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HomeMy WebLinkAbout0269 HINCKLEY ROAD a ��I N� n�� rL� sides `tiyya+ l and Comme"rcial Builder ' RATION SPECIALIST QUAWOW A4 Y _ C£ARTHYC T GT EB>WWW.M T° i October 21,2014 Town,of Barnstable Thomas Perry.CBO Building Commissioner 200 Main Stret Hyannis, MA 02601 : N RE: Insulation Permits Dear Mr. Perry, " This affidavit is to certify that all work completed for permit application#0 at 269 HINCKLEY ROAD has been inspected by a certified Building Performance Institute(BPI) inspector.All work performed meets or exceed Federal and State requirements Sincerely, Michael McCarthy ' McCarthy Construction ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION cy� Map� Parcel Application #� C ((QC l ICJ Health Division Date Issued q .Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 14 one- 1c-j ItA� Village �✓` +-1 �,��rr„� Owner S, ��-b���_ , Address S'.h e Telephone Permit Request .,Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation S-6 Q — Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 0�-' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other co Basement Finished Area (sq.ft.) Basement Unfinished Area (sgaq Number of Baths: Full: existing new Half: existing new CD Number of Bedrooms: existing _new 7P ZZ Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use t APPLICANT INFORMATION- _- (BUILDER OR HOMEOWNER) _ Name Mike-DAaC-n-�Construction— Telephone Number PO Box 52 AddressWest Dennis, MA 02670 License # Cell (508) 280-6964 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# ` DATE ISSUED MAP/PARCEL NO. s.. ADDRESS VILLAGE _ .y t OWNER y ' yr r _ e , DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT _', ASSOCIATION PLAN NO. The.Commonwealth of Massachusetts f Department of IndustfialAccidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Mike mcCartriy Name(Businms/Organization/individual): PO Box 52_ West Dennis, MA 02670 Address: Cell 5 R) 280-6964 . City/State/Zip: CSIp-hon6 HIC-169393 Are you an employer?Check the appropriate box: Type of project(required): 1.[2 1 am a � with Y emP to er 4. 0 I am a general contractor and I --- — 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition workin for me in an capacity. •employees and have workers' g Y aP tY• 9. ❑Building addition [No workers'comp.insurance Comp.insurance., required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g P myself [No workers"comp. right of exemption per MGL 12.[]Roof repairs insurance requirel]t C. 152, §1(4),and we have no 13.�ther employees.[No workers' 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 hue outside contractors must submit a new affidavit indicating such. tContiactors 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 worker;'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: St„��-��y �-�' City/State/Zip: 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 f r insurance coverage verification. I do hereby certi un the and penalties ofperjury that the information provided above is true and correct. Si atuie: Date: /Qt Phone#: Official use only. Do not write in this areg 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 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,associatioA or other legal entity,employing employees. However the owner of a dwelling house having nbt'mote 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 appuitenanf 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 (Le.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 than 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 Offl �-of Investigations 600-�Tashingtou Strut. Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-V7-MAS9A.FE Fa)(#617-727-7749. Revised 4-24-07 w.m=.gov/dia a MWER &U7HGRM7PK FOR 8 td Add D� FPro ). m CA-) m culitaAwd eub6mbnoW for PJSE EngbmAng,to act en my bzhcg to W-lin @'buCftg pry rjtd to paftrm wadc on my pro • G'J - 1 r DdW - - - - Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 b Home Improvement Contractor Registration zz C O A co W Registration: 169393 Type: Individual Expiration: 6/16/2015 Tr# 288121 r r- o 0. 1st {� V1 N i7 H i ?Y .. _ MICHAEL MCCARTHY y n MICHAEL MCCARTHY P.O. BOX 52 i '' '�, y L o WEST DENNIS, MA 02670 <, `Update Address and return card.Mark reason for change. Ca Address Renewal Employment Lost Card �� j\�� Vl '"• SCA 1e� 20M-05/11 n. U1ee W0,92ZI coracuealC/11Q4 c jCe0/uaeM License or registration valid for individul use only Q Office of Consumer Affairs&Busi ess Regulation - before the expiration date. If found return to: m v OME IMPROVEMENT CONTRACTOR n a cn a egistration: 169393 Type:. Office of Consumer Affairs and Business Regulation t 10 Park Plaza-Suite 5170 a u xpiration: 6/16/2015: Individual Boston,MA 02116 ,.: MICHAEL MCCARTHY: MICHAEL MCCARTHY 6 RAN SLEY LN SOUTH DENNIS, MA 02660 - Undersecretary Not valid without signature TE AC47'f> CERTIFICATE ®F LIABILITY INSURANCE DA10/16/20/ ,YYYY, �f• 10/1613 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 01962-001 j NAME: ---- —.. -- -- -..-.. ------.—...------- B den&Sullivan Ins A c of Dennis Inc ;PHONE 508 398-6060 t Y 9 Y :(A/ No.Ext)__( )_ — _ A/C.No.: (508)394-2267 PO BOX 1497 1 EMAIL — — — -- ---------- So Dennis,MA 02660 1 ADDRESS: INSURERLS)AFFORDING COVERAGE_... _.—. NAIC# 1_INSU8ER A_z__AJ_M_Mutual Insurance Company 33758 INSURED INSURER B_-------._... -- --- -------Michael McCarthy Construction Inc � - -- -- SURER C:--- ------ - - O Box 52 WDennis,MA 02670 ;,INSURED_:--- s INSURER E-- ----._...— ..— — ----.-------- �-- 1 INSURER F: i 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 CONDIMCNS OF SUCH POL!CIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAWS. INSR _ -- - --IADDLTSUBR -- T POLICYEFF POLICYfXP — ----- - —-- - LTR' TYPE OF INSURANCE INSR I WVD I -. - POLICY NUMBER LIMITS - ---- - —r— ------------ --I(MMIDD�. (MM/DDIYYI'Y)--1------ - ------ GENERAL LIABILITY - $ EACH OCCURRENCE _� -- - — --- COMMERCIAL GENERAL LIABILITY I DAMAGE TO RENTED $ 1 .-.-.. __ j j FpREMISES(Ea occu rence) i 1 CLAIMS-MADE I OCCUR, I I" !MED EXP(Any one person) $ -- .—. _. •.. i " PERSONAL&AD '$ JURY GENERAL AGGREGATE $ IGEN'L AGGREGATE LIMIT APPLIES PER. I rPRODUCTS COMP/OP AGG $ PRO- POLICY 1_ ' LOC ! COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY I ._------ 1------ --' --- 1(Ea accidentl.._.,_...__. $ ANY AUTO i I L1 BODILY INJURY­(Per person) $ 1 ALL OWNED SCHEDULED I I 1_ _ !AUTOS AUTOS I I BODILY INJURY(Per accident);$HIRED AUTOS NON-OWNED i ! i PROPERTY DAMAGE $ i AUTOS ',(Per accidence $ --- ---- - __TEACH --- --- --- UMBRELLA LIAB OCCUR ( TEACH OCCURRENCE $ 1 EXCESS LIAR i CLAIMS MADE ! ' .AGGREGATE I$ - J DED _ RETENTION $ WpRKERS COMPENSATION I I ._-------T-'----- I WC STATU OTH- AND EMPLOYERS'LIABILITY X'TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE�N!' I I EL.EACH ACCIDENT $ 500,000,00 A iOFFICER/MEM ER EXCLUDED? I Y )LNIA! VWC-100-6017656-2013A 17/17/2013 7/17/2014 I — — --- ---"— (Mandatory in NH) I E.L.DISEASE_EA EMPLOYEEI$ 500,000.00 If m.desc D .RIPT".O_Ne uO e _... _E_L_DISEASE-_POLICY._LI_C Y-LIMIT T I5— 50U 000_.U0OPERTIONS blw _ - — .- 1 ! I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION I TOWN OF SANDWICH Attention: BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL ANNEX z THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sandwich,MA 02563 ACCORDANCE WITH THE POLICY,PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved.