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HomeMy WebLinkAbout0251 CASTLEWOOD CIRCLE o7Sj �'!�'S'�C��Joc�� �-i2 I �N�ZI Town of Barnstable *Permit# Expires 6 mont f ron 'sue ate Regulatory Services Fee MASS anxrtsrnsre, 1 •� Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office:- 508-862-4038 > Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY ? Not Valid without Red X-Press Imprint Map/parcel Number Property Address C CZ 14�ujooj �`ra o, 2Q Residential Value of Work elC Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address PC, wyte Contractor's Name cwt t-r Jt 1 ✓t Telephone Number ,SoZJ' Home Improvement Contractor License#(if applicable) 16 a`� -PRESS PER Construction Supervisor's License#(if applicable)_ Q rj—q Q PR n ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner `TOWN OF BAR NSTAB�E I have Worker's Compensation Insurance Insurance Company Name I Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles)'All construction debris will be taken to Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side Ae?iaK. #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 th ome Improvement Contractors License&Construction Supervisors License is requir I .. SIGNA i QAWPFILES i ding permit formsTYPRESS.dOC Revised.051811 The rCommonwealtih of Massachuseffs Lkgw ment ofIndusbial Accidents I?iffice o,f Investrgatious 600 Washington,Street Boston,MA 02111 mmntmassgovfdia Workers' Compensation Insurance Affidavit: BuilderslContr2ctars/Flectricians/Ptamber-s Applicant Information Please PrintI*Mbly Name 10 4 CV,t 6 OM 6 4' .Address:_(1c;) 1 u n-vtr Cityl tateJ7p �Wtd�Jr'� aS36 Phone# Z-3�/ Are you an employer?Check the appropriate boa: Type of project(required): I.N.I am a employes with�_ 4- ❑ I am a general contractor and I Io ha and/or 6. New construction employees{ F�- )•* have hired the sub�com�actozs ❑ 2.❑ I am a sole proprietor or par uer- listed on the attached sheet. 7. ❑Remodeling ship and have no employees. These sub-contractors have 8. ❑Demolition . wadiring for me in any capacity. employees and have workers' [No workers'camp insurance comp-insurance`$ g ❑Eur7din g addition 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 l I_❑Plumbing repairs or additions myself [No workers'comp. . right of exemption per MGL insurance dl r c.152, §1(44X and we haw no 12.❑Rnofnepairs . employees.[No workers' 13.0 Other camp;insurance required.] •1Yny apphcsmt fat checks box#1 must also fill ma the section below showing their workers'compensation policy inf o2stiaa $omeoovne[s Wbo mbar this affidasrtr indicating they are doimg an wort and dum hire mmule counctors mmst 5nbmA a new affift t indicating such tcontmcrors that check this boor must attached am additional sheet slLowisg the-arse of the sub-camas:End:stnte whether ornbt those entities hake employees.If the subcontractors have employees,they mautpm ide their takers'comp.policy masher. I am an e►npligjer that is prouidttrg workers'compensa on.insurance for Rey omptayees. Befow is the polir-y stied job site informelio+r. : Insurance Company Name: Policy#or self-ins.Lic.4: l0 6 Sq 0 PI q 1 -12 Expiration,Date: 3A -2- Job Site Address: l C ab -h W'dacJC l t CitylStatel ip: QK✓��` Attach a copy of the workers'compensation policy declaration page(shO wing the policy numid and expiration date). Failure to secure coverage as required under Section 25A of MGL m 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 ofup to$250.00 a day against the udolatcm: Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIAfix insurance coverage veri on- I do hereby cgo&an the pains and pevralttes ofpeduty that the informatiorrproiiArd Q is and correcat Date: 30 i Phone#: Official use only. Do not evrete in this area,to be completed by city or town official City or Town: PermitlLicense k Issuing Authority(circle.one) 1.Board of Health 2.Budding Department 3.City/rown Clerk L.Electrical Inspector S.Plumbing Infector 6.Other Contact Person: Phone#• 6 * iaRNSrABLF • ,.