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Home My WebLink About0090 CHASE STREET �. l - -_. _ ---_- - ---------- - -- ---- -_ . -- - !, �� Cape Save Inc. 7-D Huntington Avenue South.Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 8/21/19 Brian Florence CBO 41X> �69 -Yo Town of Barnstable Building Division 200 Main St. J Hyannis,MA 02601 RE: Insulation Permit B-19-2285 Dear Mr.Florence: This affidavit is to certify that all work completed for 90 Chase Street,Hyannis has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey Appl' ation number.... r �. �.............�.� s st. JUL 0 8 20119 {� ....................... Kss. Building Inspectors Initials..V l TOWINO� 8ARu ABLE Date Issued.:... l~�.....5.�.�1.9.......................................... Map/Parcel......... ... ..... ..�...... ......... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 0 cc,re �q STREET VILLAGE Owner's Name:C/` G A, Phone Number Email Address: Cell Phone Number Project cost$ t1i Check one Residential `— Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ❑ Siding ❑ Windows (no header change)# ❑ Insulation/Weatherization ❑ Doors(no header change)# Commercial Doors require an inspector's review Roof(not applying more than I layer of shingles) Construction Debris will be going to r' CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# C�0 �O o (attach copy) Construction Supervisor's License# �d 0 3 3 (attach copy) Email of Contractor a?-eQU l`, 7?r(Q�66 ' Phone number -ro 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. I� APPLICATION.NUMBER................................................::::........�, *For 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 20 lbs. 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 ` - f APPLICANT'S SIGNATURE Signature r Date -All permit applic bons are fubject to a building official's approval prior to issuan e. 'a � 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 q Please Print Legibly Name (Business/Organization/Individual): Zk A06 girl Address: Cl r , C", City/State/Zip: ly-e-1 W11r �- Phone#: 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 6. 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. ❑Remodeling ship and have no employees These sub-contractors have g, ❑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.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repair insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑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 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 and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: (0f S City/State/Zip: r 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 certify under the nains andpenaldes ofperjury that the information provided above is true and correct. Si ature: Date: Phone#: ✓4 ado a' 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 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 be an employer." MGL chapter'l52,§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-contractors)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 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 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 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 listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department 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 that must submit multiple permit/license 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 burn 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 Massachusetts ' Department of Industrial Accidents Office of Investigations 600 Washington,Street Roston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Commonwealth of Massachdsetts Division of Professional Ucensure `�� Board of Building Regulations and Standards .c*nstru&,s `Sid rvisor CS-100393 Upires: 02/03/2020 RICHARD P CAZEAULT JR;= 198 FIVE CORNERS ROAD/ CENTERVILLE MA 02632 j Commissioner' coez office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Renisftation Expiration 168607 03/07/2021 RICHARD P CAZEAULT JR rn D/B/A R CAZEAULT ROOFING&REPAIRS L_ RICHARD P.CAZEAUL'T`JR r /� 198 FIVE CORNERS..Rp-,;,,,;f Vk . CENTERVILLE,MA 02632 Undersecretary i Work Order HOUSING ASSISTANCE CORPORATION Job Number: 19-9564 460 West Main Street Work Order Date:6/18/2019 Hyannis MA 02601-3698 Ownership:Owner Energy and Home Repair Phone:508-771-5400 Cazeault Roofing&Repairs Auditor:Joshua Trott 198 We Corners Road ` Email:jtrottnhaconcapecod.org Centerville MA 02632 Cell:508-367-5245 Email:cazeault770comcast.net Phone:508-771-5400 x107 Phone:508-420-5482 Cell:508-737-4804 i Cynthia Kaplan CLC $10,500.00 90 Chase St Total $10,500.00 Hyannis Ma 026014520 508-771-8071 , Safety Issue(s):Asbestos on Pipes/Lead Paint Possible t� AuthOrlZCd fi�* 'ACtual:' t t a. Measure Description , �r T ` C40 lv- ommentsx ' � VV Misc Measures . Major Repair-Roof Replacement 1 $10,500 $10,500.00 .00 Total $10,500.00 Contractor Instructions: Before Startingthe Duringthe Job: 1.Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978.Lead safe practices are 2.Obtain required building permit. required. 2.Total for Heath&Safety and Repairs cannot exceed$2500.00. Additional Contractor Instructions: ASBESTOS PIPE WRAP,NO BLOWER DOOR Attic Inspection form attached? Yes N/A (Circle One) Certificate of Insulation posted? Yes No (Circle One) Cazeault Roofing&Repairs hereby certifies that this job was supervised and completed in compliance with all Department of Labor Standards and Lead RRP regulations. Contractor Signature: Date: RRP License#: Date:6/18/2019 Page 1 Work Order: Job Number: 19-9564 I hereby acknowlege that all work has been completed and inspected. Customer Signature: Date: Energy Director: Date: Fiscal Officer: Date: FOR AGENCY USE ONLY . Pre Post Language Other than English needed? Yes No (Circle One) Dryer CO If Yes,indicate language: Stove CO Occupany change in last 18 months? Yes No (Circle One) H2O Tank CO Comments: Heating System CO 0.000 Number of windows Ambient CO 0.000 Number of rooms Blower Door f r I Date:6/18/2019 Page 2 1'. Town_of Ba - stable Building POWWOW Services Brian Florence;CBO Bnf1din8 Commissioner 200 Mann Street,Hyazmis,MA 02601 'WWW-town-bw=table ma.ns Office: 509-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section ff Usirw A g der, ( YN TqIff 4?CAN,J as Qwr=of the subject property hereby authorize to act on my bebaK in all matters telativ.:to work authorized by this b"'i�permit applicadon for. ORN is ( .tici ss of job) **Pool fences andi.alarrsmis are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. S' tore of Owner SignatuWof Applicant Print Name Print Name Date Q:FoR.. uW�RFE-'RW.'SIOrrPOOT s ACC)RV® DATE(MMIDD/YYYY) �,,,,_� CERTIFICATE OF LIABILITY INSURANCE 5/6/2019 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 have ADDITIONAL INSURED provisions or 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 UUNIAUI NAME: Maria DeOliveira Help-U-Insure A/C�N FAX No Ext: 5059963934 (A/C,No): Insurance Agency,Inc. ADDRESS: maria@helpyouinsure.net 2148 Acushnet Avene INSURER(S)AFFORDING COVERAGE NAIC A New Bedford MA 02745 INSURER A: MUSIC INSURED INSURER B: ACE American Insurance Co Father&Son Enterprises,Robert DeMello DBA INSURER C: 73 Russell Street INSURER D: INSURER E: New Bedford MA 02740 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FRIOCCUR PREMISES(T(Eaoccurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A BIN050619 05/06/2019 05/06/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY UOMUNLU accident) ccident $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION - ND EMPLOYERS'LIABILITY y/N STATUTE ER ANY B FFICERIMEMBEERPROPRIETOR/PARTNER/EXECUTIVE❑ NIA LID5221327 05/03/2019 05/03/2020 E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN cazeault77@comcast.net ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �y ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Town of Barnstable BUlldlri/�`Y/ v Permit MAMMA PThis�Ca� So That�rt°s�s�Uis�ble From,the Street �A , roved;Plans,Mustwtae,Retamed on J,ob and-:this Card Must be;Kept i6 Posted�Until Final Inspection Has Been Made, � ,. " _ � �� R Where a'.Cert�ficatc;of Occu .anc as.Re, aired sychJ3uldm shall No`t be Occupied unt�t a Final Inspect�onhasnbeen made . Permit No. B-19-2285 Applicant Name: William McCluskey Approvals Date Issued: 07/17/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 01/17/2020 Foundation: Location: 90 CHASE STREET, HYANNIS Map/Lot: 307-138 Zoning District: RB Sheathing: Owner on Record: KAPLAN,CYNTHIA M Contractor Nam .e William J McCluskley Framing: 1 !' ;A Contractor License 102776 2 Address: 90 CHASE STREET , k Est Protect Cost: $2,800.00 HYANNIS, MA 02601 Chimney: Description: Add R-19 cellulose to the attic.Add R-19 fiberglass to the Basement. Permit Fee: $85.00 Insulation: Air seal the attic plane and basement with expanding foam.General Fee,Paicl $85.00 weatherization. Final: 7 Date ; 7/17/2019 Project Review Req: Plumbing/Gas Rough Plumbing: t Building Official . _ Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by-this permit is commenced within ix months after issuance. All work authorized by this permit shall conform to the approved application�and the approved construction documents for whictithis permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning bylaws and codes. This permit shall be displayed in a location clearly visible from access street or road rid shall be maintained open for public inspectwn for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatureslby he Building£a rid''tire Officials are provided on tMs permit. Minimum of Five Call Inspections Required for All Construction Work:; - '" 'y ' Service: 1.Foundation or Footing ti Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). VIC+ Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division Date Issued Conservation Division Application VF ,� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH — Preservation/ Hyannis Project Street Address Village Owner r'Vzlj4i XIA j?,49 Address Telephone Jai.Z7/A50 7/ Permit Request ,� / - 20 l��t Ti2�Ci" s�/ram��.f� /� .�CG✓ �i�� Square feet: 1 st oor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation, o Construction Type s4 �11; 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 ONo 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. ex sting new Half: existing new Number of Bedrooms: _ Q�� existing —new Total Room Count (not in hiding batf�s)1-re,5R Ling new First Floor Room Count TOW U Heat Type and Fuel: ❑Gas ❑ 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 Telephone Number Address ,�� /fj/l� License # Jao fl (✓�i/ Home Improvement Contractor# 5 _!P.SSG Email !ck C�Pp SU� � Worker's Compensation #/,G/G4�a fL3 p0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE y FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION „ FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING I' DATE CLOSED OUT ASSOCIATION PLAN NO. HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: R 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: b Weather stripping; air sealing; attic& basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation the property with such equipment and materials as may be necessary to perform weatherization. 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 and give my consent. Home Owner(signature) .