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HomeMy WebLinkAbout0045 FOSTER ROAD t i c Application number.,. Date Issued...... ................................... sb Building Inspectors Initials........ Map/Parcel...... ............................................ DPP 0 J 2010 UTO �V ,AIL RNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: / 5 T l n i S NUMBER STREET VILL G Owner's Name: P�-c.1. FOS l� Phone Number �j -7- Email Address: Cell Phone Number Project cost $7 ©0,d ' Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above properly I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK k ' 0 Siding El Windows (no header change)# 0 Insulation/Weatherization Doors (no header change) # Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR''S INFORMATION Contractor's name A- 't:--0,1 Pq (z U d CA, ' Home Improvement Contractors Registration(if applicable) # � �/ ?i� (attach copy) Construction Supervisor's License# C-S— // 30-5" (attach copy) oOcU r� Email of Contractor°Y1�IzV�'� O l�0 U r � 0 Phone number '5D2-290 ?3y ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.. APPLICATION NUMBER............................................................ *For Tents Only Date Tent(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 of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours . of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer # Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side -- — - —..--- HOMEOWNER'S LICENSE EXEMPTION - --_- _ --- -- — — ----- Homeowner's Name: Telephone Number Cell or Work number 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 procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date ICANT'S SIGNATURE Signature Date f�J� All permit apClicaltioare subject to uilding official's approval prior to issuance. 1 Commonwealth of Massachusetts <,N Division of Professional Licensure Board of Building Regulations and Standard Constrction'Stype rvi sor CS-111305 r d � f ires: 06/01/2021 X ANDRE YARMALOVICH 204 CI NDERELLO TERE MARSTONS MILLS MA RAC 02648, Commissioner , �/��.,1`'-rii.rrc=:irnv 'l 3r^,��ir:urrr�rr'efC.� r Office of Consumer A 'A egulahon' tHOME IAAPR MENT CONTRACT, -- Reg str di 172476. T pe: Expra n T12/2018 pBA l f k BEL ISLANDS.HO E IMPROVE-MENT, ANDREI YARMALO 204 CINDERELLA MARSTONS MILLS ndersecretary. 1\ . \� r ACORZ@ CERTIFICATE OF LIABILITY INSURANCE DATE(M MDDIYYYY) ii.�' 4/3/2018 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 have ADDITIONAL INSURED provisions or 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 BRYDEN & SULLIVAN INS aiAME:NTACT 88 FALMOUTH RD PHONE FAx HYANNIS, MA 02601 EMAIL A/C L Ext: AIC No ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation 33600 INSURED INSURER B: BEL ISLANDS HOME IMPROVEMENT LLC 204 CINDERELLA TERRACE INSURERC: MARSTONS MILLS MA 02648 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 41181950 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 L;ERTIHICAI"E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM DOPOLICY/YYYY MM/DD EFF Y EXP LTR /YYYY LIMITS COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ ' DAMAGE RE T CLAIMS-MADE DOCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY❑PRO ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY - Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WC5-31S-615667-018 2/11/2018 2/11/2019 ,/ STATUTE OERH AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500000 OFFICER/MEMBER EXCLUDED? N NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ O 000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 s 500000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION t PHIL RYAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 7 HARBOR FARMS RD ACCORDANCE WITH THE POLICY PROVISIONS. EAST FALMOUTH MA 02536 AUTHORIZED REPRESENTATIVE Jon Smith ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 41181950 1 1-615667 1 18-19 WC 1 n0254981 1 4/3/2018 2:10:19 2H (EDT) I Page 1 of 1 • ° Estimate ISLANDSBEL ^ S Date x �, _AEsbmafe# Home Improtrement 7/19/2018 80.0. Bel Islands Rome Improvement 204 Cinderella Terrace nlame,/Address Marston Mills, Ma ,0264$ Paul^xantis 45 Foster Rd, Belislandsroofingandsiding.com Hyannis,ma 508 280-1794 508-364-6909 Terms Project t ^� Descnptton � , ; Qt�r Rate � ` Total system- POSSIBLE EXTRA. Any rotted plywood,trim boards,.lead flashing or other carpentry needing replacement will be done and charged for as an extra at rate of$60.00 per hour,plus 15%mark up materials Bel ISIands Home Improvement Guarantees the labor for Lifetime of roof and against Blow-offs for IS Years. Bel Islands Home Improvement:Caries Worksman's Compensation and Public Liability Insurance on the above work, certificate available upon request permit 150.00 150.00 dumpster 450.00 450.00 Total $7,425.00 Page 2 sr ^•.s, 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): zV1,1�°rLm/' �/912 M Z. cc7yt Address: 2 1.11 ��BL / P�f'ftC.�.,. City/State/Zip:/J Y1vk,s NCl 3 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.N�'fam 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 2.❑ 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 . workingfor me in an capacity. employees and have workers' Y P tY• # 9.'❑Building addition [No workers'comp.insurance comp.insurance. 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.❑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 Insurance Company Name: %�, v L� Policy#or Self-ins'.Lic.#: G 6� -OSExpiration Date: Job Site Address: Ci /State/Zi : �! os r � ri P 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 insuran coverage yerification. I do hereby certify u er the pai and penalties ofperjury that the information provided above is true and correct Si ature: Date: © J� 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#: i 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 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 permit o operate a business or to construct buildings s in the commonwealth for an renewal of a license or pe t t p g Y 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-obtaiwa 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 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 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.Sh=t Boston,MA 021 It Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#61.7-727-7749 Revised 4-24-07 www.mass.gov/dia