� 'Town of Barnstable Regulatory Services Thomas F.Geiler,Director_ Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis-,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A.Builder � c I, as Owner of the subject property . hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: qz— (Address of Job) tI �d (Lon—awte of Owner ate Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMS\building permit forms\EXPRESS.doc Revised 051811 Town of Barnstable Regulatory Services IMMS ABIX * Thomas F.Ceiler,Director 9�p ib ♦0� rtepl,,pYw Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508=862-4038 Fax 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT 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 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 wbo constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department 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 required to comply with the State Building-Code - Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as"supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities, many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC Revised 051811 /1 AC�® C E R TI F I C DA TE(MIWDdYYYY ATE OF LIABILITY INSURANCE ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 2 "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(es) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement onthi s certificate doe certificate holder in lieu of such endorsement(s). s not confer rights to the PRODUCER CONTACT , Robert E Bouchie Jr. Insurance . NAME: PHONE 508 564-5560 Fax 1352 Route 28A PO Box 400 MwIL / No: (508) 564-5531 Cataumet, MA 02534 AODREss: info@BouchieInsurance.com INSURE S AFFORDING COVERAGE NAICA INSURED INSURERA:State Auto Patrons Mutual MLP Carpentry and Building LLC INSURERB:MWCARP (Zurich) Attn: Michael L Palmer INSURERC: 207 Turner Road INSURERD: East Falmouth, MA 02536 INsuRERE: COVERAGES INSURER F: CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE REVISION NUMBER: 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 TFf POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN t AY HAVE BEEN REDUCED BY PAID CLAIPJIS. LTR TYPE OF INSURANCE SUB POLICY EFF PO CY EXP INSR VIND POLICY NUMB MM1D NUMBER HMI dYYYY LIMITS A GENERAL LIABILITY CTROO10206 3/24/12 3/24/13 EACHoccuFRENCE $ 1 000 000 X COMMERGALGENERALLIABIUTY DAMAGETORENTED CLAIMS-MADE OCCUR PREMI S omurrence $ 50,000 MEDEXP(Any oneperson) $ 5,000 PER SO NA L&ADV I NJU RY $ 1 OOO 000 GENERAL AG GREGATE $ 2 000 O O O GEN'LAGGREGATE LIMITAPPLIES PER POLICY PRO. LOC PRODUCTS-COMP/OP AGG $ 2 000 0OO AUTOMOBILE LIABILITY $ OMBINEDSINGL LIMIT ANYAUTO aacadent $ ALLOWNED SCHEDULED BODILY INJURY(Per pe rson) $ AUTOS AUTOSI NON-OWNED BODILY INJURY(Per accident) $ HIREDAUTGS AUTOS PROPERTI DAMAGE $ eracadent) UMBRELLA LIAB OCCUR $ EXCESS LIAB CLAIMS MACE EACH RR $ , DED RETENTION$ AGGREGATE $ B WORKER4COMPENSATION 66Zus4590P49-9-12 $ AND EMPLOYERS'LIABILITY 3/2 7/12' 3/27/13 X WC STATU- OTH ANY IOFRCEFWEMBER CLUDED�TVE YIN NIA (MandatoryE.L.EACH ACOCENT $ 100 000 inNH} E.L.DISEASE-EA EMP Loy EE $ ZOO OOO Ifyyes describe under DESCW PTIO N CP OPE RATI ON S belo w E.LDISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,IF mores pace is requ red) fax: 508-291-6510 i. CER TIFICATE HOLDER CANCELLATION Town Of Wareham SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building Dept: THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54 Marion Road ACCORDANCE WITH THE POLICY PROVISIO N3. _ Wareham, MA 02571 AUTHORIZED REPRESE NTATIVE NT ATNE Robert E. Bouchie Jr. ACORD 25( )2010/05 ©1988�010 ACORD CORPORATION..All rights reserved. 'hone: The ACORD name and logo are registered marks of ACORD r Fax: E-Mail: is } ✓fieon�ire ✓vGaaaac� Plla _ .--� Offce of Consuo7rnierzan.Aifairs&BJsiness Regulazudtion License o'r registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: y,164275 Type: j Office of Consumer Affairs and Business Regulation Expiration: .9[2812013 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 Ml AEL L.PALMER I MICHAEL PALMER ` 207 TURNER RD E. FALMOUTH, MA 02536 sue- Undersecretary I. dt valid itho t signature M-:tssachusctts'-.Dcpai.tnient of Public.Sarc¢.% Board of Building Re-ulations and Standards C,onstrucfon Supervisor License License: CS 102901 Restricted to: 00 PALMER ',MICHAEL 207 TURNER ROAD EAST FALMOUTHJMi4 02536 6 ' Expiration: k5i2012, ('ununissivnci'' Tr#: 102901 r