►a i= �� d i? Home Owner email: Date: Agent:(signature --'"""" Date. " Weatherization Contractors: Adam T Inc Cape Save All Cape Energy Frontier Energy Solutions Alternative Weatherization Lohr Home Improvement Building Science Construction Tupper Construction Cape Co nsu a► I f �* Massachusetts Department of Public Safety Board olf Building Regulations and Standards License; CS•100988 Constructlon Supervisor_„ HENRY E CASSIDY, 1�, , 8 SHED ROW WEST YARMOU�H '1"J Expiration; Commissioner 11/11/2017 I � a 6 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Ma ,�ab.h�iusetts 02116 Home Improvemet':�C•©:�l1ra^ctor Registration Type' Corporation A •�/;•• w:.'~ t�'./I Registration; 153567 Cape Cod insulation, Inc Expiration; 12/14/201 8 18 ReardoW Circle So, Yarmouth MA 02664 �•—y "SG1Q•1r5 20M•06/11 Update Address and return card, Mark reason for change, , �r �j T..--..._...._._._,....--1--•----..,...._._.._.._..___............_.._....._.„ _ f,;;:�.�.;;... ,•,,.. :.iJ3!'..L':".4�_I�t G,Z,�"?!•^„•'�n33!'a-�-1,o�L4!.�''�X�.... c�J/te cpar�cmto�ratuorr��o��`c�gJrrc�rc4elt`d Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only T.ype1 Corporation before the expiration date, if foun urn to; „..%=%. alstretlan Ex Iratlon Office of Consumer Affairs and sl ss Regulation i="•t�aa 60,67 12/14/2018 10 Park Plaza• e 6170 •;::�: ;,- Boston,MA 11 Cape Cod Henry Cassidy 18 Reardon Circfftt ''" ,2 cc~So.Yarmouth,Mp\,,91 s C� ^� Undersecretary Vrt4al4iVhout sl atu The Commonwealth of Massachusetts Department oflndustrtalAccidents Offtce of Investigations isf r, 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dla Workers'Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers Anulicant Information Please Print Legibly Name (Buslness/Organization/Individuai): Cape Cod Insulation Address:18 Reardon Circle Ci /State/Zi ;South Yarmouth, MA 02664 Phone#:508-775-1214 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 48 4. ❑ I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the subcontractors 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 working for me In any capacity, employees and have workers' [No workers' comp, insurance comp, insurance.= 9. ❑ Building 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 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' 13.9 Other Weatherization comp, insurance required.] •Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affldovlt indicating they are doing all work and then hire outside contractors must submit a new affldavit indicating such. tContractors that cheok this box must attached an additional sheet showing thfifte 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 file policy and Job site lnformatloj ,, insurance Company Name: Atlantic Charter Policy#or Self-ins, Lie. #:WCE00431:902 Expiration Date:6/30/2017 Job Site Address:��U City/State/Zip: 1W,4 ZG e/ 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;100.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to$250.00-a day against the vlolktor. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that-the Information provided above ls'true and correct, Siena Henry Cassidy �.�,`Y;, m. -Mw .rrM�� _ Dat5 2 u /7 Phone#: 508-775-1214 Offlclal use only. Do not write in this area,to be completed by city or town offlcial. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. P1lrtnbing Inspector 6.Other Contact Person: Phone#: CAPECOO.27 KDOYLE ACORA" CERTIFICATE OF LIABILITY INSURANCE E03/30/2017 / Y) 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(les)must have ADDITIONAL INSURED provisions or 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 Ileu of such endorsements. PRODUCER 2AJACT aogers&Gray Insurance Agency,Inc. �F ONE pAX I34 Rte 134 c No Ex*; ac No; 877 816-2156 South Dennis,MA 02660 mail@rogersgray.com INSURE S AFFORDING COVERAGE NAIC# INa ER ;Peerless Insurance Company 24198 INSURED INSURER 81 Safety Insurance Company 39454 Cape Cod Insulation,Inc. INSURER C,Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02884 INSURER E INSURER F t COVERAGESE I E 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, ITR NSR TYPE OFINSURANCE ADOL$UBR POLICY NUMBER POLIC EFP POLIC EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE D OCCUR R/O CBP8263063 04/01/2017 04/01/2018 DAMAGE TO RENTED 100,000 MED EXP(Any oneperson) 5,000 PERSONAL&AOV INJURY 11000,000 OEN'L AGGR GATE LIMIT AP IES PER:„ GENERAL AGGREGATE 2,000,000 X POLICYL jP LOC'�'' 2 000 PRODUCTS•COMP/OPAGO , ,GOO OTHER: $ B AUTOMOBILE LIABILITY m COMBI_MUtNED SINGLE LIMIT ANY AUTO 6232707 COM 01 04/01/2017 04/01/2018 BODILY INJURY Per arson AU70a NLY X �o�N�oa LED 00DILYINJURY Per accident 1,000,000 X 2TS ONLY X AVTOS ONLY P OPER�nt AMAGE C X UMBRELLA L'IAB X OCCUR EACH OCCURRENCE 2,000,000 EXCESS LIAR CLAIMS-MADE R/O EXCI 0006635001 04/01/2017 04/01/2018 AGGREGATE pp DEED R�ETENTIION$ Aggregate 2,000,000 D AtJD EMPLOYERSgLIABI��TY X PER UTr OTH• 8/3 ANY PROPRIETOR/PARTNERIEXECUTIVE WCE00431902 06/30/2016 00/2017 O.F,ldEFM M�FItEXCLU0E07 N/A E.L.EACH ACCIDENT 1,000,000, 1 en a cry In H) If yes,describe under E.L.DISEASE•EA EMPLOYEE 1,000,000 DESCRIPTION OF OpERATI0N8 slow -E.L.DISEASE-POLICY LIMIT 11000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more$pace is required) Yorkers Compensation Includes Officers or Proprietors, Iddltional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder, CERTIFICATE, LDE N EL TI N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Informational Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD ' l 2 2ILI �f_P1�MR-a nrAaA1arr Town of Barnstable Kv tom' Regulatory Services Fey 6 0 To . 9. NSTABLE Thomas F. Geiler,Director Building Division Tom Perry,CBO, Building Commissioner. 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us ` Office: 508-862-403 8 Fax: 508-790-6230 EXP SS P RNIIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address ! 0 �! Residential Value of Work?gg Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address IV i:i�/� Contractor's Name a �I� Af�;��6,0'r Telephone Number$ .7,9,/0_ Home Improvement Contractor License#(if applicable) d!3'C313,j Construction Supervisor's License#(if applicable) q5%046 ❑Workman's Compensation Insurance Check one: OKI am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name ' Worimian'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 #of doors [Replacement Windows/doors/sliders;U-Value (maximum.35)#of windows El 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 i required. SIGNATURE: _ Q:VwPFHM\FORMS\building permit forms\00RESS.d01; Revised 053012 r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington.Street .` Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leejibly Name(Business/Organization/Individual):Yy j e&R WaAl% e�i y Address: �� '' Ge>p 4 41V.9 City/State/Zip:i?ARRl.l�;r"/.L C'`1,4DZf.3�® Phone.#: 5m � 7 / Are you an employer? Check the appropriate box: Type of project(required):. 1.❑ I am a employer.with 4. ❑ I am a general contractor and I e ployees(full and/or.part-time).* have hired the sub-contractors 6. ❑New construction . . . 2.V I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P t3'• $ . 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 1 L E]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 R employees. [No workers' 13.;R'Other WrNov!y-J,. 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. $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 and job site information. Insurance Company Name: Policy#or Self-ins. Lic.M 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 certify under t p nalties of perjury that the information provided above is true and correct rCp a Signafore- Date: Phone 4: rp� jw 7, 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): A.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 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 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-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 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 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 listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department 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. as a reference number. In addition,an applicant ber which will be used PP Please be sure to fill mthe permit/hcense num that must submit multiple permittlicense 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 Massachuwtts Departmettt of lndustxiaJ Accidents Office Of Investigations 600 Washington Suet Boston, MA 02111 Tel.##617-727-4900 ext 406 or 1-877-MASSAFE Fax##617-727-7749 Revised 11-22-06 . www.mass.gov/dia . r oFtHE r Town of Barnstable ti Regulatory Services MASS. Thomas F.Geiler,Director. y� s639. `��, - .19. ' 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 Property Owner Must Complete and Sign This Section If Using A Builder L , as Owner of the subject property hereby authorize V'Jl&Yk" 1A �,�(� /)"1 f1/I/1 i to act on my behalf, in all matters relative to work authorized by this building permit: (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. 1 S afore of 0wner Signature Applicant c'u Print ame. Print Name D to Q:FORMS:OWNERPERMISSIONPOOLS 6/2012 THE Town of Barnstable Regulatory Services , STAB Thomas F.Geiler,Director tA+ss. 9qp 1639• .� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 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 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 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 P P q mP Y requirements. Signature of Homeowner Approval of Building Official r.. r 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 l 1 of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a pe-rsm(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. 1 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:forms:homeexempt Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supcir iso"r License: CS-0009.98 � ! yM. VICTOR J WIINI�tAINE- T PO BOX 69 s W BARNSTABLE MA O Expiration Commissioner 09/29/2015 ,�*, Ulae�p'oa�vrrwauu�a, r,o-; .toac auae& Office of Consume. Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration: >100053 Type: xpiration �6(8/2094 Individual VICTOR J.WIINIKA'INENNi Off +` � c Victor Wiinikainen 58 CAPE COD LN r BARNSTABLE, MA 02630 Undersecretary i 9 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-000998 VICTOR J WIINItAINE ' PO BOX 69 W BARNSTABLE MA Expiration Commissioner 09/29/2015 License or registration valid for individul use only before the`expiration date. If found return to: Office of - Consumer,. Affairs and Business Regulation (•'` g 10 Park Plaza-Suite 5170 Boston,MA 02116 XY -'I "valid ure I S .. i0ap �l Town of Barnstable *Permit 4�)_() D9b� Regulatory Services gee 6m ae snaxsresrt:, MASS.059. Richard V.Scali,Interim 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 PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 7 Property Address �0 [Q Residential Value of Work � Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C Contractor's NameYC,0,g Telephone Number Home Improvement Contractor License#(if applicable)/ 4> .`� -` Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance �PRESS Check e:. na sole proprietor DEC❑ I am the Homeowner 092013 ❑ I have Worker's Compensation Insurance Insurance Company Name T 0WN OF RA 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 [replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ 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: QAWPFILESIFORMMbuilding permit formAM PRESS.doc Revised 061313 1 The Cammonnvahlh o,f Massackusetts Deparhnerzt of Industrial A ccidenis 1�p Office of Investigations 600 Washurgton Street Boston,M4 02111 wwiv.mas&gav1dia Workers' Compensation Insurance Affidavit: Builders/Contractu-JElectriciansfPlumbers Applicant Information Please Print lbly Nwne gaud a-,—., anir. olL%urn ctuai):VZ4 >lz Address: Citylstate/ZiP&A X1V-S;X 0,4 Z IP A&,-Z 6 3 a Phone 4- Are you an employer?Check the appropriate boa: Type of project(required): 1.