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Home My WebLink About0136 CASTLEWOOD CIRCLE a7 _ nsi Applic tion number. . 1 1 .. ................... ID . bp� Fee............ ................................. ......... ............... Building Inspectors Initials.............. 01 '` Date Issued................... ...... ................... Map/Parcel..J .. .................:............ TOWN OF &RNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: ' NUMBER STREET VILLAGE Owner's Name: j,� ?�,� �U�N6_5/y6Tl Phone Number Email Address: Cell Phone Number 7 ZV-Z/�?, =�f' Project cost$ p,,-Id Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a b ' ding permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Siding 0 Windows(no header change)# ❑ Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying'more than 1 layer of shingles) Construction Debris will be going to 1�j1 Z22y ->Z 7-y CONTRACTOR'S INFORMATION Contractor's namell �, ,X Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# Qlo�; �-'� (attach copy) Email of Contractor c. ✓ �i "r)()Ane number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *Far 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. The Commonwealth of Massachusetts Department of Industrial Accidents — — Office of Investigations _ 600 Washington Street ` - Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ]' Please Print Legilbly Name(Business/Organization/Individual): Address: City/State/Zip: y i Phone#: ' r,:�2 Are you an employer?Check the appropriate bog: - 1NO I am a employer with�. 4. ❑ Type of project(required):I am a general contractor and I. G ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.NdRemodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, employees and have workers' $ 9. ❑Building addition [No workers'comp.insurance comp.insurance. 10. Electrical repairs or additions required,] 5. ❑ We are a corporation and its p 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 1311 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 hive 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 insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Z j %EZ-,Qif t!' Poli #or Self-ins.Lie.#: cY U,4'57/6;k 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. I do hereby cerfify and the airs d penalties of perjury that the information provided above is true and correct Signature: Date: ,, Phone#: 6Z,12�9t 1�S 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 ise and including the legal representatives of a deceased employer,or the the foregoing engaged in a'oint enterprise, g g P of g g7 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 numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the ed to c workers' compensation insurance. If an LLC or LLP does have ,members or partners,are not required arty p 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 1lOUSlTI'3!AL�i'�cYa s. ji3vtitt�i 'v i -aJ2 au''7p v T�c�-r l: r�flea.law or if�,o�,are rernLrPd to obtain a workers' i 1 `i b a r . .. 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 Department has provided a ace at the bottom Please be sure that the affidavit is complete and panted legibly. Thep p space 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 permitllicense 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hike 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 GQMMGUwealth of Massadhusdts Department of Industrial Accidents Office of Investigations 600 Washia9ton Wieet Boston,MA E 211.1 Tel,A 617-7274900 ext 406 or 1-977-MASSAFFi Fax# 617-727-7749 Revised 4-24-07 www.mass,gov/dia s 4ofU11IIIfUIIWcerlll VI IVI/rD7Al.rIV ri%/„• n»r,»n„rn,rr//�ark'�rtaa.,<ar/nrc//i Division of Professional Licensure ONiceofConsumerAffairs&BusinessRegulation Hoard Huilding Regulations and Standards HOME IMPRf3VF-MEW CONTRACTOR Construction supervisor TYPE:CerWation Expiretitzrl H 100497 03I242� CS-063537 Expires:..-,._ 10/15/2019 - R DAMD COX,INC... DAVID R COX PO BOX 401 .:a.. OAViD R.COX SOUTH YARMOUTH MA 02664 19 LAVENDER LN W.YARMOUTH,MA 02673 UndersecretarY n Commissioner a— f DATE(MMIODNYYY) AC®RV CERTIFICATE OF LIABILITY INSURANCE 0711212018 THIS CERTIFICATE IS ISSUED AS A MATTER OF WFORMATION 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 endorsement(s). CoNTAC PRODUCER N E; Mary Connor PHONE SULLIVAN GARRITY&DONNELLY INSURANCE AGENCY INC I=.14 508 453-2586 a o: E•MaL ADOR ss: kathteen.qL-ddis@sgdins.com 10 INSTITUTE RO INSURER AFFORDING COVERAGE I NAICr, WORCESTER MA 01609 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURERS: DAVID COX INC iNsuRERC: INSURER D: PO BOX 401 INSURER E: S YARMUUTt1 MLr02M 66 INSURER F! COVERAGES CERTIFICATE NUMBER: 290863 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. 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 SUB,)ECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR, POLICY EFF POLICY EXP LIMITS TR, TYPE OF INSURANCE I UBR POLICY NUMBER YY MM/D I EACH OCCURRENCE g i COMMERCIAL GENERAL LIABILITY i r CLAIMS-MADE OCCUR If P ISES(Ea occurrencel $ MED EXP(An one person) $ i N/A PERSONAL&ADV INJURY.. S •EML AGGREGATE LIMIT APPLIES PER: - _ I GENERAL AGGREGATE ;$ —1 PRO- LOC I PRODUCTS-COMPIOP AGG $ POLICY❑JECT I $ OTHER: AUTOMOBILELIABILnY COMBINESINGLELIMIT :$ I' Ea accident ANY AUTO I BODILY INJURY(Per parson) $ ALL OVVNEO SCHEDULED I I BODILY INJURY(Per accident) $ AUTOS AUTOS I I N/A . NON-OWNED i i PROPERTY DAMAGE $ HIRED AUTOS AUTOS I $ UMSRtEL.LA LIAR OCCUR EACH OCCURRENCE S EXCESS LWa HCLAIMS AAADEj I NIA AGGREGATE s DED RETENTION$ (' $ `WORKERS COMPENSATION I X I STATUTE 1 71 ER k E0MPLOYERS'LIABILITY Y/NANYPROPRIETORRARTNERIEXECUTIVE IE.L-EACH ACCIDENT s 100,0DO A ,AND OFFICERIMEMeEREXCLUDED? WA WA , N/A L.6HLIBs10X7azz1$ D7/1s/2o18 07/16/2019. (Mandatory in NH) E.L.DISEASE•IiA EMPLOYEE!$ 100,000 11 s;describe under D IPT ON OF-OPERATI ON5 below I E.L.DISEASE-POLICY UGST i S 500,000 ( N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Reararks Schedule,maybe attached It more apace is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for benefits to employees In states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This oedfloate of insurance shows the policy in farce on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwdtworkers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town 0fBarnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel M.Crow, y,CPCU,Vice President—Residual Market—WCRIBMA 019W2014 ACORD CORPORATION. AN rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD