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HomeMy WebLinkAbout0143 CHESTNUT STREET Li rI''� i Town of Barnstable *Permit# Expi rs 6 mmuhs from Law e Regulatory Services Fee + HAHI�W'AHi�. s 19 Richard V.Scall,Interim Director X® PR Building Division ESS PERMIT Tom Perry,CBO,Building Commissioner SEP 24 2014 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us TOWN OF BA q� �g L E Office: 508-862-4038 Fax: 508-7 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 30"1 r� 1 �+ Property Address \� 3 l.t/e s+ r1U+— NResidential Value of Work$ 104`7�J• n� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address HtUn 41 1 A3 &R S'j1f1,1& i Contractor's Name iA Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) D 791 [�Workman's Compensation Insurance r�\� Check one: ❑ I am a sole proprietor ❑ 1 am the Homeowner 1 have Worker's Compensation`Insurance Insurance Company Name /l��� �1'"4p 1,A/S Co Workman's Comp.Policy# W ®� / a 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) a❑ Re-side �y M Replacement Windows/doors/sliders.U-Value t 3b (maximum.35)#of windows OCR #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 rewlatioms,i.e.Historic,Consravation,etc. ***Note: Property er sign Property Owner Letter of Permission. A copy of H Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: TAXHVIN D\Building Changes\E3p S RESS.doc Revised 061313 2014-09-05 03:58 2612EXPDTR.PHONE 5089574714 >> Home Depot AHS P 1/10 HOME 1MPROVF:MEN'1'CONTRACT PLEASE 1ASE RFAD'FFW ?5l /L Sold,I�urnishcdand metalled by: Branch Name:Roston North&South Date.. �`� THD At-Hume Services.Inc.. Branch Number 31 and 33 90 d/b/a The Home Depot At-llomc c ervices 8 Boston Turnpike.Unit 1,Shrewsbury,MA 01545 Toll hree 877-9C3 3768 Federal ID#75=2698460;ME Lie#C 02439;R.1 Cunt.l.ic 9 16427 � 5�n Ci 11c#HIC 6561522;MA Heine Improvement Contractor Rc .#12689.1 Installation Address: City State 'Gip i'prchaser(s): 1Vork Phone: Home Phone: Cell Phon n Home Address: (If different front Installation Address) City State ?ip E-mall A,ddme.4(to receive project communications and Home Depot updates): ❑1 DO NOT wish to receive any marketing emails from The Home J)"t - Proiect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agree;to huy, and THD At-Home Services,Inc.("The Home Depot")agrees to fumish,deliver and arrange for the installa.lion("Installation")of all materials deserihei on the below and on the referenced Spec Sheet(s),all of which are incorporated into,this Contrac by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change.Orders(collectively, "Contract'): Job#: nn Amer ads.: ducts Spec Sheet(s)#: Project Amount Roofing Siding mdows insulation 1 1- T�6�?� ❑Gutters/Covers ❑Entry I)uurs ❑ _ � ��,!G Roofing Siding Windows Insulation �4 ❑Qutwm/Covers ❑Entry Uoors ❑_. $ Roofing Siding 'Windows Insulatio,o I I []Gutters/Covers []Entry Urxors❑ $ Rogtiug Siding Windows insulation ❑Gutters/Covers ❑Entry Doors ❑ MLdm un 25%,Depusit of Contract Anoint due upon eximution of this contract. $ Total Cmttract Maine Ptuedtnsers may not depict more amamane-third of the Contract Antopnt Amount 11 Customer agrees that,immediately upon completion of the work f<ir each Product,Customer will execute a Completion Cortilicutc (one for each Product as defined by an individual Spec Sheet)and pay any balance.due. As applicable,each Customer In der this Contract agrees to he jointly and severally obligated and liable hereunder. The.Hume Depot reserves the tight to issue a Change Order or