❑ I am a employer with 4- ❑ I am a general contractor and i loyees(full and/or part-time)- * have lured the sub-contractors 6- ❑New construction 2.VI am a sole proprietor partner- listed on the attached sheet. y- ❑Remodeling l�l?n or P These sub-contractors have shop and have no employees 8_ ❑Demolition working far me in any capacity. employees and have workers' [No workers' comp,insurance comp-insuzrance i 9_ ❑Building addition required.] 5. ❑ We are a corporation and its 10-0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'camp- right of exemption per MGL 12.:❑Roof repairs insurance required.]Y c. 152, §1(4X and we have no employees.[No workers' 13.,VOtherk£PC`z comp.insurance required.]'' W//V ®t-P>s ;Any appbag.that checks box#1 most also fill out the section below shawing their workers'compensation policy in€ormstia n- ffomemners who submit this affidavit indicating they are doing all work and.they hire outside contractors mast submit a new affidavit indicating such. Contractors that check this boa must attached an additional sheet showiag the nme of the sub-ccaactm and state whether or not these entities bwe employees. If the sub-ronuactors have employees,they must provide their worken'comp.policy number. I agar an emp*er that isproiVing workers'compensation insurance for at1'empkyees. 8etow is the policy and,job site information. Insurance Company Name: Policy 9 or Self-ins.Lie.4: Expiration Date: Job Site Address: CitylStatelT.ip: 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 andlor arse-year imprisonment,as well as civil penalties in the form of a STOP WARS ORDER and a R of up to$250-0o 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 c 1)5 under the go-lip a�� natties ofperduty-that the information prat ided abm a is bw and correct Date: Phone#: Official use only. Do not write in this area,to be completed by city or town a,jjyciaL City or Town: PermitfUcense# Issuing Authority(circle one): 1.Board of Health 3.ceding Department 3.City/Town Clerk .4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �'ME r, Town of Barnstable Regulatory Services BMMSTABMAS&'E i Richard V.Scali,Interim Director Arno�,pr" Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis;MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete. and Sign This Section If Using A Builder as Owner of the subject property hereby authorize tL �C�. c2 C-1 1 I �"7 t K C.7•� n P-0 to act on my behalf, in all matters relative to work authorized by this building permit. (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. SAatate of Owner Signa- e of Applicant b an V, Prin Name Print Name h ( � Dat C•nWNFRPFRMTCCTf1ATP(1(1T C 1(1/iZ Town of Barnstable Regulatory Services p*tHE Richard V.Scali,Interim Director Building Division s�xNsresc , * Tom Perry,Building Commissioner - 9cbMASS. 1 % ��. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6250 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 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 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 formsTYPRESS.doc Revised 061313 � pper� �e�p'ao�vrrwouoecz�o''C��6ar./zrrae� \ Office of Consumer Affair§&Business Regula ,,4 tion. r' ME IMPROVEMENT CONTRACTOR Welgistration: 0TYPepiration 6/8/ Individual VICTOR J.WIINIKAI�W-'+i 1 r Victor Wiinikainen 58 CAPE COD LN BARNSTABLE,MA 02630 Undersecretary I j Massachusetts -Department of Public Safety Board of Building Regulat4ons and Standards Construction Supervisor License: CS-600998 = VICTOR J WHNIJ�A j PO BOX 69 - W BARNSTABLE MA J,�.•� �jr � �� " Expiration Commissioner 09/29/2015 r• License or registration valid for.individul use only before the'expiration date. If found return to- Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature t public Safe Massachusetts - Departm.ent of Pub y Board of Building Regulations and Standards Construction Supervisor s License: CS-000998 VICTORJWIINWA '•; PO BOX 69 W BARNSTABLE Expiration Commissioner ' 09 29/2015 j o oFTME Town of Barnstable *Permit Permit# T Regulatory Services �&rs 6mondisfrom�`date • sAarr AIRZ, + Fee j, MASS ��eg Thomas F.Geiler,Director Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstabld.ma us Office: 508-862-4038 E"RESS PERMIT APPLICATION - RESID Fax: 508-790-6230 Not Valid without Red X-Press Imprint ENZ'TAL ONLY Map/parcel Number .�'0--7 01 Property Address ( � e 1" residential Value of Work 9 Minimum fee of$35.00 for work under$6000.00 Dwner's Name&Address 170 _ ;ontractor's Name t C.re r. i �/ r� ,M ZA/ Telephone Number 3U4— -� 3�2 �8/0 lome Improvement Contractor License#(if applicable) (3«"-- 5'r� onstruction Supervisor's License#(if applicable) ! 9 9 ]Workman's Compensation Insurance Chec�asoleproprietor , .mP ESS. PERMIT ❑ I am the Homeowner ,�U(A ._, "o,If ❑ I have Worker's Compensation Insurance urance Company Name TOO/N1 OF BARNSTABLE )rkman's Comp. Policy# py of Insurance Compliance Certificate must accompany each permit. nit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of r000 ❑ Re-side ` replacement Windows/doors/sliders. U-Value o (:f3 #of doors (maximum.44)#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. Arequ' IA copy of the Home Improvement Contractors License&Construction Supervisors License is a ATURE: ILESTORj\4Slbuilding permit formsTYPRESS.doc I I The Commonwealth of Massach use& 1 Department of Industrial Accidents 1 Office Of Investigations 600 Washington Street Boston, MA 021.71 r a- www.massgovldia Workers' Compensation Insurance Affidavit: BuRders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganimiSon/IndividuaI): Address:-5 '9 CAEF City/State/Zip:-Mp? Phone 43 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I ._ �eaaployees (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 t ?