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Home My WebLink About0024 FIFTH AVENUE (HYANNIS) Ll Llto t90 i "_,�`�-----1 I I I � � �I ,� i I i I 1 w Application number................................................ f Free J MAS& JUL 12 2019 Building Inspectors Initials... 0� 8 ARKS AB Date Issued. ��.l l .......................... ! Map/Parcel...................� Icto......... TOWN OF BARNSTABLL ?' f ". � ! EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATI-ERIZATlON .� .,i-, + , , .� PROPERTYINFORMATION ,;•,.• - , ` ,`_; {k - • ; Address of Project: NUMBER STREET .r VILLAGE Owner's Name:- Phone Number----&N8 Email Address: e_L 9 t 1 ®Cv�ca S t\r* Cell Phone Number a N f 7 v Z,-8 Ys Project cost$ 61000 r Check one Residential Commercial OWNER'S AITTAORIZATION_ As owner of the above roperty I hereby authorize Z064 to make application uilding in accordance th 780 C Owner Signature: G Date: z� �4 TYPE OF WORK j •" �i �r� u'. _. •) i. - '. ,• ..s' .. 0 Siding ,.� 0 Windows (no header change)# Insulation/Weatherization Doors (no header change)# Commercial Doors'require an inspector's review Roof(not applying more than I layer of shingles) Construction Debris will'be going to ` 0co ?tiec y�o . - - ---CONTRACTOR'S INFORMATION - --- -- - Conl tractor's name Home Improvement Contractors Registration(if applicable)#_ �� .l(o `� (attach copy) Construction-Supervisor's License#� /��er (attach copy) CvMc.,, t-1, Email of Contractor C i Y. r-Do� ('pw,�4,1'thone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN 4 ............................................................ ,* or--Tents•Only* w Date•Tenf(s) will be erected Removed on number of tents total Does the-tent have sides? Yes No (If yes please attach floor plan with_exits marked) Dimensions%f eacWent� X - - X X ~ Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes Nybattac Flame Spread Sheet of each tent mus le d. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a ealth Department approval between the hours - o 8:00am -9.30 am or•3:30 m-4:30 m.Commercial events may require Fire f p p y q r PP Department approval. P *WOOD/COAL/PELLET STOVES *' Manufacturer# Model/I.D. J Fuel Type Te g Lab Offsets from combustibles: front back left side right side _ HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work-number , t I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection rp o'cedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date, - - APPL CANT'S SIGNATIIRE - Signature Date All permit applications are subject to a building offZcial's approval prior to issuance. - � cfT�-�oomma�'iu�ea�i y�c ��eit Fr'1, fpssicess Regu#2aGti t cN a�4? Ca:u t ran ROBERT H.CHAvtcF_€iS j, ROBERT H.CHAMBFP-7 ` 102 W H1FFLETREE`A�%1- �/ �. BREW S i ER,IVIA 02631--- Undersei-eta.r s Commonwealth.of Massachusetts ® Division of-Professional L 60*ture Board of Build"tog Regul'afiars ant;-StarMaids Constructiq ';!160�f(sor Specialty CSSL-100134 ;� § empires. 03/16/2020 ROBERT H CHAMBER : x} 102 WHIFFLETREE AVE BREWSTER.M"A3 . OISS33� Commissioner 4 t9';' : The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,State 100 Boston,-MA 02114-2017 www mass gov/dda Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Infol M-999 Please Print Let?ib1�! Name(Business/Organizaflgg&ME THE ' 'ORClVS rEK MA 02631 Address: City/State/Zip: 'Phone#: Sb�$ Are you an employer?Check the appropriate box: ' Type of project(required): 1._41 am a employer with_-2,`employees(full and/or part-time).* 7. New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling arty capacity.(No workers'comp.insurance required.] 3.F�I am a homeowner doing all work myself(No workers'comp.insurance required]t 9. ❑Demolition 4.❑I am a homeowner tract-,vr71 be Kirin;contractors to eondux all warx on my property. I will 10❑Building addition ensure that All contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.F1 I am a gweral contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insuranmt 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4).and we have no employees,(1v`c.markers'comp.insurance require:.] *Any applicant that checks box#i must also fil?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 arc an employer that is providing workers'compensation insurance for my employees Below is the policy and job Me fnformadoaa , r Insurance Company Name_ NTI �C--,— Policy#or Self-ins.Lie.#: �'� ` Expiration Date: 11w t a L t /1(E Job Site Address: -T41 �A nVC, City/State/Zip: Attach a copy of the workers' cOmpensetion policy declaration page(showing the policy numbei and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation-punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi u e pains 'es of perjury that the inform ation provided above is hue and correct 7 Si ature: Date: ? 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.Otber Contact Person: Phone 9: 07/13/2019 00:02 17744704829 PAGE 02/02 DATE(MMIDDKYYY) AC 11I. R CERTIFICATE OF LIABILITY INSURANCE 07n21/2O 9 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS BELOW.CERTIFICATE THIS CERTIFICATE FIRMATIVELY OR OF INSURANCE DOESTIVELY NOT CONSTITUTE EXTEND CONTRACTTER THE BETW EN THE SSU ISSUING NSURER(S)THE AUTHORIIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURE .the pollcy(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 endorsements). CONTACT PRODUCER 3,MC : w Scott Kerry KERRY INSURANCE AGENCY IAICNE 508 255-8000 AX No): E-MADDRE • scott@kerryinsurance.corn P O BOX 1945 INSURER(S)AFFORDING COVERAGE NAIL 19 N.EASTHAM MA 02651 INSURER A: ATLANTIC CHARTER INS CO 44326 INSURED INSURER e ROBERT CHAMBERS INC INSURERC: INSURER D: 102 WHIFFLETREE AVENUE INSURER E: BREWSTER MA 02631 1 INSURER F; COVERAGES CERTIFICATE NUMBER: 424410 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 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR —POLICY EFF OUCY EXP LIMITS LT TYPE OF INSURANCE DOL. POLICY NUMBER DDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIM8-MADE ❑OCCUR eREMISE3 Ea o rren¢9 $ MED EXP Any one person S N/A PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PEA L�J LOC PRODUCTS-CO MP/OP AGG s S OTHER' AUTOMOBILE LIABILITY COMBIN SNGLEUM S 11 accident BODILY INJURY(Per person) S ANY AUTO ALL AUTOS OWNED SCHEDULE N/A BODILY INJURY(Per accident) $ AUTOS NOWOWNEO PROPERTYDAMAGE S HIRED AUTOS AUTOS Per aoGtlenl S UMBRELLA LIAB OCCUR EACH OCCURRENCE S BXCESS LIAB CLAIMS-MADE NIA AGGREGATE $ S DED I I RETENTION _ wORKERSCOMPENSATION X PER ER AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETORIPARTNERIEXECUTIVE NIA E L•EACH ACCIDENT S 100,000 A OFFICERIMEMBEREXCLUDEO? NIA NIA WCV00609514 01/29/2019 01/29/2020 E.L.DISEASE-EAEMPLOYFE S 100,000 (Mandatory In NMI If es,describe under E.L.DISEASE-POLICY LIMIT S 500,OOD DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONG/VEHICLES(ACORD 101,Additional Remarks Schedule,may be anached if more epaco is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorizatlon Is given to Fay claims for benefits to employees In states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool atwww.rnass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Bamstable 367 Main St AUTHORIZED REPRESENTATIVE Hyannis MA 021301 Daniel M,Crq<ey,CPCU,Vice President—Residual Market—WCRIBMA ®1988.2014 ACORD CORPORATION. All rights reservec ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD