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HomeMy WebLinkAbout0018 HOLMES LANE %8 � �R ��'m� �m YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you-permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,,1st FI., 367 Main St, Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. � •s�� r; f�� DATE: n Fill in please: APPLICANT'S YOUR NAME/S: A rS �r,Ly i54 BUSINESS YOUR HOME ADD ESS: l E-1 t-ti-,c r1/ �S x{x ,� o 2 l' sb 1�Ytfy�G x zr� az C� ra ELEPHONE # Home Telephone Number NAME OF CORPORATION. 2� NAME.OF NEW:BUS.INESS 2 b rZ " �,12 TYPE OF BUSINESS 1$THIS;A HOME OCCUPATION? a `YES NO ADDRESS,OF'BUSINESS MAP/PARCEL NUMBER_ [Assessing) When starting a new business there are several things you must do in order to be in compliance with the r as and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST O TO 200 Main St. (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to le y operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE n This individual has been informed of any permit requirements that pertain to this a of business. Authorized Signature** V COMMENTS: 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. At Authorized Signature** Z COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of thelicensing requirements that pertain to this type of u ine Sol v Authorized Si ture** COMMENTS: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division Date Issued Conservation Division pplication Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 9Y A)644� Historic - OKH _ Preservation / Hyannis Project Street Address Village VT Owner " 70� Address ASS. � tCex Telephone Permit Request A fir ° -cre��L �'/f iz�' R�ciod7 �# 4111, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation D Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup porting;documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King,'.%Highway]Yes, ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.fth I Number of Baths: Full: existing new Half: existing I new Number of Bedrooms: existing —new 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 APPLICANT INFORMATION S (BUILDER OR HOMEOWNER) n� Namej Telephone Number a � •(���1 r �rl Address °�� License# Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCT DEBRI REAJLTING O THIS PROJECT WILL BE TAKEN TO SIGNATU _ DATE FOR OFFICIAL USE ONLY APPLICATION# DATEISSUED MAP/PARCEL NO. .t ADDRESS VILLAGE } OWNER DATE OF INSPECTION: FOUNDATION t FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL j GAS: ROUGH FINAL y FINAL BUILDING Y DATE CLOSED OUT ASSOCIATION PLAN NO. t .. 1 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 "s Please Print Legibly Name(Business/Organization/Individual ' �' A ) Address: Svc �Y �C,/f>nCp a City/State/Zip: /`A V 1V% - `6140/. Phone.#: e0/ Are you an employer? Check the appropriate box: Type of project(required):x 1.❑ I am a employer with .4. ❑ I am a general contractor and I employees(full and/or part-tim.e). *. have hired the sub-contractors 6. ❑"New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.. El Remodeling ship and have no employees These sub-contractors have g: -❑Demolition workingfor 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 fiD 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. xContractors 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 isproviding workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: Policy#or Self-ins. Lic.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the wo rs'compensatio olicy declaration page(showing the policy number and expiration date).; Failure to secure c era as require der Se on 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,50 .00 d/ r one-year imp ' onmqht,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250. day ainst a violato Be dvised that a copy of this statement may be forwarded to the Office of I Investi ations the D for uran a ve Re verification I do hereby ertify-u r th ains ties o ry that the information provided above is true and correct Sip-nature: Date: P f /� d!