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HomeMy WebLinkAbout0006 CROSS WAY CUSS %ud- -� s, __ — __ I 416, Town of Barnstable *Permit# "1-0 9�� tres 6 months from issue date ' Regulatory Services Fee i M Richard V.Scali,Direct6 (� Building Division -----.--____-- — -._ ------Panl-Roma—Building.Commissio!gr6r2T-21�-- --------- 200 Main Street,Hyannis,MA 02601 www.town.barnstabl f RAMO� 1 A H N S A B . Office: 508-862-4038 I� ax. 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number �✓ Not Valid without Red X-Press It*rint I _I , l Property Address LCOSS LJ C,4 residential Value of Work$ 7!jdy Minimum fee of$35.00 for work under$6000.00 Owner's Name&Addresses. u- Contractor's Name A(pr,&" +- C,�> Telephone Number 0 Ey-2-)1. 2/3-10 Home Improvement Contractor License#(if applicable) (: ^' ' C)7 1 Email: l,H `kdly . c� c,� c�6�.nt-I Construction Supervisor's License#(if applicable) r_ U2./,, 0 -7 / ❑Workman's Compensation Insurance Check one: d v%- ❑ I am a sole proprietor ❑ I am the Homeowner ❑ 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(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 „3U (maximum.32)#of windows #of doors: _ *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: Q:\WPFMES\FORMS\building permit forms\EXPRESS.doc 01/25/17 I The CawmmnPwMt f Maza&u !9r D4wftff -tofrndwftdAcdJ ' 6007Pashin�&reet ,fj- �ctsin� 023 - --- -. ---—---- --- - w oemmmggaplaYi Warlmrs' Campensafim Inswmce Affidavit Eugde�Confrci W. aMecftk nsJF�bers armada _ Please Print Addle ✓�� CJPhMO — :v Are you an employer?Cheekthe appropriate bom ' Type of project(rejaire4- L❑ I am a employer w i 4. J ' km a general caufmctor artd I UCEM employees(fish andfor padt time: * bave hiredtire motors a ❑New oansEr 2.❑' I am a sole prcpZmtmr or - fisfed ontlie.attachad sheet` 7- ❑Remodeling �e sab-coatraci=hafie r' ma employees • �, Deanalifioa and have emp� ❑ g forme is emPloYees Mdhave Walker?,�o � Y- 9. 1Wding addition • [Nocamp. °� - 5- ❑ We are a=parafi=Md its 10[]Eledhical repairs or adds 3.❑ 1ama homeowner doing allyvac oflicm#raveexexcisedthem 1L❑Phmcbsagrepasmaraddiiiitms. Mysgf No wa Specs' - rig"of mr per h4GL rePairs c.M§In�webaveno LIE]Roof �o�-[No wall= � 13-El •day app&a¢ ,6-1�edsbaz API mast 0-m Ol outtbe swEmbgbw $iPkvm&eW=@mmi;nupcTc; ua . neaaho satam-aim ahey RMdain-Nn w aada mlize outside crat=:1Dsams;snbnutanewamdal6t i-H sacIi ZG I d�ec3c$ z6�nozstattsdu�asad�6onalshed sLnmingtben—of the 56-ram�4o-sxadstilemdcelbe;arnatthme hrve em9byees.MhEM&C tcfn Irm a nP1VY- ,theyan 94-Vide•9s--k-e aoatp.PGRU amnbm I arM all Slrrph��ar Scat ISgrvucrIirtg workers'cot�rtsrdian i�rsrzrarres�nr ms'ea�fn3�ess $dole is Y3aaprrficg�jab ssta €nformrrtfam IasmaaseC.onopa� e: ' Po-ficy 4 or^self--ins.Uci ¢ } pir iauDafe: Job Site Addressq Citp1Sb1wzip: At#z6 a copy dt]a workers'rompensationpolicy-decla atioa page((showing the porky nmmber and expiration date): Failure to semen coverage as requiredunder Section 25A of MCH m M can lased to the finpasifioa of cri-mai penalties of a fine up to$Ul}0:4U an&or one-gearimpris=ment as wet as civil peualEitrs n 1he form of a STOP WORK OEDERand affm of up to$2fADO a dap against the violakr. Be advised Matz copy of this sb1emed=aybe forvrarded tie the Office of kwft igaff=ofttne DIA for iw'.g=ca coverage ve am w Frl'o hwaby cerl RAdderr�tka pTirzs andponabw ofFPrjsey'�atflre aforraatraugrotuW a€>mw is tray and earred - Dom: 7 7 Plane 9: 7 7 G 2 07(J t? r��rf� Da uat write�t flifs�a��5e cmr<gTete�bF crfp artQ�4zt City or Ta-%= PermilffA-eme 4 Issuing Attr0mrafy,(dmTe one): L Board of Hmltb Ml BuWmg Deparftaeat 3. ufm Cl k 4 Electrical Ikspertar 5.Plumbing Inspector 6.User Coo act P'emonc Phone P: 6_ ormatioxa an (I Instruefions . M6Mn Ge�I Laws eh�M rues all m prUvide fortheir e mpl - P'msmmttD-this sty,an emqrkTw is deed service of mwffi r vndI--r say CMtMd af7i=t;, express or impfie4'oral or Wh=a_" All eIIWT17 r is ddmed as` a fiUEV I,per =a= a�rpotatton ur ofha Iegal e y,or�Y two or mate of fizc f=going is l jObt eftrpdscti.Bndm4"rT- the legal rep=MdE fives Of EL dEceased wmployer,or f c tM or trustee of an imp paztamship=asociai=or o$zearIegal edify,employing MMPlDYe--- However fze own=of a dwrDEEgX r��gnot more i3�i3�ree apmimet�aadvYho tides$�r�,or ffie o ofthe- dweMug hD-W O of muffior who employs pessms to do ni ce,C=*ar�'an or repair wo$c as s=h dwelFmg house or on.f3.0 gM=& or boMmg q?Mtnttf=cb shzRnotb=2=of such=pmymeaxtbe deemedto be an czoploym" MGL d3spt=-152.p5C(6)also states ffist"eve3rysbEto.or Ioca.I!M1'sEa agency Sian wiffiRold fze iss =Ct--or r m ew2l of a ficcase or permit to operafe a bvsiaess or to constrict bmlUngs is the coazraonve2l$for=T apFlicaaf�ho has notprodttred acceptable evidences of cdmpU.=mwn iim i mia-za r-overageregasefff Aaffi•rf;nr ,albr,MCrL chaptm I.5Z,§25(M states-Neithafhe _ nor airy of its poI>fical snbcTxvisicros shall erg into an frstbcp�w ofpnblin woticunzbl affable evideacs;of campii�n cewith the msor . . n.=f-of-this rhapfthavel een.prese3h�db ffic cortacting.authazitY- Applicants ' Please f of o:ot the VD k=.compensation affidavit compIdely=by d=cWmg the boys that apply to Your staBf on and,if n Y,sapj ` n=e(s). d es)andphaw=:=ber(s)sIongwttb � s)o�tbanfze Lirr i I iabffity Comparaes(LLq or I muted Liabl7itp'P (LU)' mom,=or pmtness�ate nottbqCa-Cd tD=Y wori=& ensafirm ice- If an LLC or I.LP does have rd�IoYees,a policy s regoaed. B e advimdihdtbs affids:ykmaybe sabmittt-,d fn fire Dq=tMest of hldnS iial Aacidect;for comfmation of firm a coverages ATsa be sore in sign and datE ate Tba affidavit should bmTvb=cdto-&o diyOrtD-vmffiatthD appHcafim fx3f fle,peadt or lia=e,is bcimg=qncstA nottheDepatme:ofof hAastxwl A..cmd=tL Shonldyou havo MY qnM troos regatag fie Inv or ifyou sre regained tD obtadm a wo3i=' compens�onp9TeY,pleasecaaf=DepartmentatthennmbrdlistedbeiI�ow- Self-iMurdermrpaniesshovld�dfhek self-in= n cc Hc®se mCMObM on Hie IBM. City or TOW IL Ofacials _ f Please be sore ijzat tiie affidavit is cotaple��dp�dlegibIy. The:Depatimmthas provicled a sparse at fzc bottom . offie affidav fin Put[)fill ottt inthe event the Office ofEgesfii�ons has to cOzd c Yoategarfttbe agplicaat_ Please be sore in fillies the pamt/Iioeose mnnber whichwM be used as a r nmmbet:In adEion,aa.eppHcm t fiat must subIait multiple p=UVH=1 a gTh,�Ed=in any given y�n��Y saI>mrt rme affidav�indicating cmz�t policy information.