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Home My WebLink About0176 HINCKLEY ROAD r a Town,of Barnstable *Permit Expires 6 months fr n issue elate Regulatory Services Fee -6� sAiNSTAiLE, 9MASS, Thomas F.Geiler,Director Building Division Tom.Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601'' www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTUL ONLY V Not Valid without Red X-Press Imprint Map/parcel Number 3 I D Property Address I r l'o A l n f!y P_k�, JA.!4 (-Vn n v..s ❑Residential Value of Work 7j a Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C*1Z l 1`' 510 ra E if 1r� �,-All" _,04 OQA'A e;. Contractor's Name L l rJAefG Telephone Number -257-s 5 -r' -- Home Improvement Contractor License#(if applicable)_ A 49 Zorkman's ction Supervisor's License#(if applicable) t42-9;'t Compensation Insurance SS PERMIT VI one: am a sole proprietor MAY —4 2�12 ❑ lam the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name . L l 64 0VVT_A6L TOWN OF BARN.STABLE Workman's Comp.Policy# VJ G 13S 3N._6 1—6Z Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(checkbox) E Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to 0�,0'N �� rA&oLL ^ Auwcj ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. . ***Note: P perry Owner must 'gn Property Owner Letter of Permission. copy of the Home rovement Contractors License&Construction Supervisors License is r ired. SIGNATURE: - Q:\WPFILES\FORMS\building permit formsTMESS.doc . Revised 051811 .t The Com itanwenith of massac.,h"Setir �nent ofI cdA3ents v Office ofInvertrgations 600 Washington Street Boston,MA 02111 wmvmamgov1dia Workers' Compensation Insurance Affidavit: BuiItiers/ContrActarsJF. tric anslPlu nbers Apiplicant Information Please Print Legib Name�$i]S1IDeniaalnC t.IC_riiv rin��} (J e Address: `75 OEL- A Are you an employer?Check the appropriate boa: Type of project(re�niredj: 1.❑ I a�a employer with. 4_ ❑ I am a:gespeaal c�satractor aad I have hired the sob-c�omna�ctors 6_ Q I�ieuv coi�ucfiou employees{fall at�for Pail-time)- - . 2. I am a sole proprietor or partner- listed on the attached sheet. ?_ .❑Remodeling { and have no employees These sub-contractors have �P � 8. ❑Demolition . wcddng far me in any capacity_° employees and have workers' [No`vorkeW comp.insurance camp:insuram-e l 4- ❑Btttlding addition required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all,work 11.❑Plumbing repairs or additions myself [No workers'comp_ eight of exemption per MGL 1 j Rnof repairs insurance ram)S c.152, §1(4�and we have no �" employees_[No woilms' 1311 other camp_msmmce required] t licant Any app that checks bax#1 mns4 also fiII out the section below showing this workers'compensation policy tion- Homeowners who submit this af5davi6 indicating they are doing all wank and then hoe outside contractors must submit a new affidavit indicating such. YContractm that check Ibis boar must attached an additional sheet showing the name of the sub-contractm and:stare whether or not those entities have employees-If the am-contactarslave employees,they immprovidetw woikers'tome.policy number. . I oar an empdnyer that is prataidirng workers"cat renrs 'ori i ranee for pry ertrpdnjw#& Below is thepalicy mm ob site iefornniaiurrt. Inst'uance:Company Dame: Policy#or Self ins_Lic.#: `p 0 Expiration Date: Job Site Adddress: I N, CitylState�Zip: l5 Attach a dopy of the workers'comp Jun,policy declaration page(show ng'the policy tiro ber.