/ Pho Kr Offlcia o 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 Departmenf 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, 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. of on the.grounds or building appurtenant thereto shall not.because of such employment be deemed to be anemployer." MGI;.chapter 152,§25C(6)talso,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'buildiirgs in the'comni nwealth-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-contractors)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 maybe 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 fo any business or commercial venture (i.e. a dog license of m permit to bu 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 11-22-06 www.mass.gov/dia . , w • ��a4'THE ray - Town of Barnstable Regulatory Services- Thomas F. Geiler,Director MAIM 16 ibs� .,erg Building Division PrFoy Tom Perry, Building Commissioner 200 Main-5treet,_Hyannis,MA_02601 www.town.b arnstable.ma-us Office: 50S-962-403 8 Fax: 508-790-6230 ETMn OVNER LICENSE EXEMPTION n^ Please Print DATE: JOB LOCATION: - 1115—lam �a,y ,C A/IV/�. �}o//�� number street T village p -HomEOWNfiR": nam ^ home phone# work phone# CURRENT MAILING ADDRESS: /-1%/h AJ Vl,� i-,�"tozo Cbt6o/ � ••, itty/town - statz zip code Tile current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage Ian individual for hire who does not possess a license,provided that the owner acts as supervisor_ DEFINITION OF HOMEOW7\'ER Persons)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 under ' ed"homeowner"as times responsibility for,compliance with the State Building Code and other applic e.co ylaws, s an regulations. Th dersi "ho eowner" e es that.he/she understands the Town of Barnstable Building Department um' ectio ro ur requirements and that be/she will,comply with said procedures and r ements i ature of H A roval of uilding a4 Note: Three-family dwellings containing 3 5,000 cubic feet or larger will be required to'�mply with the State Building Code Section.127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeowner performing work for which a building pernvt is required shall be exempt from the•provisions of this sccti on.(Section 109.1.1 -Licensing of constriction Supervisors);provided that if the homeowner engages a pa sons)for hire to do such work,that such Homeowner shall act as supervisor." Many homcowncrs who use this exemption arc unaware that they art assuming the responsibilities of a supervisor(see Appendix Q, Rulcs&Regulations for Licensing Cmstructiori Supervisors,Section 2.15) This lack*of awareness often rosults in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlieeased person as it would with a licensed Supervisar. The homeowner acting as Supervisor is ultimately respons�b)e. 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 hdshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by scvctal towns. You may care t amend and adopt such a forr /cmiF)cation for use in your community. Q:forms:h omccx cmp t Town of Barn-stable ` Regulatory Services f f f t • BARNS[ABLJ f v N g Thomas F. Geiler,Director E1) BuiIding Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barngtable.ma.us Office: S08-862-4038 Fax: S08-790-6230 l Property Owner Must Complete, e and Sign This S/subject i P g If Using A Buildeas Owhereby authorize half, m all natters relative to work authorized by this boil ' permit application for. (Address of ) Signature of Owner Date Print N If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. L Q:F0WS:0 WhIERPERMISS)DN - . �S�X� � r� � C l✓T���� a h . a " s, . V C.ommonwea&o f MaJdacLeffj Official Use Only Apartment of-7h e Sewice9 Permit No. Occupanc and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07 (leave blank APPLICATION FOR PERMIT TO PERF/Date- CityECTRICAL WORK All work to be performed in accordance with the Massachusetts MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION)or Town of: 18�� ector of Wires: By this application the undersigned fives notice of his or her intention to ptrical work described below. Location(Street&Number) Owner or Tenant Telephone No. ! �y. Owner's Address Zt- Is this permit in conjunction with a u Yesilding permit? No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts erhead ❑ Undgrd❑ No.of Meters New Service Amps Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electric Work: ' Completion ofthefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.o eil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets N .of H Tubs Generators KVA No.of Luminaires wimming ool Above ❑ In- [I No.o Emergency Lighting d rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Bu ers FIRE ALARMS No.of Zones No.of Switches No.of Gas Bur rs o.o etection an Initiating Devices Tot Z W Z No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Numbe Tons KW No.of Self-Contained 5. �; P .._.. _............................ �o� Z Totals: _ Detection/Alerting Devices Z w i5, � No.of Dishwashers Space/Area Heating Local❑ Municipal El Other Connection ~ Z¢ No.of Dryers Heating Appliances KW Security Systems:* �'= z No.of Devices or Equivalent Z No.of Water No.of No.o o W KW Data Wiring: Heaters Signs Ballast No.of Devices or Equivalent 0� o�W Q No.Hydromassa Bathtubs No.of Motors Total HP Telecommunications Wiring: X No.of Devices or E uivalent � N ww ' UJ �o LL OTHER: ag W W ¢ Attach additional detail i es red, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by manic al policy.) �o� o Work to Start: Inspections to be requested in accordance with ME Rule 10,and upon completion. W,W W INSURANCE COVERAGE: Unless waived by the owner,no permit for the perform ce co of electrical work may issue unless a o a a the licensee provides proof of liability insurance including"completed operation"coverag or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the rmit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is ue and complete. FIRM NAME: LIC.NO.: Licensee: Signature LIC.NO.: (Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No., Address: Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement, I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ � OVv \gr 1�11j\ tt Y{Sy t ► is t y f wV11 m• ;+{ �9 a , ON ' 'CV ov lki c T14 Eev aE G Commonwealg o f MaMacLeffj Official Use Only cc�� cc77 Permit No. 1JeParEmant o�}ire�ertrice� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL.MORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12 0 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: To the Inspector of Wir s. By this applica; n the undersigned gives notice of his or her intention to perform the electrical work scribed below. Location(Street Number) Owner or Tenant Tel hone No. Owner's Address Is this permit in conjunctio with a building permit? Yes ❑ No ❑ (C eck Appropriate Box) Purpose of Building Utility Authoriz on No. Existing Service Amps / Volts Overhead ❑ Undg ❑ No.of Meters New Service Amps Volts Overhead❑ Un rd ❑ No.of Meters Number of Feeders and Ampacity r Location and Nature of Proposed Electrical ork: Completion o the llowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:S .(Paddle)Fa No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool A ve In- ❑ o.of Emergency Llgnnng rn nd. Battea Units No.of Receptacle Outlets No.of Oil Burners A FIRE ALARMS No.of Zones o.of Switches No.of Gas Burne o.o Detection and $ Initiating Devices F � 5 o No.of Ranges No,of Air Con To 1 No.of Alerting Devices 9 P eat Pump .umber Tons KW No.of Self-Contained W No.of Waste Disposers �X 1�, Totals: Detech rti on/Alen Devices z is No.of Dishwashers Space/ACun r Heating KW Local❑ M 'c onneh'onl ❑ Other Securi No.of Dryers Heatin Appliances KW No.o Systems:* f Devices or Equivalent No.of Water No.o No.of 09 •fli c Heaters KW ins Ballasts Data Wiring: No.of Devices or Equivalent IL 92 it!� Telecommunications Wirin : �oLL No.Hydromassage Bathtubs N .of Motors Total HP > No.of Devices or Equivalent M U W o o �OTHER: - ' LL' co Attach additional detail if desi d,or as required by the Inspector of Wires. y Estimated Value of Electrical Work: '. (When required by municipal olicy.) < Work to Start: In ections to be requested in accordance with MEC le 10,and upon completion. INSURANCE COVERAGE: Unl s waived by the owner,no permit for the performanc of electrical work may issue unless the licensee provides proof of liabi insurance including"completed operation"coverage r its substantial equivalent. The undersigned certifies that such co rage is in force,and has exhibited proof of same to the p t issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andp naldes ofperjury,that