[�f neces�y)and wader"Tob�A2&mse$ze appHcaat should write aaII Iocaiao p o (edy or thz town)_"A copy of the-affidavitfzat has beat officia Y s upped or marlmd by&o city or town m ay be provided to applicant as proof tbd a valid affidavit is on file far f nfnre'pcmj!s or Iieeoses. A nCRT af5l&&East be fMCd obt Cann year.V7hem a home award or cdi=a s obt ECming a Emnm or pemit not relatod in atiy bu7smess or,y,,,,rn, y=tmm - Cie.a clog license orpctmit to br®.leavcs a c.)said peEson is DTOT requimd to cc�plete 1is affidavit The Office of Tnvestigwi s wouIdlzke to thank poain advance far your coope ion Had sbovldyc�u have�Y g am= please do not hesitain to give vs a call The Depar�s address,tlephrme and;&x=mA er: WME Of&R=Zb-nSeM - Dfinetuf�A ' . . Bmtw. Oil II Tf-L 4 617- -49W iz�±4-06 or 1-4 ILAS.fi� Fax#617` 27-' Rcvised¢24-07 mae,,c� Zr t Town of Barnstable " ✓Regulatory Services dF Richard V.Scal4 Director Building Division r AA M = Paul Roma,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: ! i JOB LOCATION: _� •/ 5 :.� r_ , „ number streex village "HOMEOWNER": -D,AA1 i- name 3 home phone# work phone# CURRENT MA WO ADDRESS: S /G,4cl, oJe,, cityAown 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 proc ures and requirements and that he/she will comply with said procedures and requirements. Signiqiii6fT4omcoivncr 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 this issue is a form currently used"by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFU-ES\FORMS\building permit fonnsEURESSADO 06/20/16 ToWn of Barnstable ` Regulatory Services NAM . ' Richard V.Scan,Director. Building Division. Paul Roma,Building Commissioner 200 Mau Street,Hyammis,MA 02601 www.town.barnstable.mans Office: 50M624038 Fax: 50&790-6230 Property Owner Must Complete and Sign This Section If Using A Builder. L ,as Owner of the subject property hereby authorize tD act on my behaK in all matters relative to work authorized by this building permit application for: (Address of Job) ** applicant Pools i Pool fences and alarms are the responsibility of the a cant P tY PP are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date QYORM S.OWNERPERWSSIOlewis �. � • TES cERnFlCA CERTIFICATE CERTIFICATE IS ISSUED AS A OF L IA g 1 L I TY BELOW. T�S�ERTIFICATEAll IT Fp�FNjA71VELyEOR NE AO INgURANC RMLY Al ONLY AND CONFERS E TE REPRESENTATIVE OR PRODUCER NSUR,q�iCE DOES VELY AIVIEND� NO RICH °q (nan�aYy�y) t ORTAWT Nthe Ce ,AND 7}II,CERTll NOT CONS7ITUiE A C UPOGTME 7/26/1 teens and COnditio rt�ficate holder Is an OR��R THE CAVE OVERAGE AFFORDED HOLDER THIS certificate holder i 101the policy, an ADDInpN,gL iNSUR�ER. CONTRACT BETWEEN THE ISS THE P PRODUCE n lieu of such endorsCertain policies rr>a re ED' the policy(? . UING INSURER($ OUCIES Schlegel & Sc errtent{s). Y 9uire an endorsement A Staten)endorsed• If SUBROG )' Al►THOWZED 34 hlegelent on this certifipte d ON IS W,41VED,subject to Main Street Ins Broker coN Acr does not confer rights West mouth PNO E ITIM HIIVll to the Ya MAN MA 02673 508 o Ess: 771-838.1 FAX INSURED--------__ SChlegelinsur No: (sob) 771_0 66 3--- �j �.� `'�--------____ +NsuRE ance@4�nail.com R-TMARD H GARDIVER ``-- - INSURER A: s AFFORDING COVERAGE ^_ PHEONI X MUTU GARDNER INSURER B TRA p'I' _ NAIC# 92 E VELERS INSURER C: MASHP PLACE WAY r MA 02649- INSURERD. _ COVERAGES 2725 INSURER.€; --- _THIS IS TO CERTIFY THAT CERTIFICATE INWRER F: -------- INDICATED• THE POLICIES OF INS NUMBER; 11 NOTWITHSTANDING ANY REQUIREMEM TE US7ED BELOW HAVE B CERTIFICATE MAY BE ISSUED OR REVISION NUMBER: EXCLUSIONS AND MAY P ERM OR CONDITION EEN ISSUED TO THE INS IIdsR CONgTIONS p ERTAIN, THE INfVI�� OF ANY CONr �+ INSURED NAMED ABOVEP�Ivc —_ OF SUCH POLICIES_LIMITS$�yOVCE AFFORDED BY TI-IL p1 i SOR OT►-IER DOCUMery-r WITH Type OF INSURANCE -AODL SUER `---------._ Y HAVE BEEN REDUCED BIES D SCRIBED HEREIN IS SUB ECT RESPECT TO W!-(ICF(THIS A GENERAL LIABILITY I� CLAIMS. O ALL THE POLICY NUMBER POLICY EFF POLICY- -- - ------.------_ _- O TERMS, x�COM ERCIAL GE CPP0709341 I MM/Dp/Y MMlpplym `'—"— NE 8/20/16 f a/zo/17 LIMITS _ CLAIMS-MADE OCCUR DANIAGCCURRENCE 1 -� MI¢EToRENTED $ - 0_�OO I ME D EJ(P(Anyone person) 000$ - 1 PERSONAL&ADV INJURY 5.000 GENTAGGREGATELIMITAPPLIES PER $ 1 000 000 4 POLICY PRO- GENERAL AGGREGATE $ 2 000 OOO I i 3 T LOC PRODUCTS-COMP/OP AG AUTOMOBILELIABWTY G $ 2 000, 00 CEO SINGL LIMIT ANYAUTO accident I$ AUTOS ALOWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS !_ HIRED AUTOS NON-OWNED BODILY INJURY(Per accident) $ AUTOS PROPERTY DAMAGE Peraocident $ UMBRELLA LIAB OCCUR 1$ EXCESS LIAB EACH OCCURRENCE $ CLAIMS-MADE a Dm RETENTION$ AGGREGATE $ E3 AND EMPSCOMPEUABILIN WC-0179798 6/3/17 6/3/18YIN wcSTATu- OTH-ANY $ AND EMPLOYERS'LIABILITY 0 ICERNEMB RR EXCLUDED?E�� NIA E.L.EACH ACQDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EIO1PLOVEE $ 100,000 :IfzYas,describe under DESCRIPTION CF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 g ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Rermrks Schedule,if more space is required) IJCHARD 'GAEZDNER HAS ELECTED NOT TO BE COVERED UNDER HIS CURRENT WORKERS COMP POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICI •BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, N WILL BE DELIVERED IN TOWN OF BARNSTABLE ACC"WITH THE POLICY P ISIONS. IN HAND, AUTH RIZE SENTATNE r l © 8.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD r—:1. , .. �e �Parn�yzarxcuealC�t a�C�/G�aac/t�??,tti r . Office of Consumer Affairs&'Business Regulation jgttation HOME IMPROVEMENT CONTRACTOR valid for individual usa only Type: Corporation (ieioi ethe expiration date..if found'return to , Rggistration Ex iratio. Offoe of Consumer Affairs and Business Regula$bn .F8 10/1 I 1.O 0-182 Park Plaza Suite 517 I Boston;MA 02116 Mogan and.Co'Mipa 'vV-In Francis Mogari:Jr < ^`== 63 Joyce Ann RYdCenterville,VA 0N32 _ Undersecretary i1b without si6nature 1 Massachusetts Department of Public Safety Board of Building Regulations and Standard-- License: CS-026071 Construction Supervisor ' FRANCIS E MOGAI . 63 JOYCE ANN RD `CENTERVILLE MA 026 'SI 1, \ CA Expiration:, Commissioner 10/03/2017 - i w Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: VWVW.MASS.GOV/DPS i r _21 -.1 P1 . Town of Barnstable *Permit# Tt1E Expires 6 months from issue date Regulatory Services Fee a +�MASS.. Thomas F.Geiler,Director `sp� PERMIT Building Division Tom Perry,CBO, Building Commissioner MAY 12 2013. 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma us Office: 508-862-4038 TOWN. OF - 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ® �y ProP e Address CROSS (Residential Value of Work �� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address W2.S 'C\e-euktoxc�y CU16 WAY Q5J 5T *�YIWPK ?QC Contractor's Name "'" w 01 0 —Y—telephone Number '8 2A 2 `�S" 0"� / 'sense# if applicable)_ ` ' �° 19 Home Improvement Contractor Li ( app ) Construction Supervisor's License#(if applicable) �S Cq S 5- 6 Dorkman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Namel Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Re est(check box) � `Q�15 i I LIDS Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ypv� ❑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 ❑ 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: fn,. XrV"PRFCS dnc . } Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-093566 ARMINAS DID& 7�, 17 PATIENCELN COTUIT MA 02635 i Expiration Commissioner 02/20/2014 `' /ea„�,Zo Lcaec��r/d�� �cuoccc/ccae - License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR V�xegistration: 169601 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 piration: ,:10l29/2014 Private Corporation Boston MA 02116+ ! QUALITY WOODWORKS INC ARMINAS DIMSA d C 17 PATIENCE LN _ a G.OTUIT, MA 02635 Undersecretary ' o valid without signature BARNSTARM TAAWL Town of Barnstable ' Regulatory Services 'Thomas F.Geiler,Director Building Division Thomas Perry,CBO _ Building Commissioner 260 Main Street,•Hyannis,,MA 02601 www:town.barnstable.ma.us Office: 508-862-4038 ,y Fax: 508-700-6230 Property Prop a Owner Must 'Complete and Sign This Section ' r IfUsing A Builder s I T 1T , +"r I"M 6140 k ,as Owner of the subject property hereby authorize V Q/1� �yO to act on my behalf, F; in all matters relative to work authorized by this building permit application for: (: C.r0_TX . �>✓-s' , Glen�1' 0 r f (Address of Job) _ r SigAae of Owner s - Date es 4e Print k4ne If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side., • I , r i C:\Users\decollik\AppData\Local\MicrosoMWindows\Temporary IntemetFiles\ContentOutlook\QRE6ZUBN\EXPRFSS.doc - Revised 053012 ' ■ The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: « City/State/Zip: CQ—N 1 tit- Phone Are you an employer?Check the appropriate b : Type of project(required): 1.El am a employer with 4. lam a general contractor and I employees(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. 7. ❑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. 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.j Roof repairs 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. $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. 1� p r.,,, Insurance Company Name: AL V Fs V *14eQ S.iNC Y Policy#or Self-ins.Lic.#: WC 5" 3 6�6g 0-063 Expiration Date: Job Site Address: �C+ C��SS " 60 IPA 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 certifyder the pains d allies of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town officiat 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 morethan 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,empfoyment 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'arid 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 r 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. Boston,MA 0211.1 Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia lid CERTIFICATE OF LIABILITY INS � URANCE 112412013 THIS CERTIFICATE IS ISSUED AS A MATTER.OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS ^.ERTIFICATE 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 poncy(les)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 Aeu of such endorseme s. f PRODUCER ALD INSURANCE AGENCY INC 60A BRIGHTON AVENUE coNracT NAME: pUKHON ALLSTON,MA 02134 PHONE No i ` - 64WL ADDRESS: i < INSURER AFFORDING COVERAGE' NAICp INSURER A I LIBERTY MUTUAL INSURANCEj INBELCAPE CONSTRUCTION LLC INSURER 13: I 42 WOODBURY AVENUE " iNSURERC + i HYANNIS MA 02601 INSURER 13. - „ INSURER E: _ f INSURER F: - COVERAGES CERTIFICATE NUMBER: 15321175 REVISION NUMBER: THIS IS TO CERTIFY THAT.THE POLICIES OF INSURANCE LISTED BELOW HAV E BEEN ISSUED TO THE INS URED NAMED ED NA 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. e ,L SR TYPE OF INSURANCE ADD'SULn _ - POLICY EFF POLICY-- POUCYNUMBER GENERALLIABIL.ITY EACH OCCURRENCE $ j pppp�7 ; COMMERCIAL GENERAL LIABILITY ' PREMISES aOC se $ CLAIMS-MADEEl OCCUR t i MED EXP(Any one person - $ . b PERSONAL 8 ADV INJURY $ GENERALAGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 8 r POLICY PRO- LOC. ' $ ? AUTOMOBILE LraerLtrr OMBIN D LE OMIT ANY AUTO • BODILY INJURY(Per person) $ ALL OWNED H SCHEDULED AUTOS AUTOS BODILY INJURY(Per dexIderd) $FIRED AUTOSNON-OWNED r AUTOS r PROacc,denPERTY GE $ UsgEBRELLA LIAR OCCUR EACH OCCURRENCE S ERCESS LJAB _ CLAIMS-MADE AGGREGATE ,e g DEO RETENTION$ i ,q WORKERS COMPENSATION wesrArU WC531S-363fi80-083 W13I2013 111=01.4' AND EMPLOYERS'LIABILITY YIN TORY UMrr # ANY r`RCFR�TOR/PARTNERA"�`(ECUTIYE E.L.EACH ACCIDENT $ - 100000 OFFiCERMIEMBER EXCLUDED? FNN NIA `c (Mandatory In NH)If yea,desmbe under E.L DISEASE-EA EMPLOY S 10000 x DESCRIPTION OF OPERATIONS Below • E.L.DISEASE-POLICY LIMIT $ .. 