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0077 DUNN'S POND ROAD
����unns Pond. �o�_. -- I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parc ,. Application # C)o 0 �� Health Division Date Issued �0-Z`S Pic Conservation Division Application Fee V �g r Planning Dept. Permit Fee r Date Definitive Plan Approved by Planning Board ? Historic - OKH _ Preservation/ Hyannis Project Street Address ( 2 Lou,0,� V ©A3 Y Q Village Owner �\ v Address '-,JC)M N,S :R0Xa VD c ^Telephone o VG' _ ljps-m f C ex P#rm Requ S Z- `D�®` 1�, `"c��P Yj �. �( Square feet: 1 st fldo�xistin��r6;osed 2nd floor: existing proposed Total new Zoning District Flood Plain NO Groundwater Overlay Project Valuation b �70 Construction Type aGadUt Lot Size Grandfathered: ❑Yes If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes t No On Old Kind's Highways ❑Yet 9-No Basement Type: JFull ❑ Crawl ❑Walkout ❑ Other { Basement Finished Area (sq.ft.) Basement Unfinished Area (sq:ft) v�` Number of Baths: Full: existing new Half: existing 612 AJ Ad Number of Bedrooms existin new Total Room Count (not including baths): existing (renew lL First Floor Room Count Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other TTT Central Air: ❑Yes 41N�p Fireplaces: Existing New �! � Existing wood/coal stove: ❑Yes 211�ko Detached garage: t r ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ G' Attached garage: ❑ sing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes If yes, site plan review# Current Use -'+� ; -- = �c�:r� -_ ._.. Proposed-Use =-�,��-- APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 6Lilli AI&MTelephone Number'CO 9�7J 7Z Address (d6 , License # MA-- 9' b `� Home Improvement Contractor# Worker's Compensation # z� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PR ECT WILL BE TAKEN TO .D SIGNATURE DATE / a r y FOR OFFICIAL USE ONLY APPLrCATION# DATE ISSUED F MAP/PARCEL NO. •r ADDRESS VILLAGE OWNER ♦F F y DATE OF INSPECTION: r ,YFOUNDATI.ONa�sr�� FRAME t INSULATION.ri R;imA-i i�. i ua—, �+ FIREPLACE ELECTRICAL: ROUGH FINAL i PLUMBING: ROUGH FINAL'' r GAS: ROUGH FINAL FINAL BUILDING" DATE CLOSED OUT ASSOCIATION PLAN NO. - The Commonwealth of Uassachuseffs n. Deparftmmt o•f`'IYdms Accidents y , - Q05ce o f`Invesagalions , 600 Washington Street Boston,M4 02111 -'� rvnnv.T��ass:got�dir� Workers' Cnmpensation Insurance.Affiidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly " Name{Busmens/O gsnization/Indhidua0_ l Address: 2-1 CitylStatrlZip-- �r 4 Phone 47 . Are you an employer?Check the a pmpriate box; Type of o'ect r uire 4_,�am s contractor and Z e J (cam �_ 1_❑ I am a employer with 6_ ❑New scfion employees(full and/or pact-time)* have hired the sub-comkractors. . 1❑ I am a sole proprietor or partner- listed on the attached sheet 7_-❑Remodeling T These sub-oontractors have ship and have no employees 8_ ❑Demolition a w for me many capacity employees and have workers' y � t3 . g_ ❑Building addition [No workers' comp_inv a comp_insurance_I required-] 5_ ❑.We are a corporation and its 10_❑Electrical repairs or additions 3_❑ I am a homeowner doing all word-,. officers have exercised their 11_0 Plumbing repairs or additions myself [No workers'comp. right of e2D=ption per MGL§152 12_.❑Roof insurance require$_]F c_ , 14,and we have no� }employees-[No worker 13_❑ s' Other comp insurance requlred_j *tlrcy appf t that checks boa#1 must also fill out the section below showing diet`woAars'roaapensatiou policy mfursmitori �H who subunit this atIdXwt MdicstMg th"are doing all wodk sad then hire outside coniractars psi submit a m w afdwh mthca�n=such .00mneowners tractors that check this book must attached an addittnosl sheet showing the name of fhe s*-cm&3cftws and state whether or not those euddes have. zWloyees. Ifthe strl-<ontmacts have employees,they must provide their workers'comp.policy number. I am art employer that is providing workers'conTemvation irm4rauce for r►ty Rmp[p),?&s Ilefvty is the po c}and,}ob site infot'matlofL Insurance Company Name: Policy 9 or Self-ins-Luc-#: Expiration bate. k Job Site Address: City/State/Zip: r Attach a ropy of the workers'compensation polies declaration page(showixtg the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c_ 152 can lead to the imposition of criminal penalties of a' fine up to$1,500.OD and/or one-yeuinipttYsonment,as well as civil penalties in the frnm of a STOP WORK ORDERand a fine of up to$250.00 a day against the violator_ Be advised that a copy of this statement maybe forwarded to the Office of ImTestigations of the DIA for insurance coverage verification I do Ftereby cr?rti u. tlts l" s erldpon s ofpetjury that the intformatian pranded abm is fnw�nld cor rect Signature: Date: LJ � { ,. Phone rOffEtial use o1,111,i7 Do-trottrrite M tIds area,to&s-campleted—iy city at-tmsmU-j—JIL.iat "x City or,Town:.. PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Binding Department 3.CityfFown Clerk 41.Electrical Inspector S.Plumbing Imspector 6.Other Contgct Person: Phone#r 6 , Information and Instructions _ Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 Iegal 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 Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth,`.or 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 perfo_-T-mance 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 LL-10 does have employees,a policy is required.. Be advised that this affidavit may be submitted to the Department of lndusiTial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit g7ie affidavit should be returned to the city or town that the application for the permit or license is being requested,not the D,:parbn.ent 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. Sell insured companies should enter their self-in=nce 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 nll 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 ad.d don,an applicant that must submit multiple perm.it/licease applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidas-it. 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; `Fhe CommonweaTf of Massachusttks ' Department of Industdal Accide:n Wke of kvesfigatioas 600 WasMngtaa Stet Boston=IAA 02111 Tel.9 617-727-4,00 W 4-06 or I-977-MAS B Revised 4-24-07 Fax# 617-727-7749 virww,mass-gov/dia i ,a�oRos. CERTIFICATE OF LIABILITY INSURANCE DATE (MM'°'° 1a17/2Io141a 1T611S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE R.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. IMIPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(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 ceirtificate holder in lieu of such endorsement(s). PRODUCER Phone: (508)888-0207 Fax: (508)888-0550 CONTACT Elizabeth F DeMQlO ALAVIEIDA&CARLSON INSURANCE AGENCY INC. N"ME: PHONE — P.OI.BOX 719 A/c�o (508)888-0207 aC No: (508)888-O.1 E-MAIL edemelo@almeidacarlson.com SANDWICH MA 02563 ADDREss: INSURERS)AFFORDING COVERAGE NAIC# INSURER : Arbella Protection Ins Co INSURED HARNEY CONCRETE FORMS,INC INSURER B : HARTFORD CAS INS CO 294�4 C/Ot MARK HARNEY r INSURER C 161 WHITE MOSS DRIVE MARSTON MILLS MA 02648 INSURERD: INSURER E , INSURER F COVERAGES CERTIFICATE NUMBER: 28691 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. TYPE OF INSURANCE ADO'L SUER - POLICY EFF POLICY EXP �7H I' wSR wvo- _POLICY NUMBER. @IwoomY� MWgD/vYVY) LIMITS f - A ;GENERAL uaBILITv 8500043146 05/19/14 05/19/15 EACH OCCURRENCE $ 500,000 I, X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1001000 F—vl PREMISES.(Ea occur ence) _- $_ —..—._ CLAIMS-MADE I IOCCUA MED.EXP(Any one person) $ 5,000 - PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1I,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:PRO PRODUCTS-COMP/OP AGG $ 11,000,000 POLICY LOC JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - -- (Ea accident) $ ANY AUTO BODILY INJURY Per person), $ ALL OWNED —SCHEDULED ( P ) _AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTYOAMkGE -- — AUTOS $ " Per accident) - UMBRELLA uAaH OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ ---— IDED I IRETENTION$ $ B 'WORKERS COMPENSATION 08WECC�G5518 08/08/14 O8/OS/15 WC STATU- —OTH .AND EMPLOYERS' LIABILITY TORY LIMITS I:, ER $ ' ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N _ (OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $. , 500,000 QMandatory in NH) N/A Lf yes, E.L.DISEASE-EA EMPLOYEE $ , SOO,000 - _ DESCRIPTI PTIa under ON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 50O,000 — -- DESCIRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE (Cape Cod Remodeling,LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN IPO BOX 2416 ACCORDANCE WITH THE POLICY PROVISIONS. Wlashpee,MA O2sa9 AUTHORIZED REPRESENTATIVE —— — Attention: rtave. �0✓_.4 ry@outlook.com Elizabeth F DeMelo ACORD 25(2010/05) r° ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �IMME rqf� Town of Barnstable ' Regulatory Services EARNSTABLE Mass. Richard V.Scali,Director 1639.