the information on this application ' true and complete. FIRM NAME: LIC.NO.: Licensee: Signature LIC.NO.: (If applicable,enter "exempt"in the license number line.) Blus.Tel.No.: Address: Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. . OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by, law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ tv 7IN Y ` t oil} Jl F vv Town of Barnstable IRE rti o Regulatory Services Thomas R. Geller,Director n[RFiCr.LRT.F. E ' 4� XAS& Building Division ��► �� Tom Perry,Building Commissioner 200 Main Street; Hyannis,MA 02601 ,47 Fax: 508-790-6230 Office: 508-862-4 8 REQUEST FOR ELECTRICAL INS. EC N 1 "ELECTRICAL PERMIT NUMBE ' ` j (Permit required in der to process inspection) f f Today's Date Requested Date of Ins ection I hereby request an insp ction under Massachusetts :. General CEEIectrici �- Law chapter 143, section 3L d 237 CMR 4.02(3). The installation will be ready r inspection at (Property Location)- Type of inspection requeste ' ❑ El Service Re-innspection Temporary Service ❑ Excavation ❑ `��Rough Re-inspection 0 Service Inspection ❑ Final Re-inspection ❑ Rough Inspection for ($100.00 Re-inspection Fee) ❑ Final Inspection for . 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''sue' -, "`" ,�. +.. —^'•—z-"=-'--,,. �, s,- -- -PL - -"`�."•^.w. -.,...�*►..._tea- ,�.�'"".,`r 'w' -=x..::�..,� 3, CD O TOWN OF BARNSTA ;BLE 3 - REGULATORY SERVICES BUILDING DIVISION STOP WOYIK TIIISSTRUC YUREAND/OR PREMISES HAS BEEN INSPECTED AND THE FOLLOWING VIOLATIONS OFTHE BUILDING CODE AND/OR ZONING ORDINANCE HAVE BEEN FOUND: 7'3) x a' YOU ARE HEREBY NOTIFIED THA"r NO ADDITIONAL WORK SHALLBE UNDERTAKEN UPONTHESE PREMISESUNTILTHEABON"E ,. VIOLATIONS ARE CORRECTED. ANY PERSON REMOVING THIS NOTICE WITHOUT PROPERAUTHORIZATION SHALI,BE LIABLE °? TO AFINE OF NOT LESS THAN FIFT I,NOR --' MORE THAN ONE HUNDRED DOt_LARS. ' Address Date E Building Commissioner �. 4 5 f x f 1 1 M; CD xBor - d y F. , r 00 f 1 t 4 '.1- M1 9' `�.:. r ) v..5� � -S. a Y -. � '�. " .w � 4 '«�' as �s�� �.d. { L�'L• ti i "'7Fm 'h �7 5i A rt 1 1 \ `a x � s , w V. W. q� v j r u 41 t !!ill t f 4 _ 4 �' `Papa � •�. IALA * ' 1 wt fa .y q a yet+ �`�� '� z: � ♦ �; �+ ; . .i n c�` tf �+�. c. .t a k e , '-:» 4 `e7Qtr^ a, 7Y�. �. 3K•, •-•� �}• /� k w .. y 31� S � Y f��, ~ �,�'�' p w , , w _ pa io _...� ��•.'C y �y r T+ F +r I's A -7)7�4t!�` t6"O.F q Awl, t0l, F':v 0 Zt z Z WWI%s'{ +x' ,.�•,.. • ,+c 4 4 � ..�. ,;:� `" @Skm R .y r a... «a_T�i ,,.d` �, - ��.., - �_ �-•� .bf ...,� 4A.. �.4• . -k-•�f' ,� •r `+�.-.:... j.1 _ _ �r ,2�:Y'�.,.+ V4"... ri„•' .,�„•s��-^c✓'['"`-�'•^G a� -''o,.. Aw-7Z' -:ft 461, • JOG Ir, �C, ,�';_•v�,�c.'��¢.F,Y$%��wk�si?"'�+��_'."�""'"G'.:,�sw:r+'an.«,.•.-...w,�;�_. ?^... V, ..w..,;,rrs:.,.,r ;�,,,,_ ...,,�.. -...�.f,.,.ydy�4�.,M'a.1+ �.V.trj: :r_.u..,5,.-... -u ..- ... ...,.r..z,Z,...<v.,�.. n .-i. Town,of Barnstable P�oF:THe, �` -Regulatory, Services v ".Thomas F. G`eiler, Director BARNSPABLE. 9�. 63, `0g Building:Division` . iOTEo +" Thomas,Perry, CI O6 Building Commissioner `20O Main Street,'Hyannis;`MA 02601 wwwaown.barnstable.ma:us; Office: -508-862-4038- ' Fax: 508-790-6230 EXIT ORDER DATE: LOCATION: a UNDER THE PROVISIONS OF 780 CMR; THE STATE BUILDING CODE, SECTION 3400.5.1;YOU ARE HEREBY,ORDERED TO IMMEDIATELY DISCONTINUE THE USE OF THE CELLARLBASEMENT.AREA�FOR SLEEPING PURPOSES. LOCAL INSPECTOR. . SIGNATURE OF RECIPIENT ,ODEADE SAIDA: .DATA: _. f `� LOCALIDADE: DE ACORDO COM O PROVISORIO 780 CMR;CODIGO DE CONSTRUCAO DO ESTADO; PARAGRAFO 3400:5.I,,.VOCE ESTA ORDENADO DE DEIXAR DE USAR, IMEDIATAMENTE, A:AREA DO MR.AOBASEMENT PARR O PROPOSITO-DE.DORMIR; INSPETOR.LOCAL ASSINATURA DO RECIPIENTS Icy �elvt�S � � � � `� - �O� - oCOo � ��� G�:�-d,�ea� C1 CY" � �� '� r / C TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION L3 Map �3 v Parcel v k,,Application # �60 Health Division Date Issued Conservation Division Application Fee . Planning Dept. ; a g ep , .Permit Fee Date Definitive Plan Approved by Planning Board �U Historic - OKH Preservation/Hyannis Project Street Addressor tv4s � N6 Village /✓ Owner P-,Q 60 v2 '�� vS ,�/¢ia�r Address PO-/V 4 1:2 Telephone 508 90/- 493 � ' Permit Request .4616710116 T-Ile X/IL X&Lrled6 15 ,�'`-�,�'or+�s fir✓ O�✓� >`r✓ /,��5�-0�-���ya �PEs r�it�-t�' ?�,�.or�l ��®r��o.v... Square feet: 1 st floor: existing proposed 2nd.floor: ,existing proposed Total new Zoning District Flood Plain - Groundwater Overlay Project Valuation 9e u Construction Type Lot Size Grandfathered: ❑Yes ❑'No If yes, attach supporting documentation. Dwelling Type: Single Family ::❑ 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 Basement Finished Area (sq.ft) Basement Unfinished Area (sq.ft) ` Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new 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 Mo APPLICANT INFORMATION - _ (BUILDER OR HOMEOWNER) Name b Telephone Number Address ` >C. - License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTI DEBRI E TING RO THIS PROJECT WILL BE TAKEN TO SIGIVA `' e AllDATE t r - °r FOR OFFICIAL USE ONLY — cr ` APPLICATION# --,"DATE ISSUED: st,MAP,/.PARCEL NO.�.Lz f • .ADDRESS,,' VILLAGE � w OWNER ' DATE OF INSPECTION: *');FOUNDATION+ FRAME � u1"1NSULATION. .�.� "' °`• "` -' FIREPLACE r r ELECTRICAL: ROUGH FINAL y PLUMBING: ROUGH FINAL GAS.:.; -�ROUGH '`�' ( FINAL — — ___ � NAUBUILDING X �_Ar_ � ; RI } i *°:..'DATE:=.-CLOSED:O .T,x ASSOCIATION PLAN NO. s _ r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street t !1 Boston,NIA 02111 wwminass.govfdia. Workers'Compensation Insurance Affidavit: Builders/.Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl. Name(Business/Organization/Individua Address: 0, C,2 .I City/State/Zip: Phone #: Are you an employer?Check the appropriate boi: (required): ; xt . r Type of project 1.El am a employer with' 4. 4 I am a general contractor and I * have hired the sub-contractors -6. .❑.New construction employees(full and/or part-time). . . t 2.❑ f am a sole proprietor•or partner- listed on the attached sheet. 7. Q.Remodeling sub-contractors,ship and have no employees These have +. 8: E]Demolition, working for me in any capacity. employees and'have workers' com insurance -11 ! I t 9.' El Building addition [No workers comp..insurance p' � 10.❑ Electrical.repairs or additions required.] 5. ,Q We are a corporation-and its officers-have exercised their t 3.❑ I am a homeowner doing all-work I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL r '12.Q`Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No.workers' 13.0 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. t 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, information. Insurance Company Name:` Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: - Attach a copy of the workers' compensation policy declaration page(showing the policy:numb er'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 a ne-ye ` ' risonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a ag inst the viol to'. Be advised that a copy'of this statement may be forwarded to the Office of Investigations th DI for` surance verage verification. I do hereby ertify u r it a pain a d penal ' f perjury that the information provided above is true and correct. Signature: Date:, /0 P Official use only. Do not'write in this area ,ato be completed by city or town official , City or Town: Permit/License# Issuing Authority(circle,one): 1.Board of Health.2. Building Departnient..3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector , 6. Other Contact Person:` Phone#: r M1 . 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 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 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. a 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-MAS8AFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia , ' a CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIVYYY) F0610112010 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). 