500000 DESCRIPTION OF OPERATIONS l LOCATIONS!VEHICLES Wbuh ACORD let,Additional Renfarks Schedale ff more space is required) .19 Workers Compensation insurance coverage applies only to the workers cornpensation laws of the state of MA" CERTIFICATE HOLDER C NCELLATION i Quality Woodworks Inc r SHOULD ANY OF T14E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE r THE EXPIRATION DATE THEREOF, NOME WILL^ BE DELIVERED IN ACCORDANCE MATH THE POLICY PROVISIONS Arminas Dimsa 17 Patience Ln '...w AUTHORIZED REPRESENTATIVE Cotuit,MA 02635 f� .Jeff Eldrid e • 01988-2010 ACORD CORPORATION.; All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i �is°cerlii'Ficate°Dcan oeTse and s2Weoise ii3es'lM'p8DIev3-of issued certificates r i. i Assessor's office(1st Fbor): a r �� Assessor's map and-lot,numb J THE T /� y SEPT,EPC o o� Conservation / INSTALLE® Board-of Health rd floor): '-Sewage Permit number w�TH TSul �_ N1/1RON�ENTi�L :... Engineering Department(3rd floor): / FJs TO �E�U House number • C� 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 ( (-V-X0I>ta-r— Z--Ic,Z� , a�c �lwz``ram c t C,<<i("A�'I1^� TYPE OF CONSTRUCTION ��9 - z�,�•�� Y 19 -9 L — TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 9-Le L%EUSS S+ .,� ; Proposed Use i Zoning District ' ` Fire District 1ti1i�r \ Name of Owner s rn..t tiC v�G. `4L Address �L� �i,w.�,., ��t 1�u��zM 1Mt�"" C,"ZI IL Name of Builder Address /4.K*'o- -`'-Z� Name of Architect al ��..5 1 Address Number of Rooms A Al,rouyws 4y�.\ Foundation N.Uv�,C-y-c_.t-c Exterior C e �� °''` Roofing r�S:J�c. �� Floors 2 Interior Heating Plumbing v S�0,-V Fireplace i Approximate Cost Area SS Diagram of Lot and Building with Dimensions Fee r ; uc,� 4 u5 l r - 3' 1 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regar ing the above construction. Name Construction Supervisor's License G Q 7 / MYKRANTZ, DON No 34953 Permit For ADDITION & RENOVATION Single Family Dwelling J � I ?/Vi4t- - Location '� Cross &t-peet 'rs Hyannis '# Owner Don Mykrantz Type of Construction Frame Plot Lot Permit Granted April 9 19 92 , _ f Date of Inspection 19 Date Completed 19 r i - kz- 1 - ,t _` .. `. '• . III COMMONWEALTH DEPARTMENT OF PUBUC SAFETY OF. 1010 COMMONWEALTH AVE. MASSACHUSETTS . BOSTON,MASS.02215 ; I ENCLOSE CHECK OR MONEY ORDER. LICENSE . + FOR REQUIRED FEE, EXPIRATION DATE � CO�3STR. SUPERVISOR ; . 06/30/199.3 MADE PAYABLE TO RESTRICTIONS EFFECTIVE DATE LIC NO. ,V. NONE 06/30/1991 026071 "COMM( �F PUBLIC SAFETY" FRAPiCIS € lOGA3V `(DO NOT SEND CASH). .16 COVE- ISLAND RD C tNT ERV I LLE MA 02632 PiIIEAS E li�l`E ;E lNCREAS.E • PHOTO(BLASTING OPR ONLY) I FEE: 100.00 E 1.EC_TIVE -RA, 1989 HEIGHT: NOT VALID UNTIL SIGNED RY LICENSEE AND OFFICIALLY STAMPED -OR -SIGNATURE OF THE COMMISSIONER - I' ' t G y.✓ DQI, NOT DETACH .LICENSE STUF THIS DOCUMENT MUST SE � SIGN NAME IN FULL-ABOVE SIGNATURE LINE CARRIED ON THE PERSON OF t' SIGNATURE F LICENSEE .THE'HOLOFR WHFN FVI;e(: - r^'��;°. .r, :.. ....�,.�-;�;t.-x^. {FF" -' 'a-+ '4.ggmpp- R .. ..,x+. ^,, c_r�q.�...,f ._ -v. .. s.' _ ,: -.. .+,.x`!�.., ..: . -4r,>+. 'i! \.. - .. �cf . ,�x� ,:.. . - �, .�,�. ?.w- -•.. -:�.__ - :•�.x .�� -�+:'�s`�4��Y.^ ram. ;r;_ � �:x p �,, '�a s• ,. ».;� x-- -F3'....., 'r,*r ti -+.w .. ..,_� ',.7�,,' a .«; y:na nE',¢•- ,ski.u--..r rs ,+-v+"�«'„:�ti;s:. w +.�-.�•' .»o-�' tir..•i�'• t � w y-„r,,, „ ,,,'•. ���uu 4 .x•-- .�<.u1S" / cr .t ._r'.-`�K - _1:.*. 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