terminate this Contract or any individual Proxluct(s)included h::rein,at its discretion,if The Home Depot or its authorized servir,•c provider determines that it cannot perform its obligations due Loa srrucntral problem with the home,environmental hazards such as mold,asbestos or Tead paint,other safety concerns,pricing errors nr txAnm.se work required to complete Lire job was not included in the Contract.Payment Summary: The Yayment Summary# C1 P'.70 c�53(_, included as part.of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. in the event of termination of this Contract,Customer agrees to pay The Hume Depot the costs of materials,labor,a cpenses and services provided by The Home Depot or Authorized Service.Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMIJUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMMNT OR CYPHER PAYMENTS MADE', Wi•I'HOUT LiMiTING THE HOME DEPOT'S(Y1'HER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agrcoment between(:asuntcr and The Home Depot with regard to the Products mid Installation services uld supersedes all pritor discussions and a;±reemenrs,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing;sinned by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has rucivicel a copy of this Agreement. A epted bY: 1 t _ i Subm't by: c C t mer's ignaturc c Date Sales C sultant's Signet Date X .v 'Telephone No. C;uStomces Si ature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS us apphcuble) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE.TO THE IIIOME DEPOT BY MIDNIGHT ON THE 'THIRD BUSINESS DAY AFTER SiGNING THIS AGREEMENT. THE STATE SU1311LEMENT ATTACKED HERETO CONTAINS A FORM TO USE IF ONE IS SPFCIFICALLY PRFSC:RIBED BY LAW IN CUSTOMER'S STATE I NOTICE:ADDMONAI.TVAM5 AND CONDITIONS ARP STATED ED ON THE REVERSE SIDE ANT)ARE PART OF THIS Co INTRAC'I 03-07-14 While—13ranch File Yellow•-Customer Massachusetts-Depadmot of Public Safety Boards of a3uilding Regulations and Standards Construction SupervisorSpedulty License:GS$L-6S�t62 z 'f'.1WiOM P c-�,,,��r •�„``a Expiration • Commissiorset �� - The Commonwealth of Massachusetts Department of Industrial Accidents 0fflce of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Leeibly Name (Business/Organization/Individual): / //nc�-t L/ T" r Address: C 1 Ad e, b /'/ve-- City/State/Zi ; 0'eh 0 1Y\ 0,__ 0a,S7/ Phone#: SO K-- Are you an employer?Check the appropriate box: [] general contractor and I Type of project(required): 1.❑ I am a employer with 4. I am a employees(full and/or part-time).* have hired the sub-contractors . 6. ❑New construction 2. 1V I am a sole proprietor or partner- listed on the attached sheet. 7. C] Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. " employees and have workers' [No workers'comp. insurance comp. inc�,ra '--t 9. Building addition required:] S. We are a corporation and its 10. EIectrical 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 re airs insurance required.]t c. 152, §1(4),and we have no p 3a.❑ I am a homeowner acting as a employees. [No workers' 13.❑Other general contractor(refer to#4) comp.insuranpe ,]. t 'Any applicant that checks boa#1 must also fill out the section below showing their workers'cotnpensatio!