•. ❑Remodeling ship and have no employees These sub-contractors have 8. [].Demolition working for me in any capacity. workers' comp. insurance, g, ❑Building addition (No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I:❑ 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.] 13.2�Ser2, *Any applicant that checics box f 1 must also fill out the section below showing thcirworkers'compensation policy information. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside.cautractors must submit a new affidavit indicating such #Contractors that check this box mast attached an additional shoet showing the name of the sub-contractor and their workers'comp,policy information. I am.an employer that is providing workers'compensation insurance for h y employees: Below is the policy and job site information. Insurance Company Name.- .Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip, Attach a copy of the workers'compensation policy declaration page (showing the policy number and expiration dots). 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 certify under4he and penalties of perjury that the information provided above is true an_ P d caned . � 7ii attire: / p Date: �® 'hone Offrcial use only. Do not write in this area;to be completed by city or town bffu:i'al City or Town: - PermitlLicense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk er 4.Electrical Inspector S.PIumbing Inspector 6. Oth • J 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 an 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()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 af5davit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-confractor(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 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 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 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 listed below.`Self-insured companies should enter their self-insurance license number on the appropriate line: City or Town Officials Please be sure that the-affidavit is complete and printed legibly. The Department 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 yod 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 permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should writer"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 Iicenses. 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 burn leaves etc)said person is NOT required to complete this affidavit. The OfEce of Investigations would lice 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 Massachusetts ' Department of Industrial Accidents Office.of Investigations' 600 Washington Street Boston,-MA 02111 Tel. # 617-727-4900 ext406 or 1-877-MA-SSAFE V 4 L 1'7 '77'7 '7-7 A n Town of Barnstable 0 r Regulatory Ser.vices '� E.1gN6Tj Rim i Thomas F. Genet Director ` 1639- 'RFD µFA B uiI ding Division Tom perry,EuiIding Commissioner 200 Main Street Hyamais,MA 02601 wfvw.town.b arnstab le.ma.us Office:.508-8624-03 8 Fax: 508-790-62.3 0 Property OwrierMust Complete and Sign This Section If Using'A BuiIdt'r I'• , as Owner of the sabject,pro proper. . hereby authorize p'� + fe,Pr to act on my beh-zl is 0 matters relative to work authoHwd by this buEI agpe=a 2pp4r2tr01: for. (Address of Job) 6 $- of Omer Da Pant ame If Prop e Owner is applying for permit please c ona le te.the Homeowners License Exemption Form On :the reverse side. �P��Trtaro� Town of Barnstable D h Reg latoiy Services i,�xrdsrasr� ? nanias F. Geller,Director 16 ;6 .* Building Division CEO { Tom Perry,Building Commissioner _ 200 Mam•Strcct; Hyannis, MA 02601 R'w41 AOTrzmbarustable.ma.us Office_ 508-9624038 Far.- 508-790-6230 IrOlKaOV N LICXN'SE EXEMPTION FI—se Print DA7F_ y • JOB LOCATION: number street village HOMEOWNER,: name borne phone# work phone# CUR.RFNT MAMINQ}ADDRESS: c+tY state zip code Tate cmT=t exc=ption for"homeowners"was extended to include owner-occupied dwrlIin>?s of six units or Jess 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 BONIEOWN'ER Persons)who owns a parcel of land on which helshe resides or intends to reside, on which.tfiere is, or is intended to- be, a one or two-farmly dwell aitachcd or detached structrres accessory to such use and/or fans structm=. A person who constructs more than tine home in a two-year period shall not be considered a homeowner. Such "Homeowner"shall sabmit to the Building Official on a fo=acceptable to 6c Building Official, that he lshe shall be resvorisible for all such Wolk performed undertbe building permit. (Section 109.1.1) The lmdersigncd `2iomcowner"asst**ncs rmponsilility for compliance with the State Building Code and other applicable,codes, bylaws,rules and regulations. The tmdcrsigned'lomcowne'certifies that hdshe•understands the Town of B—stable Building Department in . sp6ction procedures and rt gmfi t,rnh and that helshe will comply with said procedures and rcqu re ments. 5igrutisre ofHarrumvner Approval ofButldang,OfficW , Note: Thee-family dwellings containing 35,000 cubic feet or larger will be rctpirrd to comply with the ' State Building Code Section 127.0 Conshuctibn Control. SOAUxO WMM,S EXEMPTION The Code states thaC "Any botneowoer peforsrmrg work far which a bmIdins perni t is required shall be exempt from the provisions f hie sccd=.(Section l D9.1.1-11=u-i'ag of canstrnetioo Superyisors);provided brat if the hameowoc engage a pesmY(s)for hire to do such ,or,that h Hamcawna shall Ad as supervis or:,• 7y homeowners who use this exemption are un ware that they are asstmsng the responstbilitics of it supervisor(see Appendix Q ul=&F_=61adons for Liecosing Coastrucdon Superyisms,Section 21.5) Thic lack of awareness often results in serious problem,partieulsrly .jrn the homeow rr hires tmlieeasrd p==z% In this case,our Board cannot oard proceed against the unlicensed person as would with A licensed pe,%I.r. The:homeowner acting as Supervisor is uki attly responsible. To ensure that the homeowner is fully awarF of hiAcriupmmbrliocs,many communities require,as part of the perstit application, t the homeowner catify that brJshe undestaads the rnpmm"brlities of a Supervisor. On the last page of this issue is a.form otmrntly used by M tsti setts D ,•- lose s- ep woneot of Pu tlic Safetl ff�� /� Board of Ruildin(y Regulations and Standards Officelb nsumer AYfa '�( aac�ic 0eC1a B srness egn a ron Construction Supervisor License HOME IMPROVEMENT CONTRgCTOR License: CS 998 x Registration '100053. E Type: Restricted to: 00 ,=},Expiration: 6/8/2912 + t .