherization
508-398-0398
s
August 22, 2010
To Whom It May Concern:
William J. MCCluskey is an employee of Cape Save. He is authori2ed to negotiate
contracts and building permits for our.company.
Michael McCluskey
Caine Save—Owner
919-593-5939 cell
X Huntington Avenue.,South Yarmouth,MA 02
460
ORPO A"FION .I !"I mi all Hiles wugv pp�:.'t:E1 ?t r
HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE:
PLEASE FILL OUT AND SIGN TICS FORM 1F YOU ARE
THE APPLICANT HOME OWNERR.
I^_�►Lj.b ITH AA Lam.,A hereby consent to and agree that weatherization work may be
done by the Weatherization Program of Housing Assistance Corporation ( herein after referred as
"Agency") on the property located at:
i -4 C,�-APLOZMIA AVE -
H '6 Fay ti i 'S• tnA
The weatherization work done will be based on programmatic priorities and availability of funding and
it may include all or some of the following measures:
Weather-stripputg&caullang of windows and doors,insulation of attics, sidewalls &basements, attic
and other ventilation measures and possibly replacement of badly deteriorated windows.In
consideration of the weatherization work to be done at my home I agree to the following:
1. I give permission to the "Agency" its agents and employees to travel onto or across said
property with such equipment and materials as may be necessary to perform weatherization
work on said property.
2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the
weatherized unit on an ongoing basis for no more than.five (5)years after the weatherization
work is completed.
I have read the provisions of this agreement as listed and freely give my consent
Home'Owner. (Signature) eo
Date:
Agent (signature) aw-4.."
Date: .3 t zo
RAC approved Weatherization Company:
Caliber Building&Remodeling Cape Cod 1nsdation ape Save Creswell Construction
Frontier Energy Solutions Lohr& Sons Peter Smith Resolution Energy
Rock Solid Construction All Cope Insulation
7 OFF 2 6 4# : a 9
C"EO SAW
Weatherization 3= w
508-398-0398
December 14,2011
Town of Barnstable
Thomas Perry CBO
Building Commissioner '
200 Main St. Hyannis,MA 02601
RE: Building Permits
Dear Mr. Perry,
This affidavit is to certify that all work completed for permit application#201104762, Status A,
Parcel 248094 at 104 Carlotta Avenue,Hyannis,Permit type: RADD, and issued on 9/13/2011 has
been inspected by a certified Building Performance Institute (BPI) Inspector. R-18 Cellulose
insulation was added to the attic. R-10 cellulose insulation was added to the slopes and floor. R-11
fiberglass batts were added to the open rafters,walls and kneewalls.Walls were dense packed
with R-13 cellulose insulation. Basement sill was insulated with R-19 fiberglass batts. Basement
perimeter was wrapped with R-5 reinforced foil or vinyl faced ductwrap.All work performed
meets or exceeds Federal and State Requirements.
Sincerely,
William McCluskey
Town of Barnstable ' I ate` f Li�oFrru�oh� �71e 'Permit
e - Regulatory Service Lrpires 6 mouths'from ntrtr nle .
s Fee
y dASS..
Thomas h': Geiler, Director
Building Division
Tom Perry, CBO,.Building Cornrnissioner'
200 Main Street, Hyannis,- MA 02601
www.to wn.barnstab le.ma.us
Office: 508-862-4038 Fax: 508 790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not V171id Will/ottt Ret1 X-Press ltnprinl
Map/parcel 1Vurnber. Oil
Property Address
[ Zesidential Value of Work ?''C�_ Minimum fee of S35,00 for work under$6000.00
Owner's Name & Address
Contractor's Name
Telephone Number --
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) lyp - ��t r` r
EjWorkman's Compensation Insurance
Check one: Jl1lit
❑ I am a"sole proprietor ~010VN' 1
[] I am the HomeownerOF BARNS TABLE
LE
have Worker's Compensation Insurance -
Insurance Company Name +/�-
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accornpany each permit.
Permit Request (check box) A
eRe-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to-
Re-roof(h urrica n e nailed) (not stripping. Going_over existing layers ofr000
Re-side � I
#of doors
Replacement Windows/doors/sliders. U-Value (maximum .35) #of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License & Construction Supe
re uire_d. rvisors License is'
IGNATURE: s
AWPFILESIWRMSWpilding permit formslEXPRESS.doc
evised 072110
They C6,r ineonwealth ofMassachitselts
-- - - - - Dep—a ineret ofIndustrinl cciiletlts
OJJice ofInvestigalions
600 WashiI..r ton Slreel
t- Bvsloz,, 02111
i ivnmv.mass.govIdia
�Vrorlcer-s' Campensation Insuu-:laceffclrzt: Builders/Cnu.tr.ictot s/Llectiiciaus/Pl:tunbers
Applicant lyforltnation Please Print Le,, bI-v
Name (Business/Or aniza6on,Zndivldual):
Address:
City/State./Zip. Phone #: 2 Z/
Are you an employer?Check the appropriate box.: T}ge ofpi^ojet t(required):
L VI am a employerit ith 4. E] I air a general contractor and I
6.
employees(EA and/or.pdrt,-time).* have hised.the sub-contractors
0 New construction
2,❑ I am a sole proprie=tor or partner- listed on.the attached sheet_ 7. ❑.Remodeling
ship.aril have no employees These sub-contractors have g .Detno:lition
work for.me in an capacity-: employees and have warkers'
u?$ Ycomp-insut'amce::7; 9. ;E.Building addition
'[No workers' coiup rr�s:usance P 10.❑Electric,al repairs or additions
required.] 5- Vu'e are.a corporation.and its
officers hatie exercised their
3.❑ .I am a.homeowner-doing.all work 11..EJ.Plunibing repairs or additions
myself.[No worken'pomp. fight of exemption per NNEGI 12. Roof repairs
insurance required:]f c. 15'� §1�4):, and.we have no'
emp.lo fees- [No workers' 13,.E Other
cofup.:in urance required-]
'Any applicaut that chiecks box Almost also filloutthe section below shu ing their wor3 ers'compensa:1i.0n`p6liciimfor=tian.
7 Honieowmers wbo submit this affidavit indicating they are doing all wort and then hire autside-contraclars must 6ubmit.anew affidavit indicating saclt
3Cantrac.tnrs that check this box must attacbed sv addifiori0street showing the nmiL of the sub-coutrscto-rs and stare whether or not'thosn entitieshave
employees. Ifthe sub-conlractorshsve einplcr)ws,,fhe}•.must provide their workers'comp.paltry number:
I alit an eutplo:yer that is providing,workers'contpe-uxalion itasur arrce for rn ,eircplayeas. Below is the policy ari.d jo.b site
if1formatiott
Insurance Company Name: � ��ze
Policy#or Self->ss:Li.c. : —,jg? � Expirntrfin Date:
Job Site Address: eo;ze City/State/Zip:
Attach a copy of.the worke-rs'•compeltsation policy declaratiompage(:slto►t ng the policy number and expiration&—te).
Failure to secure coverage as required under Secfiori ZSA of MGL c.. 152 can lead to the imposition of criminal penalties of a
fine up to$1.,500.00 and/or one-year iniprisonnment,as well:as civil penalties in the form of a.STOP'WORK ORDER and a fine
of up to$250-00 a dayagaimt the.viokitor. Be advised that a copy of tbis_statenment may be forwarded to the Ofce•of
Investrgations.of file DIA for insurance cotierage'erifica:tipn.
I ado hereby certify i er tine paws al pact es of peliliry that the infortuation prmzderl aboiv is true and correct_
Si lure; Date: 7
phone#:
Ofcial use octly. Do riot wite lit this area,10 be con)pbrted by�citt or towit of ciaL
City-or Town: PermitlL icense#
Issuing Authority(ri�rle one):
1.Board of Health 2. Building Department.3.City/Town.Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: --
of IHE rp�y
�+ BARNSTA MASS.
te. Town of Barnsta We.
plFD hIA�A F
Regulatory Services
Thomas F. Geiler, Director
Building Division
Thomas Perry, CB0
,Building Commissioner
200'Main Street, -Hyannis,.MA'02601
www.town.ba rnsta ble.m q.us
Office: 508-862-4038 Fax: 508-790=6-230
Property Owner .Must -
Complete and Sign This Sectio
If Using :A, Builder
as.Owher of the subject property
j�
hereby authorize to act on my behalf,
in all matters relative'to work authorized by,this btuldin2 permit application for:
(Address of Job) -
(J.
fignature of Owner `Date
Print Name 3
If Property Owne.r:is applying for permit, please complete the Homeowners License Exemption Form I on the
reverse side.
Q`.\WPPILESWORMS\building permit forms\EXPRESS.doc
�0t T ti Town of Barnstable
' Regulatory Services
x
ia°` asSB $` Thomas F. Geiler, Director
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma,us
Office: 518-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE.EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER"
name home phone H work phone N
CURRENT MAILNG 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
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-yearperiod shall not be considered a homeowner. Such "homeowner"shall submit to.the Building Official on a form
acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit, (Section
109.1,1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws, rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures.and requirements,
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be rewired to,comply,with the State-Btuilding Codex
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 oRen 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 actin Supervisor
responsible. g as p isor is ultimately
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 caret amend and
adopt such a,form/certification for use in your community.
Q:1bVPFILESIFORMSIbuilding permit formsEXPRESS.doc
Revised 072110
C�® CERTIFICATE OF �LIA�IL.ITY II�SIJRAIVGE - oPID KG [7ATE(MAUDD;YYYY)
9/14/10
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 po Icy Ies must be endorsed. UBROGATION 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 NAME:
Northwood`Ins. Agency, Inc. (wc,No;Ext):' �._.__..._. ,_:(A/C.NOI;._.:.......-..------ —.—
-E7N'AIL
:540 Maim' Street, Suite 9 ADDRESS:
H annis .MA 02601
Y cus o eR DA4ID-2
Phone:508-771-1632 Fax:508-393-2955 INSURER(S)AFFORDING COVERAGE NAICAl
INSURED INSURER A: Travelers Insurance Ccmpar 1
David Cox Inc. INSURER
- -.__ -- Y
r INSURERS-_--__._-_...._-.___
P. 0, Box 401 .. _....
S Yarmouth MA 02664 INSURERC:
INSURER D:
1 INSURER E: -
INSURER F: I_
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER-
THIS IS TO CERTIFY THAT THE POLICIES OF INSJRANCE 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 SSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, -
E1CCt1)6',04t6 ASi9^JNG1jYJPI50f 6uCN,P4L1C4ES.LIMITS SHCLVN MAY HAVE BEEN REDUCrA SY PAIU CLAMS.
R�__—V-•-- TYPE OF INSURANCE-•. - ^-• NSR�SWVDt POLICYNUMBER !(MW DIYYYYF)(Mh&DDNYVY) LIMITS '-----
i GENERAL LIABILITY I EACH OCCURRENCE £ 1000000
A COMMERCIAL GENERAL LIABILITY 16801481M796 �03/14/10 103/14/12 PREMSESO(Eao w ante) 1 s 300000
I 1 ! i..