'RODUCER - - UUMAGI Schlegel & Schlegel Insurance Brokers Inc NAME. PHONE (508) 771 - 8381 34 MAIN STREET (AC,No,Ext): (a�No):(508) 771 - 0663 E-MAIL - - _ADDRESS:- CUSTOMER ID#: - West Yarmouth, MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# NSURED INSURERANGM INSURANCE Adilson Segolini Dba Segolini Construction INSURERBGRANITE STATE 117 Minton Lane INSURER C: i INSURER D: i - West Barnstable, MA 02668 INSURER E: INSURER F: :OVERAGES 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. VSR _TR TYPE OF INSURANCE POLICY r1C­YEXP INSR WVD - POLICY NUMBER (MM/DDfrffYY) (MM/DDIYYYY) LIMITS GENERAL LIABILITY- MPT8486II 05/07/2010 05/07/2011 DAMAGE EACH OCCURRENCE S1,000,000 _ . MAGETO RENTED---- -'—"---'-- `-'-'---'------ $ :COMMERCIAL GENERAL LIABILITY � PREMISES(Ea occurrence) -S5O0,000 _ CLAIMS-MADE I^ 'OCCUR - MED EXP(Any one person) $10,0 0 0 - _ PERSONAL&ADV INJURY S1,000,000 - GENERAL AGGREGATE - $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - - - - PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO- JECT LOC _ S AUTOMOBILE LIABILITY - - .. COMBINED SINGLE LIMIT ANY AUTO - - (Ea accident) $ALL OWNED AUTOS - I BODILY INJURY(Per person) S - BODILY INJURY(Per accident) S i SCHEDULED AUTOS - - PROPERTY DAMAGE HIRED AUTOS $ (Per accident) NON-OWNED AUTOS $ S UMBRELLA LIAR OCCUR - EXCESS LIAB - EACH OCCURRENCE $ CLAIMS-MADE I(� DEDUCTIBLE AGGREGATE $ :I RETENTION $ $ ' S B WORKERS COMPENSATION + WC-007-648-4368 05 23 201005 23 2011 wcsTATu- orH- AND EMPLOYERS'LIABILITY / / / / X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN - - OFFICER/MEMBEREXCLUDED? ❑ NIA - E.L.EACH ACCIDENT S 100,000 (Mandatory in NH) - If yes,describe under - E.L.DISEASE-EA EMPLOYEE S 100,0.00 DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT S 500,000 IESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ADILSON SEGOLINI HAS ELECTED COVERAGE FOR HIS WORKERS COMPENSATION POLICY :ERTIFICATE HOLDER CANCELLATION DONE ON'FILE SHOULD. ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE - THE .EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ' AUTHORIZ REPRESENTATIVE O 1 CO,ACORD CORPORATION. All rights reserved�_ fj tCORD 25(2009/09) The ACORD name and logo are registered marks of ACO Town of Barnstable 0pIHE tp�y o Regulatory Services EARN.-rBLF- ; Thomas F.Geiler,Director Building Division PrEo µay a - Tom Perry, Building Commissioner 2.00 Mairi.Street,"Hyannis,MA.02601 Rww.town.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6236 HOMEOV NER LICENSE EXEMPTJON nn Please Print DATE: 0/7/4 JOB"LOCATION: �> a- x/0("',Jam. �� ' number sirctt village "HOMEOWNER" 1� YI Co name home phone#' work phone# �^� F CURRENT MAILING ADDRESS: c ty/town 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,'piovide`d that the owner acts as supervisor. ,DEF1N ION OF HOMEOWNER Persons)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 under the building permit. (Section 109.1.1) The undersign �hoqmeown sumes sponsibility for compliance with the State Building Code�and"other- applicable des la, ,rules an a ons. 1 ',t The un ers' ed"ho to. r"certifi .s t.hdshe understands the Town of Barnstable Building Department tnspectio ro es apd.r irements and.tbat he/she will comply with said procedures and , require en Si re of'No eo f ' .r - Appr a Note: Three-family dwri ings Z6n/taining : 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. } ' HOMEOWNER'S EXEMPTION .The Code states that: "Any homeowner perfomring work for which a building permit is required shall be exempt from the provisions of this section.(Scction 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." E. Many homeowners who use this exemption are unaware that they arc assuming the responst&litics of a''supervisor(see Appendix Q. Rules&Regulations for Liccruing Construction Supervisors,Section 2.15) This lack of awareness.often results in strious problems,particularly when the homcownc hires unlicensed persons. In this case,our.Board cannot proceed against the unlicensed.pmon r as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is folly aware of his/her responsobilitits,many communities require,as part of the permit application, that the homeowner certify that helshe 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'fornikartifiration for use in your community. Q:for rT s:homccxcmpt J Town of Barnstable F Regulatory Services w1ss. Thomas F. Geiler,Director Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: S08-862-4038 Fax: S08-790-6230 Pr perty Cromer 7er t ' Comple and,Sign Thection - If Usin A Bui1 as Owner of the subject ro e P P riY �— ere y authorize ' S- 06 ' r j'/Z(IC repm/ to act on my behalf, in all matters relative to autho ' this building permit application for. (Ad ss o Job) S na Date not ame If Prove Proverty er is applyingI or permit please com ete the Homeowne License Exemption Form on the reverse 'de. Q:FORMS:O'AWERPERMISSION ,: 11 R i I II .. 