`poky information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContraaors 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: Cc>m f Af r&Q— AS U(AA an tW 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of . Investigations of the DIA for insurance coverage verification. I do hereby cerh under th pains and enaldes of peiyury that the information provided ab ve is a and correct Si a Date: 2.3 Phone#: Of Cial use only. Do not write in this area, to be completed by city or town ofjiciat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• The Commonwealth of 1IIassaciausetts DeParMent of Industrial Accidents 0 Of�e of investigations 600 Washington Street Boston'iVIA D�1 l P www.massgov/dia ers Woriters comp ens Insurance AffidavitBuilderslContractorslElep as Print� bl A iicant Information -V/tz-5 — i1e ict„;,,elOreaniiation/Indtvidual):. ^ Address: , r�i7�l �. �?��- ��• �State/Zi 3o3 Phone#: l City : Type of project(required): Check the appropt�late x: Are you as employer? 4. I am a general contractor and 1 6. ❑New construction 1.0 1 am a employer with have hired the sub-couu—actc.., 7 0 Remodeling employees(full andlor part tom)* listed on the attached sheet 2.❑ I am a sole proprietor or partner- .use sub-contractors have 8. ❑Demolition ship and have no employees employees and have workers' 9. ❑Building addition working for me in any capacity. comp.insurance.$ lo.o Electrical repairs or additions [No workers'comp.insurance 5. We are a corporation and its 'airs or additions required•i omcers ititYG H.w'��i.�=d the rir 11.0 Plumbing.eP 3.❑ 1 am a home doing all work right of exemption per MGL 12.Q Roof repairs myself.[No workers'comp. c. 152,§1(4),and we have no 1 / insurance required.]f employees.[Ato workers' comp.insurance required.] Chair workers'c*n p ltlw policy info .s..v pe,nlirant that checks box#1 must also fig out the section below showing „r not chose entities have o o ,show end then hire outside conh wrs must submit a new affidavit indicating such- work t meowners Who Submit this affidavit indicanng uwy a r-AO*:vs— of the sub-contractors mud stow—�•M....- - �Contraetots that wing the nsur- check this box m+mt attached an additional sheet their 'COTS•policy n�• toss have employees,they must provi dc employees. if the sub•contnc 1 ee& Below is the policy and job site I am an employer that is providing workers'compensation insuronce for my emp oy /V information. e # ` a �© Insurance company Name 1167 -�- _ C� Y Ito Q I Expiration Date: Policy#or Self-ins.Lic.#• W - �{ - /� City/Statelzip: �! frff res job Site Adds: ( � 3 policy.if number and expiration date). Attach a ropy o€the workers'compensation policy declaratioa page(showing lttes of a Failure to secure coverage as required undo Section 25A of MGL c.152 can lead to the imposition of criminal pens V j„�,....�,.,, veLl as civil penalties in the form of a STOP WORK ORDER and a fine up to$1,500.00 andtor One-,ear im>0son"c- ded to the Office of of up to$250.00 a day against lator. Be advised that a copy of this statement maybe forwar Inn+esti ations of the DIA for ce covera a verification I do hereby certify under n allies of perjury that the information provided abov is true and correct Date: SiPUI �� _ �� ®0 Phone#: feted y city or town offlciaL OffIelal rue only. Do not write In is area,allitille comp City or Town: PermlvUcense# ;;g 4nt rarity(circle ore): •*_ a a Phimhino Insp 1.Board of Health 2. ector But�ding Department 3.£ityrTown Cleric 4.Bieco`eat,aspect .ft--�---. 6.Other Phone.# Contact Person: • I a 1, dTXe 0 /., Office of Consumer Affairs and Business Regulation �3= 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement-Contractor Registration _ - - Registration: 126893 Type: Supplement Card Expiration: 8/3/2016 THD AT HOME SERVICES, INC. A N DR E W SWEET :. ---- - -- --- ------ 2690 CUMBERLAND PARKWAY SUITE_30-0. -- ----- --- - ---- ATLANTA, GA 30339 -= Update Address and return card. N4ark reason for change. SC.A 1 c.