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Home My WebLink About0200 GREENWOOD AVENUE v�s� �.��u�aq��- _ _ \ Town of Barnstable �itt Q� Expires 6 months from issue date . Regulatory Services Fee MASS 039. � Thomas F. Geiler,Director Building DivisionY Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.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. Property Address :;L0 o >�� ,Residential Value of Work_(9 6DO Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Ste,A-y' 0 N Al MAI Contractor's Name O�"r t� eX*_1 Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License.#(if applicable) JQO/ RIWorkman's Compensation Insurance Check one: AUG — 6 Z��2 El am a sole proprietor ❑ I am the Homeowner 2LI have.Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name. f't'f 6-�G \ "_r Workman's Comp.Policy# VJ LV .( Copy of Insurance Compliance Certificate must accompany,each permit. Permit Request(check box) KRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to . ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)` ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. . Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy o the Home Improvement Contractors License&Construction Supervisors License is ire SIGNATURE: Q:\WPFILES\FORMS\building permit formsTMESS.doc Revised 053012 l The Comrnonwea th of Massachusetts DeparhnentofIndustyialAccidenys WJOgre of Inmtigotions 600 Washington Street Boston,MA 02111 nmas�govldia Workers'.Compensation Insurance Affidavit Builder/Contrackw.siBlectric ans/Ph mbdrs Applicant Information (r11 ( Please Pent Lembly Name Musi l)- �C T G��4v�-bQc' 'N C- _ Apt . c tylstateJzig_—�Ll Phone 47. SZny ILI Are you an employer?Check the appropriate box: Type of project(required): 1.9I yn a employer with S— 14. ❑I am:a general contractor and employees(full atrdlor part-t>me). :have hired the sub-conlractofs 6- [—]New construction 2-.ElI ain a sale proprietor or partner.. listed on the attached sheet. 7. ❑Remodeling ship and have no employees. These sub-contractors have 8_ ❑Demolition working far me in any capacity. employees and have workers' [No worloers'.comp.Uwarance comp.msu ranml 9: El Building addition required] 5. a am a corporation and its 10-El Electrical repairs or additions 3.❑ I am a horaerY ivner doing:aR Rmk officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'co p- : right of emotion per MGL 12.gRoof repairs �14 152; insurance re'quire�-]t c. ( �'and we have no employees.[No workers' 131-1 Other comp insurance required.] •Any appluaat tdat merles boa#1 umst also fill out the section below showing�erockew cn�sativa porLcy infwnn&m- �FYoaoeowu�eis who sub®it this affidavit indicating they are,doing&U arark and then hue outside contmints>nnst submit a new affidavit indicating such- . 1Coauactars that check this box must atm Led an additional stet showing the sane of the sub-cemdcactocs>nd:00 whether orim those entities ham etmpkriees.,If the:subtontactersliavea ployee%theymmwpmvidetheir workers,camop•policy,number- am art employer that is providing workers'conepensation.insurance for my employes& Below is the policy and job site . information. Insurance Company Name:. Poky#of Self iris.Laic.#: IA/LV Expiration Date: ��j Job Site Address : W /rt City/Stat&Zip: 8G13—rJAG(-C— Attach a copy of the workers'compensatioupolicg declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Sectiori 25A of MGL c.. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 an&6r one-year mi 4xi nmetit,as:well as civil penalties in the farm of a STOP WORK ORDER and a tine of up to$250-00 a day against the violator- Be.advised that a copy of this statement may be krwarded to the Office of Investigations of DIA`for insurance coverage veriftaticm . I do hereby c u its0djOrnabies ofpeduty thatdre information provided above is tor$and correct Si }ate: - � "I Z_ Phone#: -<X .U,JjzciaL ruse only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# Issuing Authority(circle one): 1.board of Health 3.Building Department 3.Cityl own Clerk 4.,Electrical Inspector 5.Plumbing hispector 6.Other. Contact Person: Phone 9: 6 dFIME + RARNSTABLE. 9 ,m 'Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building;Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 0.2601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder, as Owner of the subject property hereby authorize K to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) ;,91 Z Signature of Owner 6ate - Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORWbuilding permit forms\EXPRESS.doc Revised 051811 , r� �tME Town of Barnstable Regulatory Services BARM^B Thomas F. Geiler,Director 9`bprfo;A,►``� 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 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-Cod e 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 persons)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:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 051811 Office of Conm�er ffarra usinesgu a g Y License or,re tstrabon valid for mdrvidul'use onl HOME IMPROVEMENT CONTRACTOR before the expiration date. .If found.return to: Registration:, 1,3'4169 Type. Office of Consumer Affairs and Business Regulation Expiration 10/4Z2013 Private Corporati ,iti 10 Park Plaza-Suite 5170 Boston,MA 02116 R RT H.CHAMBER,INC ,ter - T _ ROBERT CHAMB , :LL k r 102 WHIFFLETREE AV..EL BREWSTER, MA 0263:1` r., Undersecretar J. Y Not valid Zw1iihod/lit signature tt Massachusetts -Department of Public Safety " Board of-Euildin g Regulations and Standard C(RlstruCtion Super l isur Specialtj. - :License: CSSL-100134' ROBERT H CHAMBERS nip 102 WIFIIFFLETREEF�,YE.. Brewster MAr 02631 Commissioner Expiration 03/16/2014 07/26/2012 11 :47 FAX 6174886501 UNDERWRITING Z001/001 g ptk vW 7/26/201 2 • 6� -Amff "I ON THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERT151CATE 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 INSURIER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT; If the certificate holder is an ADDITIONAL INSURED,the policy i0s) Ust.be endorsed. if SUBROGATION 13 WAIVED,subject to the terms and conditions of the policy,certain policles may require an endorsement A statement on,US;Do tificatt does not confer rights to the certificate holder In lieu of such endorsomonts(s). 'CONTACT PRODUCM NAME' FAX PHONE Kerry Insurance Agency,Inc. A/C.No.EXII); (508)255-9000 (AI No.:) E-MAIL PO Box 1945 ADDRSS; North Eastham,MA 02651 PROMIrr-Ft r.1 IsTnIYIF5 In INSURERS AFFORDING COVERAGE NAIC# INSURED INSURFRk Atlantic Chartcr hisurance Company VDAC 29211 Robert Chambers,Inc. INSURER a: INSURER Cl 102 Whiffletree Avenue INSURER V. Brewster,MA 02631 INSURER E: INSURER F: COVERAGES: CERTIFICATE NUMBER; 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 16 SL)BjFCT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE 13EEN REDUCED BY PAID CLAIM$. INSR TYPE OF INSURANCE ADDL AUEIR POLICY NUMBER POULY PFFECTIVE POUCYEXRIRA'nON LIMITS LTR INSR wyn DATE(MMIDONY). DATE(MMIDDNY) (in Thousand Il aFNFRALUABILITY fAC;H OCCURRENCE $ DAMAGE TO RENTED PREMISES COMMI!ktIAL OFNERALUASILITY (Ea=mtroiiek) CLAIMS MADE L] OCCUR F-1 Ll MED EXP(Any om pamm) PERSONAL&ADV INJURY. CENERALAGGIRECIAT0. 3 GENTAGGREGATI!LIMIT APPUE$PER: PRODUCTS•COMPIOP AGG 3 POLICY ❑PROJECT ❑LOG A MQBILIE UA8 UTY:., COMBINED SINGLE LIMIT (EA 4vZani)... A14YAM BODILY INJURY ALL OVYNZI5 AUTO* a (PVT P—) SCHL93ULED ALIT04 BODILY INJURY HREDAVTO', PROPERTY DAMAOE $ NON,OVWNDED AU`r05 (Ea AcclderR) (UMBRELLA ❑ OCCUR EACH OCCURRENCE UABILM EXCEU UAB MADE AGGREGATE -LAIME, VeDUVNBLE $ RETENTION WORKM51GOMPIENSATIONAND x BTATUTORY OTHER A EMPLOYEAS'LIABILITY WCV00609507 01/29/2012 01/29/2)013 LIMITS ANY F`RDPPJETOR/PARTNEMDmcLrnVE Y'N OFFLCEPJMFMBER EXCLUDED? WA EACH ACCIDENT 100,000 Moaftoy14NH POIICy byes,duodbe under SPECIAL PROVISIONS Imlow DISEASE-POLICY LIMIT 500,000 I3I5FA$E-EACH EMPLOYEE 1 100,000 .OTHER DESCRIPTION OF OPERATION64,00ATiONSIVEHICLES(Attach ACORD 1011,Additional Remarks Schedule,9rrmr%*p*c*is(*q.Ajra4j All 51011P , . lIOIONI i IN A N110 NI0ig28 -O912" 1 'i ? pml fl, ",il 1I T AM, ""A 4qt,SHOULD ANY OF THE ABOVE DE5ORIB91)POLICIES BE CANCELLED BEFQRF-THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Town of Barnstable 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. 200 Main Street BUT FAILURE TO DO SO SHA .POSE NO OBLIGATI OR LIABILITY I Hyannis,MA 02601 OF ANY KIND UPON THE IN 4ITS AGENT SOLIABILITYESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 28(2009ID9) A kAh&k"r , All rights mmemeEL Page 1 of 1 CERTWICATE RIDIZER COPY