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HomeMy WebLinkAbout0342 CASTLEWOOD CIRCLE C ;lf-7d-,-zl TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Applica`tr?nV5 Health Division Date Issued Conservation Division '" Application Fee Planning Dept. >'Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis f — — n Y Project Street Address •� - ����,P 000d 11e. Village lMh Liz Owner 6��� vty� Address J Telephone —7 014 1 01 2— _ � Permit Request "Oopk;- ` —` I§g dl�j Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood`Plain Groundwater Overlay Project Valuatio Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single.Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) 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 ' CEO Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other , fv o Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove:cEl Yes-j❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing 0-Wew size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: V` Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ rn Commercial ❑ Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Nid 4S 6A� 'lip Telephone Number 509 MR Address License# C 3 0 4 Home Improvement Contractor# l 1773 Worker's Compensation # ALL CONSTRUCTION EJEBRIP RESULTING FROM THIS PROJECT WILL BE TAKEN TO >�f SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# r DATE ISSUED ,r MAP/PARCEL NO.. ADDRESS VILLAGE OWNER . DATE OF INSPECTION: _ ;..FOUNDATION t FRAME INSULATION : } { FIREPLACE K ELECTRICAL: ROUGH FINAL Y PLUMBING: ROUGH FINAL GAS: ROUGH d FINAL ;FINAL BUILDING",_ k � • DATE CLOSED OUT ASSOCIATION PLAN NO. s • } r4k j T/ze Commonwealth of Massachusetts I Department of Industrial Accidents t 1 Office of Investigations 1 L!e J 600 Washington Street Boston, VIA 02111 =` www.mass gov/dia Workers' Compensation Insurance-Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print LeLyibly 1 1 Name{Business/Organization/Individual): Ift1"1 8W [me Address: 1 City/State/ZiP: g - Phone #: SOS � 3 Are u an employer?Check t e appropriate box: Type of project(required): l, j am a employer with 4. ❑.I am a general contractor and I 6. Ne employees(full and/or part-trine).* have hired the sub-contractors w construction 2.❑ I am a sole proprietor or partrier- listed on the attached sheet t �• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working forme in any capacity.. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their . 1 0•❑ Electrical repairs or additions 3.❑ I am a homeowner doing.all work 'right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t. employees. [No workers' comp. insurance required.] 13Other fl '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 now affidavir indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. >� �1�►H f Insurance Company Name: Y Policy#or Self-ins. Lic. #: n Expiration Date: 2, Job Site Address: `�- , City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy num 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. 0 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.0 a y against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations f th DIA for insurance coverage verification. I do4,16rebycrider the pains and penalties of perjury that the information provide abov is true and correct Si ate: �.VPhone : 0�� ®��� • - F only. Do not write in this area,to be completed by city or town offtcial n: Permit/License# 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#: w 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 bean 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 info 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=contractors)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 iifsurance 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 Iisted below. Self-insured-companies should enter their self-insurance license number on the appropriate line. City or Town Officials i Please be sure that'the affidavit is complete and printed legibly. The D.epariment 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 I that must submit multiple permit/licease 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 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 Massachuzetts D-,partmcent of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-8,77-•MASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass..gov/dia ofV r To wn of Barnstable . .�.. Regulatory Services _ F • F LIRNSI•w$T^ F MARL Thornas.F. Geiler,Director Building Division - Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.iMa.us Office: 508-862-403 8 Fax: .508-790-6230 Property Owner Must Complete and Sign This Section ' If Using A Builder I, 'ZAkQas Owner of the subject.property hereby authorizei FT -'�,C � to act on my bebalf, in all matters relative to work authorized by this building permit application for. (Address of Job) ignature of er. Date Print Name ' If Pro e Owner is a I n f P �' or ermit Leas PP Yr g e cozn P Iete th. P p e Homeo wners License Exemption Form on -the reverse side: .. Q:FORMS:O WNERPHRMISSI0N l I1 aF txta r� . Town of Barnstable ` D Regt� atory Services yY, sdx M,BLF- Thomas F. Geiler,Director XAM . g QL65p. � Building Division Tom Perry,Building Commissioner 200 Main-Street,_Ayannis,MA.02601 www.to wn-b arnstable-ma_us Office: 50 8-862-403 8 Fax: 508-790-623 0 IiORMOWXER LICEI\'SE EXEMPTION Pleare Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town rtatrl 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 J supervisor. ' DEFIRTd-ION OF HOMMOWNER Person(s)who awns a parcel of land on which helshe resides or intends to reside, an 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 OfEciEd 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) Th,e 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 requiremcnts and that he/she will comply with said procedures and requirements. . i Signature of Homeowner Approval of Building Ofneial 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: "Aay homeowner perfornmig work for which a building permit is required shall be exempt from the provisions of this section.(Scction ID9.1.1-Licauzug of wrist uction Supervisors);provided that if the homeowner engages a persons)for hire to do such work,that such Homeowner sball act as supervisor" Ir any homcown¢s who use this rxeraption are unaware that they are assvrrvng the responsibilities of a supervisor(see Appendix Q, Rules&Rcgblations for Licensing Construction Supervisors,Section 2.15) This lack of awareness bftcn results in serious problems,particularly when the homeowner hues unlicensed persons. In.this ease,our Board cannot proceed against the unlicensed person as it�rou)d with a licensed Supervisor. The homeowner acting as Supervisor is ultimately rrrponsrb)e. To ensure that the homeowner is fully aware of his/hcr=sponsibilitics,many communities require,as part of the permit application, that the homeowner certify that he/she understands the resporurbilitics 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 fomrlcertification for use in your community. Q:forms:homeexcmpt / „accaRD® CERTIFICATE OF LIABILITY INSURANCE °A"M�°°"""' �...� 08/12/2011 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 endorsement(s). PRODUCER CONTACT NAME: Mark Sylvia Insurance Agency PHONE Fax 771 Main Street A/c o 508 428-0440 ac No:508 420 9227 aoDRLEss:mark@marksylviainsurance.com Ostervllle,MA 02655 INSURERS AFFORDING COVERAGE NAIL# INSURERA:Farm Family Casualty Insurance INSURED - INSURER B: Niall J.Hopkins Builders,Inc. 118 Lakefield Road INsuRER c PO BOX 231 INSURER D South Yarmouth,MA 02664 INSURER E: INSURER 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 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 TYPE OF INSURANCE ADDL JSUBR POLICY EFF POLICY EXP LTR INSR POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS A GENERAL LIABILITY - 20011_6275 _ 1O/3O/2010 10/30/2011 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS-MADE Fx�OCCUR MED EXP(Any one person). $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X I POLICY PRO- LOC t A AUTOMOBILE LIABILITY 2001 C53575A 6/25/2011 6/25/2012 .CO ao%"a SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ 1,000,000 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ 1,000,000 X NON-OWNED PROPERTY DAMAGE $ 1,000,000 HIRED AUTOS AUTOS Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION 2001W6459 9/8/2010 9/8/2011 W0 STATU- X OTH- AND EMPLOYERS'LIABILITY ER Y/N S ANY PROPRIETOR/PARTNER/EXECUTIVE - - . E.L.EACH ACCIDENT $ 500,600 - OFFICER/MEMBER EXCLUDED? FN_1 NIA _ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below. - E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Carpentry,Electrical CERTIFICATE HOLDER CANCELLATION (508)790-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable Building Department THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED.IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD lla�aac.hasct`t Uepullment of Ptihiie Safrt� l;oarcl of Builting Re ulations anti�taiidard .Construction Su;pei-utsor Liat'nse, ltcfgse: CS 8491<6 NIALL J HORKINS _ BOX.231 � . SO,YARMOUTH,MA 02664 „ G� Expiration: 41212013 r : Tr#: 14504 �:1af1A7eicjUif ef': ,, °� Office o�i`(o mer: ftta'rcs&:'$ n "s ITegulii`{ T itense.or registration and for indtvidul use only Q , HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to 12egistraton 161773. Type:` Officebf Consumer Affairs and Bpsmess Rcgulaio , a, Expiraton 11l2Dl2�72, Private Corporations : 10 Park Plaza Suite 5I7� NI LLfHOPKINS BUIL"L7FERS INO - Bnsto i;'iIIA Q :,.6 . MALL :HO.PKINS 21 G FRUEAN AVE _ SOUTH YA ;N1A>j2e64 �— i y Undcrsecrctar} — iYotval: wittsoutsignature ,.