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Home My WebLink About0034 GROVE STREET y �� -, �--- 1 i I i I i i 1 Application number.......................................... S Imo" Fee...................... APR :........... Building Inspectors Initials......... � ................... . II Date Issued...............1��Gt�j.l.............................. 84,91V 4, Map/Parcel...........: ........ .. ......... TOWN OF-BARNSTABLE - -EXPEDITED PERMIT PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION- PROPERTY INFORMATION .Address of Project:' qG)Q00C - A-& A;i .5 NUMBER ,---,STREET VELLAG Owner's Name: Ai A u cA o so u Phone Number "'M�— 3�6 e -AU L., co,-, Email Address: Wvje_�; & j c Cell Phone Number Project cost$ 0-0-D Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby a orize 9QCrN—r-C_4 M x_�-t s to make application for lding permithi:=ate: 780 CMR Owner Signature: 1zTYPE OF WORK S ding 0 indows (no header change)# 0 InsulationAVeatherization 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 \1 o L+k k d I-, L CONTRACTOR'S INFORMATION Contractor's name Q�o c ✓�•4� 5'f° _ Home Improvement Contractors Registration(if applicable)# 7 b G (attach copy) Construction Supervisor's License.# CS S I (attach copy) Email of Contractor i�t.,C�.1A- Cv=� �o�-�I. Phone number L06 ALL PROPERTIES THAT HAVE STRU URE 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. Purpose of Event 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 Fuel source being used LP tank 20 lbs. or>Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. 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 AP�LNANT'S A URE Signature Date All permit applicatio s are subject to a building official's approv for to issuance. ;J 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 (� t- Please Print Legibly Name(Business/Organization/Individual): eA9 � fY\.�A-�� -e—AJ Address: tiS 46'U Lam- ' Z � !�4 (7� ��4-�5�._. ��_�. 700 ,¢SS - City/State/Zip: \ ACwLa OA MA- Phone#: +l A yo n employer?Check the appropriate box: Type of project(required): 1. re I 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 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P t3'• t 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.El am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right'of exemption per MGL 12.0 Roof repairs" insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurafice 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. am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: e? l/ie- �e�S Policy#or Self-ins.Lic.#: t—t U 05 k 160—0 t c7 Expiration Date: h Job Site Address: . 6,,C1oL-L 5'F. City/State/Zip: y4-a&(K, 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 insurance coverage verification. I do hereby certify under pa' d allies of perju th th information provided above is true and correct. Signature: Date: t, ! Phone#: �� a; 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 hire, express or implied,oral or written." An employer is defined'a's"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-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 obtain a 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.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www,mass.gov/dia PRODUCER �. TRAVELERSJw FAX: 877-634-371a Date:03-05-19 Policy No: (6HUB-1K86160-0-19) Effective Date:02-25-19 PROJECT MANAGERS CC LLC 9 SALT MARSH LANE POCASSET MA 02559 THE TRAVELERS INDEMNITY COMPANY OF AMERICA has been assigned as the servicing carrier- for your Assigned Risk Workers Compensation Insurance policy.We welcome you as a customer. We have received your application and premium.Your policy will be issued shortly. Please note that.your binder is proof of coverage until cancelled or the policy is issued. In the meantime, should you find it necessary to fife a claim,request a certificate,or communicate with us, please note the following: For a certificate_of insurance: For Claims Reporting: For Policy Services: Fax a written request to: 1-800.832 7839 800-443-4404 (8TT)336-6036 THE TRAVELERS INDEMNITY COMPANY OF AMERICA'. a_ The Claim Reporting system is a toll-free service that is available seven days a week, twenty4our hours a-day. Usage of this system has been proven to provide significant benefits, with the immecliate assignment of a Case Manager,automatic production of the First Report of Injury form,and earlier resolution of employee claims, _ Safety and Lass Prevention are critical concerns to any business.We have long been,a pioneer in the-field of ac cident prevention, having the experience, resources and capabilities to provide a complete-range of safety ser- vices.Your policy will include more details regarding these services. -- Please keep this Information available. Reference the above policy number on any correspondence and have it, available when contacting us or submitting correspondence. It is our pleasure to work with you.If we can be of service,please call. Sincerely, The Travelers a� I cc: MURRAY & MACDONALD INS 550 MACARTHUR BLVD BOURNE MA 02532 W20M3G10 Page 1 of.1. 001201, - 3 Massachusetts Department of Public,Safety `. } Board of Building.Regulations and Standards License: CS4)95981 COiiStrl3itiori Supervisor WILLI M E PLAkINSHEK 15 L.EXINGTON LANE YARMOWH PORT MA,,0 6ili` %;.-,• `%1 r r;�t�� Expiration: Commissioner 10f2512018 Cx Office of Consumer Affairs and Business Regulation: 10 Park PlaZa-Suite 5170 Boston, Massactusetts 02116 Home Improver - o"gtor Registration v. Types LLC ANA PROJECT-M MS LLC - � O>1_ 1 � 15 LEXINGTON Ulf. rasm ti5]14w19 YARMOUTHPORT,MA 02675 Update Address anal rehn. caa Mont reason for e. SC AI v MA-Oam �g � ••�1r�{�rc�tec�i?rcr..�l�,s�^-��at:,�,r�r�:ell,;� j '- Office of Consumer Aftwis is Business Regulation F_ HOME IMPROVEMENT CONTRACTOR Registrabon valid for tralMdual use only G r. TYPE:LLC f o tine e> on date. If found return Uoi ' Reaistrafion tcRpiraiHon Office of Consumer Affairs and mess Requidion :135863 W114IM19 10 Patk M=-Suite 517 PROJECT MANAGERS Scslo!4 MA M14d .- WILLIAM PLANINSHECC r 15 L EXINGTON W - __.._ . :YARMOUfHPOP.T.MA-02675 M401d nsatm- Undersecretary_ .- 9