�a�O� 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 I as Owner of the subject property J P P riY hereby authorize A5�� to act on my.behalf, in all matters relative to work authorized by this Idding permit application for. -77 (Address of Job) Pool fences andxalanns 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 Signature of Applicant 'Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS , Town of Barnstable Regulatory Services . ��oFe Tolryy Richard V.Scali,Director _ Building Division snarrsraBM * Tom Per Building Commissioner ry, g ��� 200 Main Street, Hyannis,MA 02601 prFD MA't A www.town.barnstablema.us Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION _ Please Print DATE: JOB LOCATION: number street village /f "HOMEOWNER": name home phone# work phone#` CURRENT MAILING ADDRESS: / city/town state zip code The current exemption for"homeowners"was extended to include owner-occn ip ed dwe �s of six units or less and to allow homeowners to engage an individual for hire w o does not possess a license, rovided at the owner acts as su ervisor. DEFINMON OF HOMEOWNER Person(s)who owns a parcel of land on which he he resides or intends to reside, which there is,or is intended to be,a one or two- family dwelling, attached or detached structures ac essory to such use and/or f structures. A person who constructs more than one home in a two-year period shall not be considered a omeowner. Such"home wner" shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall res onsible for all s work erformed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility fo complian with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understan the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply wi d procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings con g 35,000 cubic feet or ger will be required to comply with the State Building Code Section 127.0 Construction Control. v HOMEOWNER'S EXE TION The Code states that: "Any hom owner performing work for hick-a building permit is required shall be exempt from the provisions of this section(Sec ' n 109.1.1-Licensing of cons ction Supervisors); provided that if the homeowner engages a person(s)for hire to do such ork,that such Homeowner sha act as supervisor." Many homeowners who use is exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulati s for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, partic arty when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed pe son as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the home caner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeo . ner 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 for Y p m/certification for use in your community. Q:\WPFII.ES\FORMS\building permit forms\EXPRESS.doc Revised 061313 Mass aC 1Ga8_ a -.nelJai li Y=! Ji dub S a..,;e -Board at Building Regularl'ols and Sianldan.s F {.U11stI'Uiglll7 Sllpc'1'1'Isot' �. � ': .` ice se: CS-084771 RICHARD T AVERY` `Y PO BOX 2416 Ar Mashpee MA 02649 ; mi I?.S 3 0 Z? 01/15/2015 R�f�.r!'^•llnyl�ic�r��r�(! s Officeof Consumer Affairs&Business Regulation License or registration valid for individul use only ' OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: I} ,Registration: 178816 Type: Office of Consumer Affairs and Business Regulation Explratlon: 5/22/2016 LLC 10 Park Plaza-Suite 5170 CAPE COD REMODELING,LLC Boston,MA 02116 RICHARD AVERY /' z 39 FOUNTAIN ST MASSHPEE,MA 02649 Undersecretary Not valid without signature • t a 77 �vor4r, Cape Cod Remodeling,'LLC. Contract ' Contract Made as of the 7th day of September in the year of 2014 BETWEEN the Owners: Thomas J Ruhan 77 Dunn's Pond Road Hyannis,MA 02601 Map 240 Parcel 098 And the contractor: Richard Avery, Cape Cod Remodeling LLC ' t c) ; L PO Box 2416 . . - 206-27 Market St., Mashpee Commons n •Mashpee,MA 02649 508 958 7373 (cell) MA HIC#: 178816 Expires 5/22/2016 CS#: 084771 Expires: 01/15/2015 a Email: ravery@outlook.com The Contract work is: Contract work is to be performed at 77 Dunn's Pond Road, Hyannis, MA Consists of the following: ` Remodel existing exterior and interior of this Cape style house and install a new 3BR; septic system. Remodel the home to remove the door on the bedroom at the top of the stairs to change the house to a 3 bedroom house. Install a door on the other upstairs BR and bath. Complete`the sheet rocking on the upstairs ceiling. Replace the kitchen cabinets and countertop. Replace the bath fixtures. Repair the step to the ground for the front and back doors. Replace the bulkhead. ` r , 1.1 Owner. Owner agrees to make the payments as work is approved: 2.1 The date of commencement for this contract is September 15. This is the date from which the Agreement Time of Paragraph 2.2 is measured, and shall be the date,of this Agreement, as first written above. 2.2 The Contractor shall complete the entire project by December 19,2014, subject to adjustments made to the date of completion in any Changed Order agreed to by all ; parties to this contract. -A 2.3 Assignment of responsibility for this work contract to the Contractor, Richard. Avery. The owner(s)warrants to the Contractor that they agree to assign Contractor sole responsibility for and control over construction means,method,technique, sequence and x, Cape Cod Remodeling, LLC. Contracts 6.2 Other documents, if any, forming part of the Contract Documents are as follows: (List of any additional documents which are intended to form part of,the Contract Documents). o other documents are part of this contract. ARTICLE 7 Approvals ,— -9 .. . - Date ✓ Thomas'TR -'; - . •�jj:' ; ; , Signature Date fC ' Richard Avery, Cape Cod Remodeling,LLG- 4 . ; �.I*,4�-�,�.1--_--�-�-=I-I--�-��-:I-iI.II:.��:..a.1.'-.I�.;.I�-.�.�I-I��,.I�-"I 9-�-.wII---.�.--I�:-I%-.I.11...1 III�..--...-.'.-I 1�-.1-,�I.��,�..-...�I,-I-."1I.-.�I-;1-_.,.1 I1--.�-I 94I..,.��9.I:..-,I�.,..1.I'�II.:,....,.,.,..19.....�.II..�.�-I�....I1�,'9 I-.I1 I 1:I..L�I.�:,.I.-�.1��I�II.I-.I..-.II,.....-.-1 I_..I.II.1-I�.I.9.1�-�I1 1I I.,.I..-I.I,..�,-�II...1�I,_-I--I:.�I--...I�III 1..I-I I..---�,I II.m..-.--..I...�..�..-�I_.-4,I I�.-.,I-.,I.�II.�1.:...-I I.,.-%II.�..I....-�I._.I-%I-�I�I�9..�,I,I.1�...I=i.....�I..�I.--.I,.�--...I i-,.�.I�I.9-1.-.I II.I-�I�.I-�.I.I.I...qI.II�.�-,.WI-I.�.=.-,.---1.1.I,�I.-_::I 11.I;,..�.,;I.-I....I�1%,.IL..I......I....I-.,.I�.."...1-I...I....�-I��.:..9 I'.I-�I-I.1.-..I..�.q�.�1�.���..�.I.I.-.-..�I-.�I-I I"".1.I..I.I.;:..9I�-'...:-.9I-.:II�.I....",�,I,I.4 b,-�I Ii.C-�-�1�.I�..II I...-.�I,1.I.I.II I,I..�,...,-��9,.....--.,..,.I-:9.�...III,.I-�I-I I�.,�-�.--,.-,.:I�-�'--,1 I I,�--...�.I.��..-..I I.7....-��...9..7-�-r I.1�.-.I.-..II..-,.,.:.I1.A-I�-...�.,--.I...,.,7..,-..':....,.-...1...1,.,.I.�,..,..4;...:.�,-...I.III I-1..�.....9I�.,...-I.1 I--.-1�-.4...I...�I-...I.--,.1L:..,..�.9�I I.-.-I.I.,-.-.II.-9.I��.-...9:.-.I-.-�,I-I..-I I-��.I--:..--l�.q...'..---9.I.III pz,--'�I-I.-.�....-I�.�.-I I�1......I-:�..9;.�I.-I.%.�,.I1..�.,.�I��I-.I.9-..I--I-.I.I-.b91.I.9.I......--�.:�-I.-.-.l1.I.--�,..�..�-�...II,I...�I,.1.�...-.....I,I9,I..�I,�.-I.-.I.I:..-�..I,..�I,...-:.�I......I I.-I..-.-*,*,-II�.9.I��.I..-,.II-.....r.-...�1-.���.I�9,":..I.II:.h.,I-..�"....I,.-.I�:..`I-::1�...I,�..-.,-�1�.I.I1.,--�-..�I.-...-,...�1 I�...I.,....��I..,.��-.I�.�.-,�-...:....-:I I-..:-.�.1-....II..I-.,....-:II-.�...I�I-..9.1.I-,II.�.�.,.1:,.......�:I..,.,,�,1:-I�-�..I,,9�,.��9 I�.-..,-..I..:..9.-I..,..,II....;I z.�,--....I�,�I.,".-.I.-.1..-..I";,.:-��,-I�-I..,..�..I-.F..,.,,,..!.,.;�-�.�.I.'�..-.�.I,��..�,1 I,...�,��-..�.I I��....".7�I...-I:.1'�..�%�7,�.9p,,�.II.I�,.L..,.-..-1..,.'.,-...VI.�...:j.-...:,..�...--.I.I-i.....".,�..I,....;I�.,...:...I..,.,I�t�-,-.-�1��,�:.,..,--.,..,I,,z,I.%.,.�.1..-..I..I.iI..,:-..1 I.,1."-..-.I..1,i.-1.-.,..�...--I-�.�,,,.-.�;.�,..I,..-I,�.:,"�1..,.i..�-11I I..1..-1I:I��,I.��.,I1,�.I.I�.:-.�Z�.i.�..�-,",.1,I���'1....I.,�:�-.�.I.I;��:1-Z-,..1...:��,�.-:.,,.,..I.,..�iI,l-..��-,:I.�..",-,-�.,.,,.I��:�.l I.:Il.-I�..I�:..�1�.-,.i::..9 I 1:I 1�._I-,�-1....-..%�,.-..1.�I..-.-�.-:�..�..,..�,%.��-...,.,.I.:��.I,�..-.-..,.��,.I..I..-'.�;,::..�..1.�...�.,I.,I..�.-.,;-,.:��o�9..�...��.I.1��-..i-I;.,.,.'I.�:.��:�,.�It.�....�...,:..-.7.�...I�.:.---...I,..,-.I;..-.:.....�1,:I.,.",.-I�,.�:....I..-%1.,I-,-�,.II�I...�I.-:�..;�,�...,:...�%��.:'�I,:I,I,.I I-I.�.I,:.�.,..I1,��.,L...-i��:I:.::..,--.,�1 q..:�II1 I I...-:.�::I-I':,,�I..�l.�...�'-.��.-�..--..l.;.".�I,-.,...-.�'�-��::,.�I I:�.:-..�:..-I-,m�,I�':.:--..,..�'.I'�-I:.I.I...�..9.�..,.,.�,�.L.,�...��.�;.1t�.-�..-,,.�-,,..:.:.,-..�.-,.I:.�:..I l-�I.I ,,...I9.,..%%..�11:I I�.',,:.%I��,::I�-.,...���1,��:,-9�I�...,.,o:;I....�.!�I�..,....I I.,:��,.,�",I.�::i.,�,..".-.:'..I-,..I�.,......,,,.-.,d.:I.L:.:,.�,�1:N,,I.:....�,..---..I....:1'1.'I,,�-I.��A.-,�-r.,,,�.1.��...;�.".I�....-�,.:.,.�'1::.?�..%..:".�.�-II.I.--I.i..�!�1:1..-II�I19.,,,..,1: . .. . 3 ..�..!,--.,I:����,.:i..I.-:,..,�I,.�.�,:,L%,-I-I'1����I I,...,.-,*I I�;.1.....�,-.::�,I:....,�:--.I�.,I.,;;:.�:..W"..1:'9.;F-,�..I-�:-,,-:.,-�,-:.�"-�-��.�.,1:--,,I-.�i:.,,-.`.��.��,.�I�.-,:,,.�,I.-I..��-,--;..-.,-�-.,".�.*,I..;�I�.':,,I*�":'�..�N 1.1��i.��::.,�I-��-..�II..-,..-.II-�..4.,..�,:..f.�-0..�,.I.�;I:,�:,-.-�..-..--.,-,t.:.....-�I.;.1-.,".%%%...:,11:,.,�:,�,1:-..',,.I�...----�!,""...I.��-.�..�..t.I"�4..�,:.�,,�.,,.I,.�.1�.,,��.,I�II..,.I I-l��--%-,9 L!:..9,I�.'-.".-,.0,:-.-:�.,,,.I��-...�..%....f-'.-..:.�.-:I',�IL-�.:.-:�.-.::..�.4-It..�,���-�-,"I;..9'.:�,,...'�:.�I'..-,:,,..,�..-�,�I"i.�",�.1,A1�.'...I�'I.�.,,..:..�..,?."l 1:���."�1.,,.,1.,.,.1..j.�.�I-.,:.�..".-"�.0�;.���"!;!I...-���;.,I,'-:L:,�-�-.�,,,.�.:,�i T-I-�`-�I�..