� Individual t'4, VI OR J. WIINIKA VICTOR J WIINIKAINN , PO BOX 69 t" err . Victor Wiinikainent� W.BARNSTABLE, MA 02668 58 CAPE COD LN i x r j 4., I BARNSTABLE, MA 02630� + 4 Q 5 Underseccre—tary. I fy jam—` Expirati*n: 9/29/2011 ('unuiiissioncr Tr#: 2294 I ` c i c , o � � � a •�� H I i c � C w c 4. - L H o Z - v , °�T► r�,, Town of Barnstable *Permit#Po2!T0 a, 7, Expires 6 months from issu ate Regulatory Services Fee * BARNSTABLE, MAC Thomas F.Geiler,Director 9� i639. ,fig a 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 PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid.without Red X-Press Imprint Map/parcel Number 1 Property Address 9 Residential Value of Work % Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address C >11-y 1 W (o 45 c� Contractor's Name (Gt �.`,' �` r r CILf`�lO�d`Y `1' Telephone Number .�✓d.�'�` �° 2"`?�l� Home.Improvement Contractor License#(if applicable) ze® � Construction Supervisor's License#(if applicable) a SS PE ❑Workman's Compensation Insurance P RE Check one: NOV 1 9 2009 I am a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTABLE ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. .Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will,be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors * El--Replacement Windows/doors/sliders. U-Value }' ,(maximum.44)#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 Supervisors License is required SIGNATURE: - �' �ld✓ '�--a Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 090809 { The Commonwealth of Massachusetts Department of Industrial A ccidents l� Lr Office of Investigations f' 600 Washington Street � •y Boston, MA 02111 wwm mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:,,_.-5__aV �� City/State/ZipA!8,YS/ ��a243a Phone C> �`� 791c3 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.®'i am a sole proprietor or partner- ship and have no employees These sub-contractors have g• E] Demolition working for me in any capacity. employees and have workers'comp. 0 Building addition [No workers' comp. insurance comp. insurance, 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no R 4/s C employees. [No workers' 13.�'(lther �� comp, insurance required.] �l/Y �me 23 *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. (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: Policy#or Self-ins.Lic.#: 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 certi under th ains and penalties of perjury that the information provided above is trice and correct. . Si ature. C�'"(X� �1- Date: Phone# je�� ^ 2 7 �F 1 d 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: ;a 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, constriction 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 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 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 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 listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department 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 that must submit multiple permit/license 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 i Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE j Revised 4-24-07 Fay, # 617-727-7749 - www.mass.gov/dia A i �1HET Town of Barnstable Regulatory Services anaxsr^sLE. Thomas F. Geiler,Director 039. �`0� 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 Property Owner Must Complete and Sign This Section If Usine A Builder I" (2 )CL , 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. H cl,J'3 r) Un CIL C, (Address of Job) Signa e of Owner ate Y Print Name t If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O W N ERP ERM IS S I ON r Town of Barnstable oFz� o Regulatory Services T Thomas F.Geiler,Director MRNSrABr.e, MASS. 9�a 039. a�� Building Division lfD MAl 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 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 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/certifrcation for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC r -'� iVlassachusctts- Dcpurtmcnt of Public Sxfch Boar(] of Building tr Construction Supervisor License tndar ds License: CS 998 Restricted to:. 00 3. VICTOR J WIINIKAINEN f PO BOX 69 t W BARNSTABLE, MA 02668 - ` Expiration: 9/29/2011 (ounuissil... - -- Tr#: 2294 ` 4YG1ze -�anv7w�urealt��o��/�craaaelu�aet�a !�' Board of Building d ng Regulations and Standards HOME IMPROV EMENT CONTRACTOR Registry only 100053 "` Expiration 6%8/2010 Tr# 267944 3€ Type Ind.ivdual t . VICTOR J.WIINIK 'INEN 4rF zf Victor Wiinikainen 58 CAPE COD BARNSTABLE,MA 02630 Administrator f r i r License or registration valid for individul use only before the expiration date. If found return to: e Board of Building Regulations and Standards One Ashburton Place RM 1301 Boston,Ma.02108 t valid without signature r - ` .. q^'ft-i7#'',','$�?'s.-xYiq?'%..,:e ^c�y,�.�`��✓PS;,'«�`%Y *" ro`�'.'�tKs w'`G�'r'��+ � , `c"' Y i'?+.. '4 Assessor's office(1st Floor): ry Assessor's map and lot number 3y / ✓� f� o�TN E>o Board of Health(3rd floor): � T r � � F Sewage Permit number lij ,A c c-r- A, 1Z Ll s� 1; aaas9rsntc Engineering Department(3rd floor): j`� r. s -House number 9� r�.i!!.a C S 7- - t�' °° '•4s9 Definitive Plan Approved by Planning Board 19 °-No°r\ APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ( U �� i� •�2 TYPE OF CONSTRUCTION I✓00© 1 -17 r1{ TO THE INSPECTOR-OF BUILDINGS: The undersigned hereby applies for a permit according to the following information, Location < f/ �C fl//;7rt��s Proposed Use /�/rv00/✓t �. 