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 andlor one-yeai imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a:ne of up to$230_00 a day against the violator_ Be advised that a copy of this statement may be fbi warded to the Office of Investigations of the DIA for Inslimce, overage verification.. ' Ida hereby G 'a the 'ns an d ahies ofpeditty that the irnf0rMM'6ant,prnueded a`7 is and correct Sr Date: Phone#: 0 Fidonly. Donot write inr this area,to be compWabd by cityor town offs at n: PermitlLicease# Issuing Authority(circle one): I.Board of Health 2.lading Department 3.Cityfrown Clerk 4 Electrical Inspec for 5.Plumbing Inspector 6.Other, CORbCt Person: Phone 9: 6 / 7 ® DATE(MM/DD/YYYY) AC®M® CERTIFICATE OF LIABILITY INSURANCE 5/2/2012 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 NAME: FIRESIDE INSURANCE AGENCY, INC. PHONE (508) 487-9044 FAX (508)487-0649 A/C No Ext: A/C,No: #10 Shank Painter Cmn. PO Box 760 E-MAIL ADDRESS:firesideinsurancel@hotmail.com Provincetown, MA 02657-0760 INSURER(S) AFFORDING COVERAGE NAIC# firesideinsurance.com INSURER A: PATRONS MUTUAL INSURANCE INSURED ANDREW LINDERA INSURER B:LIBERTY MUTUAL INSURER C: 75 HELM ROAD INSURERD: EASTHAM, MA 02642 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER - POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence)' $ 50,000 CLAIMS-MADE CI OCCUR MED EXP(Any one person) $ 5,000 A CTR0007687 02/13/12 02/13/13 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ JECT 71 AUTOMOBILE LIABILITY BI ED I I Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ NON-OWNED I PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION Y/N WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE C� E.L.EACH ACCIDENT $ 100,000 B (OFFICER/MEMBERMandatory EXCLUDED? N/A WC131S-351687-021 05/11/11 05/11/12 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CARPENTRY/INDIVIDUAL LOCATION: 6 NELSON AVE. .-UNIT-A PROVINCETOWN MA 02657 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF PROVINCETOWN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVRk L 1 A Ri _ 110N. All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered marks of P RD i I + RARNSTABLE • t'own of Barnsable 9� i6;q. ,0� . Regulatory Services Thomas F. Geiler,Director . Building Division Thomas Perry,CBO. Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us - Office: 508-862-4038 Fax: 508-790-6230 Property er Owner Must Complete and Sign This Section If Using A Builder I, YY1.R1 I C� , as Owner of the subject property ll , hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: unck- I e—t-4 V (Address of job) �FrnnwS Signature of Owner Date — mpozXE Vua2. Print Name If Property Owner is applying for permit,please complete.the Homeowners License Exemption Form on the . reverse side. Q:\WPHLESTORMS\building permit formsTNPRESS.doC Revised 051811 i 'THE Town of Barnstable Regulatory Services 9� Masa. $, Thomas F. Geiler,Director 1659. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 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 (Seetlonti 109.1.1) } l+y The undersigned"homeowner"assumes responsibility for compliance with t o State Buiiding`Code and other appli:681e eddes, 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) _ r Approval of Building Official g q P Note: Three-family dwellings containing 35,000 cubic feet4or larger will be required to comply with the State Buildin g-Code Section 127.0 Construction Control. lftOMEOWNER'S EXEMPTION _ �, `�E" "�' •` ?,r.' 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 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 respon9i'bil es'of a supervisor'.F' (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 �r�:_ 11.t>sacht{>ctt. - l)�Irti•ttttcnt�,t'Pitlalic �t#� ��, , Btiard of, Sttiti#i,n- Rc;6I;ttiims:and t,tndartl� t �t�ti r, Sup %aSCr License:. CS 87349.. « ANDREW C LINDERA -44 k •75 HELM RD r ' 46 EASTHAM; MA 02642 ExpiratioP: 11/18/2013' { .aitani.vi rrcv T,fz: 5413 ¢ XI /J'1(X.CM�C6eG(� • •a Office of consumer Affairs&Business Regulation License or registration valid for individul use only 4 E HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ^� : Registration: :142941 Type: Office of Consumer Affairs and Business Regulation Expiration: ,6/3/2014 Individual 10 Park Plaza-Suite 5170 \ Boston,MA 02116 ANb2EW LINDERA ANDREW LINDERA # R 75 HELM RD. EASTHAM, MA 02642{_ Undersecretary_ y Not valid without signature