�-��"/:.,t1 s I I.��v�I:-:%.,�,-.,-,,��.;.,.-e;,�,.".,..l�I.l-.:.,!9..i,:..�I.,..-��.,:�0I_".,::c.V-�I.,'t!..�,",.I,.'.;.,�,.�.-I�;I..,:..,L.%,�-��-I.,,-..�.�:"-�,t.""7:�:,,-a,-."I,�,,..;..�4:1-,-I:::_�,.� ,'-7,,;..,I i,,�.2...":..,,I�:.-1:.�.I..-,1 N.�,I�,-,--�,.I.-.,��I�...,.�""',",,-I:,.:,,,.1 1.-,I�,..'..-,:�,1-,�,,'.:.II.��1'':1:-.��.z.-..�;.,R.....,:...�.�"-,,.;.,.,-.",,1.:,.-�..,,��,,��.��.;',%"9:1�,.L:,,..,.�,1-,A:.',,.'.,..-1,-,,7...�.'.-��-::'.�4":.,..,�-,,,,'l 7II.-�.1-%:.",-�-1,...,I..*,:w,--�.:,1�,'.g.::��:'4�1L.-....,,��,�.�.I'......,i""�_:�*"..I.�-,,i��v:V:,::.,'-.�,,-�.,.,�-�.�,.�,,II. 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' l RICMARC AVERY ' t P O Bax 24 MASNPEE,=MA 02'699 -- " CEhL: (5OA) 95H -- 73 / ; i.h x -T- 3 1 f t Y s etJ J p '�9 t F :,; 7' i t ,Ff -:! nr L !t u fF y F,.. t 7 1. - yt • a" -�-7 jP� 6?e / q6 l � oFIKE Town of Barnstable *Permit# Expires 6 months rom issue date * Regulatory Services Fee f 7` s� * nnxxsrnnix, v Richard V.Scali,Director 1639. �0 TEn �a Building Division IT Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 SEP 15 2014 www.town.barnstable.ma.us Office: 508-862-4038 TOWN OF BARA81€? TAKE-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY O Q Not Valid without Red X-Press Imprint Map/parcel Number Property Address72 CJ 1J S o ,Residential Value of Work$ 7 coo Minimum fee of$35.00 for wok under$6000.00 Owner's Name&Address Contractor's Name 1 Cif�, I r,&A_ Telephone Numbe y& 17S8 73 7S Home Improvement Contractor License#(if applicable) /w �/ t� Email: I Construction Supervisor's License#(if applicable) aye 1 eV orkman's Compensation Insurance / n Che ne: 5 - A�rfiAcGk�-�C I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) l Re-roof hurricane nailed (stripping old shingles) All construction debris will betaken ® ( )( PP g g ) to 9—Re-side (hurricane nailed)(not stripping. Going over existing layers of roof) Re-side 'S Replacement Windows/doors/sliders.U-Value (maximum .35)#of windows #of doors: Z ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance ofthis permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is Urefired. SIGNATURE: QAWPFILESTORMS\building permit forms\EXPRESS.doc Revised 061313 o the Com mtri rm--tt h of Massachus 81wtrrrent&f hulrxstritd Accidents - Ofil ce gflnves a ions 60f0 Waylr&igtvn,reet Boston,,MA 02111 ' moray.inassgo Idia Workers' CompensafionInsurance Affi-davit:$udders(Contraactors/Electriciansfaumbers Applic-ant Iufarmation Please Print Lepib f. Name{ tOsganizationitndividna9_ l _ _ MOLE City/S tatz/Zip Phone 4 .�C 7 S 8 Are you an einployern Check the appropriatebo� c of T . ' d-. I am a: e contractor and I 3'Po Iect(required) . l_❑ I;-m- a employer tuith "� o 6- ❑Near oaas: c m e:a loyees{hill an --time}* have the sub-coatcaciors. 2_❑ 12 7n a sore propneior or partner- listed on e attached sh>e 7- ❑ -emodeltag ship and haste no employees llaese sub-contractors have g_ ❑Demolition tvc fking for ffie in any c ci en plm}�and have workers' Y � �r_ 9_ M Building addition . r IN wo+leers' comp:mmra-anre comp-insurance -c rured-I 5.0 We are a corporation and ifs It}_.❑Electrical repass er ad�ions 31 El am a homeowner doing all wof offirca�have exercised Jeff 11..0 Plumbing repairs er addUions Drysel£ PITo tvorbMss'OW23P. right of e,zer ption per MGL 12-❑Roof repairs: i},s�cerequired_}f A c-152>§1(4} and we have no e-ployees IN-W-4MM' 13_❑O.thes comp_mi=mc,e rNuireri_j 'Any aggn-3114 ffixC rh;- k boa f1=5t also fM oit the secaoa heIow skiing ineir won;en'mavrD>a60n Fob 9 TTam c�cwn s rsnv s bz rt dais a;�dxvit Ulrpr F they are tiamg s1 tso>3C then hose Gsiside cotiiacmrs mnsi stabrn s rte�x sLdr it�nzrE earn tCt--txacmrs test cl_-ck this bc,mist s-"cbed a(sdditiono sheet s zocrirng he nam of tine sole co cmrc xad stst whEth K Donn,these'mritaes 5sv` �mho}�. T�tha sob-cant mCam hmre empIo�s,thb!y must pmtiide t�u� en'cam-.poll nvMber I act an s�tpr ihati�prot i ttrorzrs'c-arrrpgturliv.n irtr�irtcs fat t1z srr�r£try�es Et��aaF is Ba�Po�c}.and job silt irzforrrtrr�o;'� - , Ise-arance Gcmpan-yl�ame: Pol cy of Self inR_Lim Fxpitatiortl ate: Job Site ALt&ess: Citvistate/7rp: .. Attack a cop of the workers'comp egsati,au policy decLrstios page(shuwiag the policy n-amb era nal expb:-atiou date). Failure to secure coverage as required under Section 25 A of MGL c 152 can lead to the imposition ofc-riminal penalties of a fine up to$15 DD-00 and/or on,;-year-impxiwn mat,as well as ciirii penalties in the fom 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 maybe forwarded to:the Office.of Im estigation_.s of the DIA fat insursrnce:coverage v t tion- Ida hereby c that the informatLm protided a 0 fs true anrf correct Simatuze: A-VBate: Phone 9: �� J OffEciaL usQ onl .'Do,not wriMe in this area,to ba coNtpteted by city or town off'c&L City or"i own:, _Pereuitff acense ig Fos„g Anthar4(drde oae): 1.Search.of 3eAtl Building Departatent I Cityffowu Clerk 4_Electrical Inspector S.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. Pursuantto 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 i-wo,or more of the foregoing engaged in a joint enterprise,and including the Iegal 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 maimenance,construction or repair work on such dwelling house or on the grounds or building appur tenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also sates that"every state or Iocal licensing agency shaII vftbhold the issuance or renewal of a license or permit to operate a business or to construct buildings isr the comrzon-rrea_tl:fo,-ayj.y applicant who has not produced acceptable evidence of compliance the insurance_cover ag--required." Additionally, MGL chapter 152, §25C(7)s`a. tes "Neither the conmonwealth T�or any of its political aibdivisions shall enter into any contract for the per o_rmance of public work until acceptable e-�idence of compli.a.Dcc the insurance ._ requirements of this chapter have becn presented to the contracting authomy_- Applicants — Please till out the workers' compensation a� davit completely,by check, ,g flue boxes that.apply to yco�r si'�uauou a d,17 necessary,supply sub-contractors)na ne(s), addresses)and phone r_:m-,be'(s) along with the r ceT TLc !c(s) of insurance. Limited Liability Companies(LLC) or Limited Liability Part' iersh_ins(LLP)Sri alno cinrloyccs other than the members or partners,are not rem„sed to carry workers' compensation 1s1?-ance- if a LL.0 or LLP does hate employees, a policy is requ-<ed fie ad vi ed_hat this affidavit nay be s_b?i<<ed to be Depal ent of indu��;aI Accidents for confirmation oft��nance cover age. Also be sure to sign and date the affid2 t. 'l1e affida,,it sho old be returned to the city or town hat the applic- ion for the permit or licemse is being reouested, not the Depart�rlent of Industrial Accidents- Should you have any questions regarding the laivv or if you are requited to obt.:_in a workers' compensation policy,please cal tl,;_DeparLnent at the number listed.below. SeIff-iiasued companies s:101,11d enter e r self-insurance license number on fh.t appropriate line- City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Deparfmtnt has provided a space at the bottom of the affidavit for you to ill out im the event the Office of luvestigations has to contact you regar ,g the a Ican- Please be sure to fill in the perm lLcense number which will be used as a reference number. 1n addition- an appL cant that must submit multiple pern_it/license applications in any given year,need only submit one ai davit ind cating C=tnt policy information (if necessary) and order"Job Site Address"the applicant should v rite"all locations In _(city or town)."A copy of the affidavit that has been officially stamped or marked by tiie city or town may be proGrided to the applicant as proof that a valid affidavit is on file for future permits or liceases- A new of Edavit ins.,st be tilled out each year-Where a home owner-or citizen i--obtaining a license or permit not related to any bu_s?ress or commercial venture (i-t_a dog license or permit to burn leaves etc.)said person is NOT rep Tired to complete this affida;it The Office of investigations would like to thank you in advance far your cooperation and should you have any quesions, please do not hesitate to give us a call. TheDepartment's address,telephone and fix wumberr. ' rF_ht,Commnnwr_a1!h of Mass achuse-i1s Depthatni of hidnstual Aociden`s € f1t�e Of Invesfrntimna GGG Washingtaa SLre TCJ,-A,-' 61 7-72 -49-Q0 W1 406 or I- 1Zevised 4-24-07 Fax fil 61 7-f-27-7 7 4 a THE t Town of Barnstable ! i Regulatory Services t ■ HARNSTABLF, Richard V.Scali,Director iL6�fo 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 Builder7 , I, - as Owner of the subject property hereby authorize Ir ILA_ to act on my behalf, in all matters relative to work authorized by this building pe 't application for. 7 ? Rio (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 Signature of Applicant ti Prifit Name Print Name �sloaa Date Q:FORMS:O VJNERPERMISSIOINTPOOLS Town of Barnstable Regulatory Services ��oFixe T�cyy Richard V.Scali,Director ' Building Division RARNSrABLZ Tom Perry,Building Commissioner arns& 200 Main Street; Hyannis,MA 02601 ATFD '� 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. DEFIN rION 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 shaU 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. P To ensure that the homeowner is fuIIy 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 Iast page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 I Cape Cod Remodeling, LLC. Contract Contract Made as of the 7th day of September in the year of 2014 BETWEEN the Owners: Thomas J Ruhan i 77 Dunn's Pond Road Hyannis, MA 02601 Map 240 Parcel 098 And the contractor: Richard Avery, Cape•Cod Remodeling LLC , PO Box 2416 k' 206-27 Market St., Mashpee Commons Mashpee, MA 02649 508 958 7373 (cell) MA HIC#: 178816 Expires 5/22/2016 CS#: 084771 Expires: 01/15/2015 "Email: ravery@outlook.com The Contract work is: w Contract work is to be performed at 77 Dunn's Pond Road, Hyannis, MA Consists of the following: Remodel existing exterior of this Cape style house (windows, siding and roof)and install a new 3BR septic system: The Owner and Contractor agree.as"set forth below: ' ARTICLE l THE WORK OF THIS CONTRACT 1.1 The Contractor shall execute the entire detailed description of work described in Attachment A: Detailed description of work"that describes the tasks, payments and schedule for the project. 1.2 Change Orders: All changes to this contract will be done in writing. Each change will include a date,a statement of impact, if any on the final date of completion and the total price for the change. Change Orders will be numbered consecutively beginning,with 1. Change Orders must be signed by the Contractor and the Owner. Owner agrees to make the total payment for each change order when it is approved Cape Cod Remodeling, LLC. Contract . 6.2 Other documents, if any,forming part of the Contract Documents are as follows: (List of any additional documents which are intended to form part of the Contract Documents). No other documents are part of this contract. ARTICLE 7 Approvals Si Thomas u Si nature. t ,< :2,Gj'('^-�"" / Date Richard Avery,Cape Cod Remodeling, L'LG j T e 4 �Jln c!%arlr.�rr""o.uraerrlf�o��C�llrc:i:;uc�cr�ell' • , - , .._Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME,IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 9 178816. Type: Office of Consumer Affairs and Business Regulation eistration „�jExpiration 5/22/2016 LLC 10 Park Plaza-Suite 5170 W es" Boston,MA 02116 CAPE COD REMODELING LLC F RICHARD AVERY 39 FOUNTAIN ST t /6ll��ie� MASSHPEE,MA 02649 �=' -- -- Undersecretary Not valid without signature 9 Massachusetts -Department of Public Safety Board of Building.Regulations and Standards M Construction Supen isur License: CS-084771 RICHARD T AVERY ' PO BOX 2416 Mashpee MA 02649 Expiration Commissioner 01/15/2015' (MMDDIYYYY) A`ORa CERTIFICATE 75/29/2014 OF LIABILITY INSURANCE 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 Maranda Raynard Patriot PCL Insurance LLC NAME:PHONE 508-534-988 FAx '508-546-8000 131 Cedar Street E MAllo Ext ac'No Hyannis,Ma 02601 • ' AOOREss: Marandapatriotpcl@gmail.com ' IN AFFORDING COVERAGE NAIC# INSURER A: Atlantic Casualty Insurance INSURED INSURER B: Almerindo Ries Filho INsuRERc: DBA Alcon General Construction American Zurich Insurance INSURER D: 638 Main Street INSURERE: - Centerville, MA 02632 INSURER F: COVERAGES CERTIFICATE NUMBER: 179 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. ILTR TYPE OF INSURANCE - ADDL SUER POLICY NUMBER MM DD/YYYY MMDDIYY Y LIMITS GENERAL LIABILITY L143003926 4/30/2014 4/30/2015 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE IX I OCCUR - - MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 11000,000 - „ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG S 0 X POLICY PRO- RO LOGJECT AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT - Ea accident S ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - - NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS - - Peraccident - $. UMBRELLA LIAB OCCUR I - EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE '$ DED RETENTIONS $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY 2E186217 - Y LIMITSI ER ANY PROPRIETOR/PARTNER/EXECUTIVE. Y/N ,4/30/2014 4/30/2015 _ D OFFICER/MEMBER EXCLUDED? � N/A E.L.EACH ACCIDENT $ (Mandatory In NH) - -If yes,describe under E.L.DISEASE-EA EMPLOYE $ - - - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS,/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) For Jobs normal and usual to the insured's operations Almerindo Filho DBA Alcon General Construction has elected to be excluded under his workers compensation policy Cape Cod Remodeling,LLC is listed as additional insured written by contract only 4. CERTIFICATE