• 20rA•05111 Address FA Renewal i__j Employment (:j Lost Card � (i��L' ((rt/////rCNI/l:['(/���I/�%((rY.i.i(rP�/r.i r•�% _\--Otlice of Consumer:ltEurs& Business Regulation License or registration valid for individul use only I HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:I - Office of Consumer Affairs and Business Regulation Registration: 126893 Type: 10 Park Plaza-Suite 5170 Expiration: i30W16 Supplement Card Roston,,NIA 02116 Twn AT LI(lneC CCOII('CC nii_` /1 TIME FIONIE DEPOT AT HOME SERVICES ANDREW SWEET / 2690 CUMBERLAND PARKWAY S =>uG ;-%'•v.- -- 4 - 14 I— DATE W MID D,,�Y j A�ID CERTIFICATE OF LIABILITY INSURANCE 1 021, ,7�, 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 MARSH USA,INC. NAME: TWO ALLIANCE CENTER AIC,NPHNo Ext: FAX No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS INSURER(S)AFFORDING COVERAGE NAIC# 100492-HomeD-GAW-14-15 INSURER A:Steadfast Insurance Company 2&W INSURED INSURER B:Zurich American Insurance Co 16535 - THDAT-HOMESERVICES,INC. ----- — 'DBA THE HOMEDEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co 123841 2455 PACES FERRY ROAD INSURER o:Illinois National Insurance Company 123817 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003242685-Oi REVISION NUMBER:3 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. ILT R TYPE OF INSURANCE A S R POLICY NUMBER POLICY MMILDICY EXP D/YYYY LIMITS LTR A GENERAL LIABILITY GL04887714-04 03/01/2014 03/0112015 EACH OCCURRENCE $ 9,000,000 DAMAGE To RENTED 1000000 X COMMERCIAL GENERAL LIABILITY_ PREMISES Ea occurrence $ LIMITS OF POLICY XS MED EXP(Anyone person) EXCLUDED CLAIMS MADE OCCUR t Y Pe ) $ OF SIR:$1M PER OCC PERSONAL 8 ADV INJURY $ 9,000,000 GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:. PRODUCTS-COMP/OP AGG $ 9,0OQ000 PO- X I POLICY JECT LOC $ B AUTOMOBILE LIABILITY BAP293886311 03/01/2014 03/012015 COMBINEDSINGLELIMIT 1,000,000 (Ea accident $ X ANYAUTO BODILY INJURY(Per person) $ ALL Or SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED per ac cident) DAMAGE $ HIRED AUTOS AUTOS UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LtAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC049101882(AOS) 03/01/2014 03/01/2015 X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY I S ER C R YIN N WC049101884(AK,AZ,VA) 031012014 03/012015 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N NIA E.L.EACH ACCIDENT $ _ D (Mandatory In NH) WC049101883(FL) 03/012014 03/0112015 E.L.DISEASE-EA EMPLOYEj$ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 03/01/2014 031012015" (EL)LIMIT 1,000,000 C WC049101886(NJ) 03/012014 03/012015 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2465 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 , AUTHORIZED REPRESENTATIVE t of Marsh USA Inc. Manashi Mukherjee �'Loiu»> C2dr•�u ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map D cl /�:f! Parcej Application # Health Division Date Issued q-23 P Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis . Project Street Address Village !7` 6QA/il S r Owner lid 1,�p rF C2 1 Address Telephone 03-Y9& - qU q5_ f s � Permit Request 4,0-e- °7 :Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation VlOk• Construction Type G l o E Lot Size Grandfathered: ❑Yes ❑ No If yes, attach 1�,t5u' porting0g.curMntation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kingsl ighway:_rp Yes= ❑ No Basement Type: A Full ❑ Crawl ❑Walkout ❑ Other c Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)i ' Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas g"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) �PP Name :TpAoc, C4keki 1406c1 v'Let . Telephone Number �g " f '�D Address J4n _Seba J t- License# Sc,n0f4�p/ C Home Improvement Contractor# 10 G V e Email Aew Cvn mWorker's Compensation # 4110.2R-76D ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE C r FOR OFFICIAL USE ONLY ' APPLICATION# a ; f DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER . DATE OF INSPECTION: t FOUNDATION FRAME f INSULATION FIREPLACE ELECTRICAL: ROUGH - FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATME CLOSED OUT IK, ASS TION PLAN NO. The Conwonwearft ofmassatchuse r OJ of InmtdSaatdons 600 Washdngiton Strut BooWn;.hit 02111 wwwKgav/dfa Workmt Compemden 1=uarawe Aftsvit eWContr*ctonWeCtdd /Plumbers Agaftakif—or—MatwilPrint IdOft Name Addros A —revi - Ci 1 J71iL • Muth—=#i �• Are you an smphryer?Ckt&Lille appropirtate box: 1. I am a employer with 4. [ Z am a-Wnwd contutor and 1. Qi'pro�ectt(rag : employees(f&and/orpart-tjmej o ham hhW iile sub-cooftotts g• ❑New CoMbuotion 2.[f 1 am a sole propsfetor or parttteir listed on the athwhed aheet, 7. Retodeli:lg ship and have no employees Thin sub-contteora leave g, DamoUtiou World% for the in any Capacity er*oyees and bove wodml [No wo&au'comp.ins aaamp.iramr umt �� ❑Huildimg dddition regtduwd.] 113 We are a ootporadon ad its to-[]Rk*w repab or additim 3.❑ 1 am a home weer doting all work OfflOm have nowed their 11.[]plumbing repuita or wdwoms nVeelf.[No wo*ere'oonap. rlgltt of Oxempdm per MO3OL 12,�ito�rspaira in�uance r�ait�d]t o.152,J 1(4�and we have no etup1 .[No wow' 13.0 Other insumnae ] • . *AlW Mffi eat dtat oaks box#1/vast ateo fill out Ow section sb blow nft tb*vote #w�poq�,k&M*vM HOMWWnem who submit leis affidavit Wdkaft they are ding ett wa&and dim fdW outside eeatiawors m=t submit a now aMvtt fixumtins malt.4Conbulors that chok dih boa nraa aftacW an addtt W dent dwwlntg die mme of the imb-Coahaotm and swo whotw or not ttatso antltiea have eneployew• if Ow sub-aon uke boo mp*cL%they mast i wvJ&thc[r wow oomp,polloy nwaber. �"�wvlmw Ait 4SPOW&g`"AM,CMP adna b�u ouefor my etaploym. Adow is the potitay and job ske Insurance Company Name: r Policy#or Self-Ina.Lk.A. Bapimdon Job Site Ad Attach a copy of the wwd ers'eqmp@"sdon paltry deeltiratakaa pale(*Ow tote policy numll►er and ex*ation d04 Failure to savors ooMMO as r OkOd tinder SeMou 25A of MOL o, 152 can lead to the Doti of whMfiW ptmaldes of a Bne up to$I tSOO,OA and/or cn►e-yw i�risaun�as wOn as civil PM46ea k the fa=of a MP WORK t MBR e:ad.a fine Of up to$250.00 a day against lhe violator. Bo advised dint a copy oft3tis statement may be fcwarcifed to the Ofte of ltivwdgad=of the.01A1.for inscmce covrsage v+erlflnadolL I do hereby tkwpatw OwpMawn OfPsdary drat the inf rmedsnpMA*d abat►g 6 bw=d currecl: O&W use or►(µ Do not waft In i[trts am%to be cOAWkW by dop or Mw qffldat My or Town-. p�mitlL9ceuae# � lwaing Aut&ofy(chvie one): 1.Board of Heap 2.BuMAng Department 3•GitylTmm Cork 4.Electried llOepeetor S.Phimbing Impectar 6.tester Contact Person: Phone ft i Hlghtfax NZ-1 1L/lb/-LU1J, IU:Gl :J0 API YAuz ar vvY r&A owz yc t AC U CERTIFICATE OF LIABILITY INSURANCE DATE 2 6-2013 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: "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: OCEANSIDE INS GROUP PHONE Fax 52 WEST MAIN ST HYANNIS,MA 02601 Ennll INSURER(S)AFFORDING COVERAGE NAIL d INSURER A:AMEtICANZURICH INSURANCE COMPANY �I INSURED INSURER a: BENABBY INC DOA INSURERC: DISASTER SPECIALISTS P O BOX 480 INSURER 0: SANDWICH,MA 02563 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 ADD SUB POLICY EFF POUCY F-XP LTR TYPE OF BISURANCE INSR yrVD POLICY NUMBER MWW wO01Y LIMITS GEMMALLLABIUTY EAQ-10CCURRENCE S COMMERCIAL GENERAL LIABILITY PAMA1F TO RENTEED S CLAIMS-MADE I OCCUR - MEOE7W(Any omI Parson) g PERSONAL&ADV INJURY S GENERAL AGGREGATE s . GEM AODREGATE LIMIT APPLIES PER: PRODUCTS-COMPrUP AGG S POLICY I P.7 LOC s (LE L.IABIIM OMBI D SINGLE LIMIT S - nr. n • ANY AUTO BODILY INJURY(Par pamm) 8 ALL OWNED SCHEDULED S — AUTOS AUTOS BODILY INJURY(Per ecddent) HWEDAUTOS A AUTOS E S S UMBRELLA LIAR occUR EACH 13G"RENCE s EXCESS I" CLAIMS-MADE AGGREGATE S DED I RETENTIONS S WORIQ?RSCOMPENSATION X WCSTATU- OTIM AND EMPLOYERS'LIABIL" - TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE._,N 1 A E.L.EACH ACCIDENT $500,000 OFFICERIMEMSER EXCLUDED? UN 6ZZUB 01-01-2014 01.01-2015 (ManeaWy In NH) 4102P700 E.L.DISEASE-EA EMPLOYEE $50(1,000 r yas,eaacrrla murm E3 I OF OP ow E.L DISEASE•POLtO1 Uwr $500,0DD DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Sahedtil%N more space Is regkdreA THE INSUREDS MA WORKERS COMPENSATION POLICY AND ITS LIMITED OTHER STATES INSURANCE ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSURED'S MA EMPLOYEES IN STATES OTHER THAN MA.NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS IN ANY STATE OTHER THAN MA IF THE INSURED HIRES,OR HAS HIRED,EMPLOYEES OUTSIDE OF MA,THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA. DER CANCELLATIQN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE l0liN J,LUPICA•PatsidMI rightsreserved. ACORD 25(200105) The ACORD name and logo are registered marks Df ACORD O V (• � c�//ae�oarrirrroaecvealC/a���ittac/cc�eGt� -'.;�__._._�_.__.. . -,--•._m Y-d,,_..__..____..._. ...._._- e Mee of Consumer Affairs`&Business Regulation � x,+ l icerse or registration vand'for individul use only ( : before the expiration date. If found return to: ' ME IMPROVEMENT CONTRACTOR P f e istration ! Office of Consumer Affairs and Business Regulation 9 108642 Tvpr , 10 Park Plaza-Suite 5170 Expiration 8/20/2014 ,`; Supplemert , rd Boston,MA 02116 BENABBY INC/DISASTER.SPECIALIST JOSHUA COHEN .1, y .J: Box 480 , Sandwich,MA 02563Undersecretary Not valid without signature i t i Massachusetts -Department of Public Safety Building Board of Regulations.and Standards R 9 Construction Supervisor ` , License: CS-071„402 "`ER,$ JOSHUA L COHE$ 1082 OLD STAGS CENTERVELLE MA I" Expiration Commissioner 12/31/2015 oFTMETa,, Town of Barnstable o Regulato Services 9 ABM NIUR Thomas F.Geiler,Director Building•Pivision Tom Perry,Building.Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.6s Office: 508-862-4038 : Fax: .508-790-6230 Property Owner Must 'Complete and Sign This Section /`f as Owner of the ro subject l property e heteby authorize DO SG G 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. Signature of Owner: tore of Applicant 4 0 ke A.,.� Print Name Print Name. Date WORMS:OWNERPERMSSIONPOOLS 62012 Town of Barnstable Regulatory Services o� { Thomas F.Geller,Director . 1 ¢ .�� Building Division Tom Perry,Building Commissioner 200 Maui 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. DEFINPTION 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 parson 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:fbiTM:hom=empt