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HomeMy WebLinkAbout0113 ESTEY AVENUE �� �`� �-,'-e- ,� r i1 le t#ermi oFt„E r� Town of Barnstable Expires 6 months from issue date Regulatory Services Fee r M [� � Thomas F. Geiler,Director 9� i639, . pTFp MA'1� Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �0(0 O'l o k Property Address 06V k) 1 2 r// desidential Value of Work 3 001GA-" Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address c Contractor's Name C ;L- e, Telephone Number—. tz �oZ�'=J 34- Home Improvement Contractor License#(if applicable) ZWorkman ction Supervisor's License#(if applicable) 's ompensation Insurance PAuL M 4420 L-A ife- -71-7( C ck one: I am a sole proprietor . ❑ I am the Homeowner lPS PERMIT ❑ I have Worker's Compensation Insurance SEP 2 6 '2 Cii. Insurance Company Name TOWN OF BARNSTABLE Workman's Comp. Policy# t,9 � � � �� " �� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side � a�1v�82Sb�' �� #of doors Replacement Windows/doors/sliders. U-Value 0. �F3 (maximum .44)#of windows O *Where required: Issuance of this r2p per-inpt compliance with other town department regulations,i.e.Historic,Conservation,etc. *** `" Property Owner Letter of Permission. Note: Propertyp rty copy oovement Contractors License& Construction SupervisorsLicense is required: SIGNATURE: 1WPFILES\F0RMS1 in ding permit forms\EXPRESS.doC vised 070110 L _ The Commonwealth of MassachuseUs Department of Industrial Accidents Office of Investigations .600 Washington Street Boston, MA 02111 wwM.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly SN2.n1e (Business/Organization/Individual):. �p , C ,,� -i�� 0 Address: 60 - Z.u-e-L �� e,� � t'lilt�L� ��tl ?76 447e/ City/State/Zip: 90 Q 4 4 9 Phone #: 6 -9834 F re you a employer? Check the appropriate box: Type of project(required): : am a employer with � 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp,insurance. 9. ❑Building addition required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I'am a homeowner doingall work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no 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 isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �R-A4 ,e_e Policy#or Self-ins.Lic.#: f.✓C 000 37 �j®,�'�}3�� L!b ' Expiration Date: Job Site Address: 1 13 ';—:Z S �-c-� /�1Jla City/State/Zip: :��d{t.�l� 144 04:vx/ 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-Dbk-fo—rinsurance coverage verification. I do hereby c fy under t pains and penalties of perjury that the information provided above is true and correct Si nature: Date: Phone#: �d1 iL I'1' �� "77 —A-A Official use only. Do not write in this area,to be completed by city or town official Cityor 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#: '``6 CERTIFICATE OF LIABILITY INSURANCE 923/D123/201/DD/Y1 `—� 1 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 Kathy Silvia NAMEThe Fair Insurance Agency Inc. PHONE (508)775-3131 No:(508)790-1677 619 Main Street n DD RIESS.fairins@capecod.net P.O. BOX 430 INSURERS AFFORDING COVERAGE NAIC 9 Centerville MA 02632 wsuRERAMain Street America 29939 INSURED INSURERB:SafetY Insurance CO.. 39454 GCI BUILDERS INSURERC:Savers Property & Cas.-ARWC 31771 PO BOX 509 INSURERD: INSURER E: MARSTONS MILLS MA 02648-0509 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1191900145 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 DLSUBR POLICY NUMBER POLICY MID Y EFF MMIDDI EXP LIMITS GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000 DAMA E TO R X COMMERCIAL GENERAL LIABILITY ENTEDnce $ 500,000 PREMISES Ea occurre A CLAIMS MADE a OCCUR Z43707 /28/2011 /28/2012 MED EXP(Anyone person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY M PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E,,cadent 100000 ANY AUTO 30DILYINJURY(Per person) $ 250,000 B ALL OWNED SCHEDULED 5052134 /3/2011 /3/2012 AUTOS I ALTOS BODILY INJURY(Per accident) $ 500 000 NON-OWNED PROPERTY DAMAGE HIRED AUTOSAUTOS Per accident $ 100,000 Underinsured motorist el split $ 250,00 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4 EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE 0 E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) 0002374 /28/2011 /28/2012 E.L.DISEASE-EA EMPLOYEq$ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 B 200046 /13/2011 /13/2012 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN John Kettlewell ACCORDANCE WITH THE POLICY PROVISIONS. 113 Estey Ave AUTHORIZED REPRESENTATIVE Hyannis, MA 02,601 Jackie Stewart/FAIMCI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 t-)ninm)ni Tha At npn n2ma anA Innn or*raniefararl morlre of ar]npn THE Town of B am stable Regulatory Services s�ttsreszts, MASS g Thomas F. Geiler,Director . 1639. �m r�ra` Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize GI C :Z to act on my behalf, in all matters relative to work authorized by this building permit (Ad ess of Job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be. utilized until all final inspections are performed an fed. S afore of Owner C7Signature of Applicant Print Name Print Name Date Q:FORMS:O WNERPERMISSIONPOOLS THE r, Town of Barnstable Regulatory Services i sa$taMBLE, * Thomas F. Geiler,Director grass. i639• ��� Building Division rfD MA'i A Tom Perry,Building Commissioner , 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 I HOMEOWNER LICENSE EXEMPTION Please Print DATE: - JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code . The current exemption for"homeowners"was extended to include owner-occupied'dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. , DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official„that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner perfdrming work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would%with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt Board of Builditt_�Regulations and 5t t1S Construction Supervisor License�-. One-and Two-Family Dwellings License: CS 57934 PAULJ MAZZOLA PO BOX 509 MARSTONS MILLS, MA 02648;" "Expiration: 6/19/2013 (runmisirrner Tr#: 18136 Office ot-Co tamer A airs Viness�deuo HOME IMPROVEMENT CONTRACTOR Registration .152253 Type: Expiration 8/11/2012 Private .orpera.: G i BUILDERS INC t L �. } PAUL MAZZOLA } 644 RIVER ROAD II'I MARST ONS MILLS MA 02 48:" ' 6 Undersecretary i