1 i 1 i a f I 1 1-00 i10 ........ � . 1 ._ ll - - --- .. ........ .. i' 3 zs� _. _ _ _ ... 3 - - - -- . __. .- ...._ _ - I -_.--..._._-_... ...__- -'----��t(- �� - - ------ C 5d L PPP ---- -----= -- - V � s r 3� - .... - - - - -- - - - ------ - --- - --- i - G C>?C)/m 39F Op SHE Tp� Town of Barnstable Permit Expires 6 mwrths from issue date Regulatory Services Fee < g i r BARNSTABLE, t MASS. w r Thomas F. Geiler,Director 1639. AlfDMA1 - ESS PERM', t Building Division . Tom Perry, CBO, Building Commissioner �1"f; 200 Main Street,.Hyannis,MA 02601 1_, wwtiv.town:barnstable.ma.tas TOWN Or BAR�d`�:�ABLF-. Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valhi rvithoui Red X-Press Imprint Map/parcel Number6 Q 13 Property Address [ Residential Value of Work 9�t Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 7056 1�05 rj�IZI,7�- _s Contractor's NameLSOwGOI.��/� Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name .JtELEGEL Workman's Comp.Policy#- 3 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side 10 #of doors Replacement Windows/doors/sliders.U-Value Oa (maximum .44)#of windows_ *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. k**Note: Property Owner must.sign Property Owner Letter of Permission. . A copy of the Home Improvement Contractors License & Construction Supervisors License is required. c The Cointnonwealth ofNlassachusetts T Department of Industrial Accidents d� Office of Investigations t 600 Washington Street 1 Boston, 111A 02111 www.inass.gov/dia Workers' Compensation Insurance.Affidavit;.Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly_ R t Name (Business/Organization/Individual): �G�ar �� l.EY"�f'T/CCJETICJ� Address: /l 7 City/State/Zip: !, j 7 T Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1. I am a em to er.with � 4. �] I am a general contractor and I P Y 6. ❑New construction employees (full and/or art-tim .* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and.have no employees These sub-contractors have g, ❑ Demolition workingfor me in an ca acit , employees and have workers' Y P Y 9. ❑ Building addition [No workers' comp. insurance comp.insurance. ] req uired. 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, [Norworl�ers'_cozrrp, _ . nght of exemption per MGL 12.❑.Roof..repairs, . : ,.. insurance required.] t c. 152,-§1(4), and we have,no employees. [No workers' 131:1 Other S 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 isproviding workers'compensation insurance for in employees. Below is thepolicy andjoh site information. Insurance Company Name:. l Policy#or Self-ins:Lic. #: Expiration Date: Job Site Address: 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 tinder 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,�erehy certify under the pains'and penalties of perjury that the information provided ahove is trite and correct. Signature Date: IPhone# , ' Official use only. Do not write in this area, to he completed by city or town official I City or Town: Permit/License# y Issuing Authority (circle one): I Board of Health 2. Building Department 3, City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: 1 Information and Instructions i 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 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,NIGL 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 notrequiired to carry workers compensation nsurance.'If an LTC or LfP'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. 1n 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 homeowner or citizen is obtaining.a license or permit not related to,any business or commercial venture ( g or i.e. a do license 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 CERTIFICATE OF LIABILITY INSURANCE =DDrrfyy) 10 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: Schlegel & Schlegel Insurance Brokers Inc PHONE (508) 771 .- 8381 508) 771 - 0663 34 MAIN STREET E-MAIL"Ertl: (ac.No ADDRESS: PRODUCER CUSTOMER to p: West Yarmouth, MA 02673 INSURER(S)AFFORDING COVERAGE NAIC/ INSURED INSURERANGM INSURANCE Adilson Segolini Dba Segolini Construction INSURERBGRANITE STATE , 117 Minton Lane INSURER C: INSURER D: - - West Barnstable, MA 02668 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 - B LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP (MMIODIYYYY) (MMIODNYYY) LIMITS A GENERAL LIABILITY MPT8486U 05/07/2010 05/07/2011 EACH OCCURRENCE S1,000,000 "-"'- " --- --- J( I COMMERCIAL GENERAL LIABILITY DAMAGE76RENTEDPREMISES(Ea occurrence) S500,000 CLAIMS-MADE C'OCCUR _ - MED EXP(Any one person) $10,000 I I - - PERSONAL&ADV INJURY s1,.000,000 I - GENERAL AGGREGATE $2,000`,000 GEML AGGREGATE LIMIT APPLIES PER: - . - PRODUCTS-COMPIOP AGG s2,000,000 POLICY PRO • JECT LOC - $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ' ' BODILY INJURY(Per person) S 1 ALL OWNED AUTOS i w BODILY INJURY(Per accident) S !SCHEDULED AUTOS PROPERTY DAMAGE 8 HIRED AUTOS (Per accident) NON-OWNED AUTOS - _ _$ UMBRELLA LIAB OCCUR - - EACH OCCURRENCE S 1 EXCESS LIAB _E'CLAIMS-MADE . AGGREGATE $ DEDUCTIBLE S RETENTION S S B AND EMPS YERS'LSATION WC-007-648-4368 05/23/201005/23/2011 WC S.. OTH- AND EMPLOYERS'LIABILITY �,I N - TORY LIMITS- ER ANY PROPRIETOR/EXCLUDED' E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandatory i E.L.DISEASE-EA EMPLOYEE $ 100,000 under It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ADILSON SEGOLINI HAS ELECTED COVERAGE FOR HIS WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION NONE ON FILE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Af AUTHORIZ REPRESENTATIVE 09 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACO 4 1 R low. itilassachusctts- D 0, cnt of Public Safvtj Board of Bud(ltn�'.R����lat'ons Sup an rc�tid Stand b :. ervisor S construction pecialt t License CS3SL 99907 Y License Restricted to RF,WS,DM � ^� } ADILSON SEGOLINI #' 117 MINTON LANE_ 4' 3 WEST BARNSTABLE, MA 02668N sY ('umnrissiunc; Ex iration: 10/14/2011 Tr#: 99907 :r °� , - ~istt �u#t fof,III Vt u9 vse bs,�y `TM' Office of Consumer Affairs&B s�ness"Regulation i �, �,- i. ::.. etie tie a spat at��nAt8;.;11 tDtnii,return to HOME IMPROVEMENT CONTRACTOR 1. (' Registration �15959Z Type. Clf i e of Consumer Affairs aria ilsinessllegelAm a01' riz Pia "8n 517.0 �. Expiration 51k572012 DBA :fe I S LINI CONS_,,RvC y i a ADILSON: SEC I gg 117 MINTON LAPIE ' WE$T BARN.STABLE. .A C2 Undersecretary N alid.without slgnaiu e i� t- Regulatory Services f BARPSTABM v rsass. � Thomas F. Geiler,Director 16 Building Division Tom Perry,Building'Commissioner 2.00 Main Street,Hyannis,MA 02601 www.town-barnstable.ma.us `office: 508-862-4038 Fax: 508-790-6230 . Property Owner Must Complete and Sign This Section If Using A Builder a as Owner of the subject property P P nY hereby authorize -e DUI t h I (Litt C]YLkJ w, . to act on my behalf, in all matters relative to rk authorized bythis building pernut`application for. } Sign a 6r er Date , � . Print Name . If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse'side. Q:FORMS:O WNERPERMISSION- - - ' _. , F - � v�D 2 _ �, �Q� - �S� - ors _.., ,. A r �..._..r �...,... � .. ' - _ _ S - �� ........... � .. Xcingular� raising the , , Roger Santos Cingular wireless Retail Sales Consultant Cape Cod Mall 769 lyannough Rd. Hyannis,MA 02601 phone 508.775.6593 fax 508.775.0593 cust.care 800.331.0500 warranty 800.801.1101 e-mail roger.sahtos@cingularcom opt r Town of Barnstable ti Regulatory Services + BABNSfABLE + MASS. g Thomas F. Geiler,Director 039. Building Division Thomas Perry, CBO A Building Commissioner 200 Main Street, Hyannis, MA 02601 ' y www.town.barnstable.ma.us V Office: 508-862-4038 Fax: 508-790-6230 January 9,2005 Jose P&Cacilda G. Santos P.O.Box 2746 Hyannis,MA 02601 Exit order 18 off lines Lane LHyannis;.IVIA Dear Mr. &Mrs. Santos: This letter serves as a follow up to our conversations on January 5and 6,2006 concerning the residence you own located at 18 Holmes Lane in Hyannis. As we discussed the basement must be vacated immediately because of lack of proper permitting and the bedrooms in this area lack the proper emergency egress. Until this is corrected persons are not allowed to sleep in this area. Sincerely, Thomas Perry Building Commissioner 1 t.