CLAIMS-MADE 4..'x.J OCCUR I j �MEOEXP(Any one rer an) 1 s j0-Q0
�{ Business Owners PERSONAL&ADV;NJURY I s 1000000
I i GENERAL AGGREGATE is 2000000 _
GEN'lAOGREGATELIMITAP°LIESPER.~_. ...I - PRODUCTS-COMPIOPAGG £2000000, -
..__., 1 . PRO• r—I ---- -- -.,._�------'_____-_----
POLICY I JEC7 `LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
I ANY AUTO BODILY INJURY(Per person) i.$ -- -
ALL OWNEDAVTOS•
B I:_..,.., i OD:LY INJURY jPer acodent).;E
.....; SCHEDULED AUTOS r I PROPERTY DAMAGE _-- t - -
HIIiED AUTOS i 1 I P )-( er accedont £
..I NON•OWNEDAUTOS I i i Is
UMBRELLA LIAR OCCUR ' EACH OCCURRENCE £
EXCESS LIAR CLAIMS-MAD� f AGGREGATE £
DEDUCTIBLE I I t
.......... ---
RETENTION S I I I I $
A WORKERS COMPENSATION 6KUB91OX742210 i07/15/10 107/15/11 TORYLiMiTS ER
AND EMPLOYERS'LIABILITY YIN -
IANYPROPRIETORIPARTNERIEXECUTNq—� I I El EACH ACCIDENT $]000QQ
i 1._.. _.._. _ ._-. -'.-
tCE^JMEM9L:!ExCLUt�`)'± IA:' ---.- _----
I(p9angatory In NH) -I --' E L DISEASE-EA EMPLOYEE;£ 100600
tl yes,desWbe under I I ! _F..__- _.-.---
DESCRIPTION OF OPERATIONS 001W I I E.L DISEASE-POLICY LIMIT I$ Cj000QQ
I i
f
DESCRIPTION OF OPERATIONS I LOCATIOND I VBHICL6S (Attach ACORD 101,Additional Remarks Schodulo,if mory space Is requlrod)
CERTIFICATE HOLDER CANCELLATION
- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BECANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Walter Korntheuer AUTHORIZED REPRESENTATIVE
10 Gages Way
E Dennis MA 02641
01988-2609 ACORD CORPORATION. All rights reserved.
ACORD 25(20,09/09) The ACORD name and logo are registered marks of ACORD
Office of�o Sumer ffairs u�siness egu alle License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR Ibefore the expiration date. If found return to:
Registration: ,y g00497 Type: Office of Consumer Affairs and Business Regulation
; Expiration: 3G25I2012 Private Corporation Bo 10 Park Plaza-Suite 5170
ston,MA 02116
D COX, INC k
David Cox +'
19 LAVENDER LN
W.YARMOUTH MA'02673 Undersecretary Not valid without signatur
Massachusetts—Department of Public SafctN
Board of Building Regulations and Standard
Construction Supervisor License
License: CS 63537
Restricted to: 00
N.
DAVID R`COX
PO BOX 401
S.YARMOUTH, MA 02664
cL_ / Expiration: 10/15/2011
Commissioner Tr#: 51M
Assessor's map•',and lot r' �!M� r numbeplc r ./C...
Sewage Permit number .. p .... °.............
CJ •-s 73 E
QyOFTHETO� a TORN OF' BARNSTABLE
' BAE.HSTADLE,
9o�Ya.�� � ,D#UIDING z INSPECTOR
M �O 163
" 4, .. Qr
Y. APPWCATIOPf-`FOR PERMIT TO ...:l .U:'�LQ.. cl/,G/Q .........................................................................
. :
TYPE OF CONSTRUCTION ............':... .......... .... ..... .f . ...................................:s r
r L_ :......... j . l ....19:?5
rU
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ...,. ..`(......�`'. -. (.... .Yh......../ .. .:..........:. ..�`.`. .w..................................................................
ProposedUse .../�..'.+V.l..h�. ..........C .. ?..A.��. .. ............... ........................................ ........................
Zoning District .......R-A.....................................................Fire District ... .a.....................
Name of Owner Z 1 ..... Address l �—
Name of Builder ..'S 1./....oS... .... .a. .........Address ..3..5......C. .......91 . ..........1y113 f �/...N .
,
Name 'of Architects �f' red Y!.:...... 1 1CAAl ......Address 2.3 6, Z/ 3.
Q � C�•,�,,
Number of Rooms' ..... ... .I.. .............�..Foundatiodn /t?�!�.k..��.. i/if
..........
Exterior S /�f �? . �' ............................................Roofing �-
............... ... .......... .. .................................................................................
Floors ......................................................................................Interior
Heating .. ��� .........................................Plumbing ...................:...................................................0........