HOLDER CANCELLATION Richard Avery SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Remodeling, LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Fax#(508)445 07604 AUTHORIZED REPRESENTATIVE k Ma ra vtd a.Ra:yvlard, ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD i t Town of Barnstable *Permit# i_� S SS ti Expires ti mont�s from issue date � Regulatory Services Fee / �: 10cl s�,xrvsTna[E Thomas F.Geiler,Director MASS. �•� Building Division plf A DES PER STPerry,CBO, Building Commissioner MAY 1 200 Main Street,Hyannis,MA 02601 2008 www.town.bamstable.ma.us Office: 51 � rr�� Fax: 508-790-6230 TX�ARRE��RMT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number. ;7 =dress f�ial Value of Work �� 000 1 G� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address aa 1i lac, 9� 0 Contractor's Name &� -J ? Tele hone Number '500 !� 1 P Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance el one: m 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 be on file. Permit R;�Re-' ph6ck box) roof(stripping old shingles) All construction debris will be taken to ❑Re- oof(not stripping., Going over existing layers of roof) y R ='side Replacement Windows/doors/sliders.U-Value (maximum.,3A *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Yrlerty Owner must sign Property Owner Letter of Permission. A c py of the Home Improveme Contractors License is required. / SIG J ;C1 Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Blectricians/Plumbers A licant Information Please Print Le 'bl Name(Business/Organization/nndi al): Address: City/State,/Zip:. V "I Phone-#: / / 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 6. ❑New construction loyees(frill and/or part-time).* have hired the stab-contractors 2. 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 camp. # o workers' co .•insurance � � insurance. � � 10. Electrical re airs or additions ed. 5. [] We are a corporation and its ❑ p requn- ] 3.❑ I am a homeowner doing all work officers have exercised their I LFJ 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 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 inf nTnation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state wbether or not those entities have employees. If the sub-contractor;have.employees,they must pravidt 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.Lie.#: 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 tip to pcoftbbDU and/or one-year mipns nt,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$ y"gains a violator. B advised that a copy of this statement may be forwarded to the Office of Investi ti or ins cc er a verification. I do h eby c,rti un e 'Ins-ann ' s of perjury that the information provided above' true ppd correct Si a e: Date: v _ Phone#: 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 hue, 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),addresses)and phone number(s) along with their certificates)of insurance. Limited Liability Companies•(LLQ or Limited Liability Partnerships(LL.P)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 nurnber 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 TO. #617-727-4900 ext 4-06 Qr 1477-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia i °FtHEr° Town of Barnstable Regulatory Services 4 1 vBAMSTA"BLE, Thomas F. Geiler,Director rFnMarIN 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 a er of the subject property CIA t n hereby authorize act on my behalf, in all matters relative to work authorized by this building permit application for: ddress of b) L ature of ner Date Print Name If Property att 3 Owner is applying for permit please complete the Homeowners Licens e, Exemption.Form on the reverse side. n u s Town of Barnstable VE Regulatory Services r r Thomas F.Geller,Director r • BARNsrABLE, ` 1� MASS. Building Division AlfD ,�p Tom Perry,Building Commissioner . 200 Main Street, Hyannis,MA 02601 w'w'Iv.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,dwellinas 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 aie 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 personas 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. s �lze TDo7rina�reuiea.�i o�.�aao¢c�iuve�6 V Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Regist1 �Qn-\114889 Expjptior 1 75/2009 Tr# n 261099 � BOSWORTH ASS� , SOCIATES� � WARREN BOSWOR hiR='�/r't 1645 FALMOUTH Ri1 CENTERVILLE,MA 02632-' Administrator a License or registration valid for individul use only ii before the expiration date. If found return to: Board of Building Regulations and Standards a One Ashburton Place Rm 1301 Boston,Ma.02 I No witho s' tore I i b r