1/ , Zoning District 3 Fire District Name of Owner %/`I� /+ Address Name of Builder Address Name of Architect Address Number of Rooms Foundation / Exterior �/��, yC �S' � Roofing r �Pr G G�r�1: ?n Floors / / >/�� Interior'' Heating Plumbing Fireplace Approximate Cost Area Diagram of Lot and Building with Dimensions Fee., I 4 } OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I`hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. NC,onstruction Supervisor's License w .R• KAP vANP CYNTHIA A=307-'138 No 33737 Permit For Add nn-nn--r Single Family Dwelling - Location 90 Chase Street I�yannis Owner Cynthia Kaplan Type of Construction Frame Plot Lot Permit Granted June 1 , 19 90 Date of Inspection 19 3 Date Completed 19 ` PERMIT COMPLETED 111.1 9/ Assessor's office(1st Floor): Assessor's map and Jot number d'"Qyo`T�a>o�♦w Board of Health(3rd floor): T� 6 Z'� S �yG,.2 - Sewage.Permit number 2L4 Bo Engineering Department(3rd floor): = asassTeDLL � r+ua House number CC w A-S C S 1— Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO f 1/� TYPE OF CONSTRUCTION 1fO9O 19 9(7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location V lore Proposed Use Zoning District 3 Fire District • -V y Name of Owner C m ' /L Address 70 C Name of Builder / Address Name of Architect Address Number of Rooms/ Foundation Exterior V / ,S/G J Roofing I`� (rrl ZO y� 5 /�f7lrCl� Floors Interior Heating ✓' Plumbing Fireplace Approximate Cost �h Area Diagram of Lot and Building with Dimensions Fee U r OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rul and Regulations of the Town of Barnstable regarding the above construction. Name . Construction Supervisor's License KAPLAN, CYNTHIA . 9 rY i 1 No _-3 3 7 R 7 Permit For Add Dorme r Single Family Dwelling i Location 90 Chase Street Hyannis .` Owner Cynthia .Kaplan Type of Construction Frame a; k Plot Lot t e Permit Granted June 1, 19 90 t Date of Inspection 19 Date Completed �`� y/� 19 l r t" _ LA-1 -_4�-�. '.�.�..-t5.�.�-�. ,�..-. -.� L�f wxt p _ r -P �-- - - R� � + � aR •♦. � t � � y..=�\� ,l'4'/l�l_�� 1.a. .. rW` r.\/ M1 L' a P.� r . 12 �_ _\.- .-(t 5Q` 'l 1`�� ' ti -�r►;•?�� rJl�l N�. YL ` .,.�r �'. 1 r " *g \� '+ to-V)jl rt" p._.:' ✓.. `d'' y ":a,. � � � 4 .�+.�Q II 'N`'z� t C tl' f'. '. �•r ;�,+4�. a�'1. .. 'T s..' .> �. er- wd S r•, h'1�b',gNe M1 r.!"✓,Na `' '.:,L yr ..tip ,.n.'• ♦ ♦. .r.. y \\ } t•' $y'` _ ^ k1 y" Js Y • ^ y y r.E. 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W a t, �' >f krv. i s tg vc^kr R. ro f 'i rt k e,. h.Z✓w `'♦ �: :"., a*: •:ra^ ..c` Yt '_y' , k p * ax.� ":tr o rr ii� top ' i{• it ti` t" t `w V ".:T- '7 r� ,x 1 *-." 'G y - ,' } M1 �r 'Y y4J ... .,. y :.1 5 � F." �7r^ - L ., h r �, ,.5. ''. r..., .W-.• ,�`ti r .{ f t TOWN OF BARNSTABLE e BUILDING DEPARTMENT s HOMEOWNER LICENSE EXEMPTION Please print. r • DATE � .. , 1 '`J� J06:.LOCATION um er. • . , re a ress ecti OT T.OWrf "HOMEOWNER" .C • . .. a e e p one or pone PRESENT`MAILING ADDRESS" e, e 1p ` The, current exemption. for :"homeowners" was extended to inclu l!' dwe1.lings: of six: un de. Owner-occu its .or a pied,•` ss an o al low,such homeownters; to engage, an..i n- I ivi ua .for hire, who.does not Possess a license; provided that the owner• acts .as supervisor. (State Building Code Section ?DEFINITION OF HOMEOWNER: `Person(s) who owns a parcel of land on which he/she resides or intends to r side, on which there is, or is intended to be, a one to six familydwelling,e '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 res ons' ,for all such work Performed- under the buNding permi ec ion p ible� 'The undersigned "homeowner" assumes responsibility .:Building Code and other applicable codes, by-laws, rules.oandiregulations. ance with t'he State ;The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building DepartmentAinimum inspection procedures and requirements !a nd that he/she will comply with said procedures and requirements' HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic � i feet,""dr'lar ,er will be required .to :comply with State Building Code Section 127.0, Construction i on Control. 8 .. j HOME OWNER'S .EXEMPTION The Code state that: •• "Any Home Owner performin perm I t I s requ l re g work ••for wn"I d shall ch a bu ilding sect)n (Section 109.1 .1 _ be exempt from the provislons,of thls` sectlon 'Home Owner engag88 aiperson((s)ng ffornhirectood Supe:r�`A rs') x , T �^ shall act as supervisor, prov,7ded :that. If a o .sucn-wo work, athat�s tch Home Owner . 'Man Hoy _ �• � � . . �� I Y me use t�� hls a empt.lon are unayrare that the the essIb l I I t ies` of . Y "`are r tor. Llc�nsln Constr a supervisor (see. A assuming u a � pp4dlx'Q� Ru""les ct1 w n on � . d� R e ,�• �e�rvi � f x gulatlon p sor" � s often res i * ' s,. sect:ldon U t sI ,_ .15 4. n ser i,ous p�obrems, � )•" yh Is5 hack. of awareness Unlicensed' -Wv t,I 6u 61;.I t�ersons. Y when the H I n' th I s case our , goa, Home' Owner hires unlicensed person 4 ; cannot as It proceed a ..�yas.ssu ervisor Is " ulq x� c, bey. u against -the r..�.�?w.... ... . �teiy �. parlor.. . The Home net In w- sponsble. �1 g To ensure thatto Home`. e:r is fully aware communities re"qulre, ` as part of the permit application,r. re{ponsl.bilitles, many certify that he/she .understands the responsibilities `of a .shat the:•Home Owner last.` supervisor. ' page of this' Issue��is �a, form current ) On the 'care to'amend and adopt `sUch a form/certtflcatlon for us � '� 6. Y used by several towns.. You may your community. . 5 • k• � a i," r"F. rr1 � 9 •a i S . v v. s