..
........................ ...........
Fireplace ...N....G�................... d d ,
p � � ............................................Approximate Cost ...2:..�.........................................................
Definitive Plan Approved by Planning Board _______________________________19________. Area Z,yd. 4
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH D4_•
001—
VW-) �
I � e
r -
I
10 5 ( �0
I hereby agree'fo.conform to all the Rules and Regulations of the Town of Barnstable regard ng the above
construction.
Name .. ................................. ............ .......................
Meece, Dean & Virginia
No ...17941 fo'r ..dormer
P6ef'nit ............ E ' _
.............`.......t..........................................................
location• .... . 104 Carlotta Avenue
L�.. ..�.......... Hyannis........................*.... ...
Owner ........Dean & Virginia Meece _ �
Type of Construction ...... frame. .. ..........
.......................}................................ ......................
Plot '........................... } Lot ........r:.......:........... - 1
Pe�= September 19. "� 75
rmit Granted
I '
t Date.of Inspection .c..... :::..:........../`':....::-.19
Date Completed
_ R
•1 r
PERMITt REFUSED ' ]
................................................................ 19
t
h -
............................................................................... }
...............................................................................
Assessor's map and lot number ,..�.'`' !� 9�1
Sewage Permit number ..........................................................
;-
t
y�FTNET� TOWN OF BARNSTABLE
Z BARNSTABLE, i
"639 �•`� °, ,. BUILDING � INSPECTOR
APPLICATION FOR PERMIT TO L n
yT �_ � .. v1 1 W'
TYPE OF CONSTRUCTION .............................:...............:::.Y!'!f....................................................:.....................
Y .................. ..... �....19.���.,
r "
TO THE INSPECTOR OF BUILDINGS:'
The undersigned hereby applies for a permit according to the following information:
Location .... .�/ C L r- t. fi .........................................►/ k �' /� A' �h. ............
Proposed Use ) IL.J /1/ i; <, ( � a f! C`' ............................ ..................
Zoning District ....... ................................. .... Fire District v
..... .............. ..............................................................................
Name of �; /=.Address ..... ?...!.... ...... .....!.. ..:.....................
Name of Builder ..-SP 4? 0, . 6A ti v t?..l:n!!,!..C.........Address ...?..�...... K +t( C1 K V A1,A.�s
F / �= ('r 1�. Y i L>�t A!v T.......Address ................... .? . ... / G
Name of Architect 1.....-.... ............................
Number of Rooms ..... +.... ?"`".. .' ..Fou d io 1 ' �f � '.
Exterior ��. ,/>`/, -~1.. .. .. :...................... Roofing �� C
Floors ..........................Interior .r?. ',. .. •.r,.. t
Heating .. .!�...�•..T:_�. ..............Plum.bing
......................................
-.K tj
�/ ra ..........Approximate Cost ... ..�� o
Fireplace ........................... ....................................................... �
Definitive Plan Approved by Planning Board -----------------------------19--------. Area f :..�� A..........................
Diagram of Lot and Building with Dimensions Fee .
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I �
lzjiL
Q
A
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. �)
t-✓'-T• ,ter-�'wlti , �,G �l � h `'�� .� �
r-� Name � ..c.....":......`..... ....!.... .. "':...`a......................
L
Meace, Dean
°
17941 dormer
No ................. Permit for ---___--.��—.. '
- .
'
'
--------'^---^--------'-----'
.
' 104 Carlmtta'Jb/enom - '
Location ...........................................
. ^ '
' Byuzoz10
----.---------.------------.. '
' '
Dean & Virginia Mamom ' -
Owner ���������.�����������..
. .
' frame �
Type of Construction ...........................................
^ .
,
.----~-------------^------- '
'
Plot ............................. Lot ----------'
- _
Permit Granted
— ---S' 'l9_jV 75
� Dote.of Inspection ---.--------.lQ
Dote Completed ---- ' lV
��-------.. '
- `
^
PERMIT REFUSED
� .
� ...................................... lA
� --------..----------..�------
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