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HomeMy WebLinkAbout0160 IRVING AVENUE %6� ._.L.-.,eve w'ry' j��s-; TOWN OF BARNSTADLE BUIL DING PERMIT APPLICATION,,,, 5 a ozdT( Map Parcel: '= 'Application # 4 � w Health Division ��- r -:-Date Issued l� Conservation Division Application Fee Planning Dept: Permit Fee Date Definitive`Plan Approved by Planning Board ; !v`� •s Historic _ OKH Preservation / Hyannis Project Street Address Ad 0 P06 ' Village ' Owner O Address /666- Telephone OH 1/Y4y b Permit Request / 0_1 �X/S fig YL� R�� / i� �ilcv�, �e 1r, /`00 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay .Project Valuation Cw Construction Type Lot Size °3'l(s-c- Grandfathered: ❑Yes Ul"No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure W1 K, Historic House: aes ❑ 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 a Detached garage: existing 0 new size—Pool: ❑existing ❑ new size _ Barn: ❑.existing D new size_ f _1 Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: "? Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ o Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) �5_ecw. RO L c ro 0 i 1 Name C60iEpp'C t�U�KA-P ?)U%A d aS =i\c Telephone Number Address (,�5 E&-el S" ►` b\ License# CS g_�XS O AA o b 1- Home Improvement Contractor# Worker's Compensation # I tJ 3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO (� S1i SIGNATURE DATE 4 l�919011 r " FOR OFFICIAL USE ONLY 1_ ' APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION 4 FIREPLACE F: ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING S f DATE CLOSED OUT ASSOCIATION PLAN NO. ; F i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 19 600 Washington Street Boston,MA 02111 UV , www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ Please Print Legibly Name(Business/Organization/Individual): (-oil c,rof+ r Kuehre 1 g deirs i -ToC . Address: 6 S 12:k9c/1 5k-n i ti I oa cl City/State/Zip:C-fir y; I J,c N& 02632- Phone#: --77 4 4R--3& (c,6 Z.q Are you an employer?Check the appropriate box: Type of project(required): 1.L�J 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 working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. # 9. ❑Building addition 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 rep insurance required.]t c. 152,§1(4),and we have no 13.�. er 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 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 is providing workers'compensation insurance for my employees. Below is thepo/icy and job site information. Insurance Company Name: sr-ct n rk &I CL4- —�--i'I SC.U"Cti�C,r c U:'17(�Ci►�111 J Policy#or Self-ins.Lic.#: 1 '2(o f le 3 y Expiration Date: Job Site Address:_160 if V idq /- yer'm e- City/State/Zip:��oor, M H 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 ce fy unde�jthe 'ns a d en 'es ofperjury that the information provided above is true and correct Si ature: '1N ✓' Date: 0 ( Phone#: 7-7 L4- 3(--(o 2— 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#: HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED Y THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUING INSURER 8 AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. MPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION S WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement A statement n this certificate does not confer ri hts to the certificate holder in lieu of such endorsement. PRODUCER Southesstem Insurance Agency 641 Main St Hyannis,MA 2801 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Roycm t&Kuehne Builders Inc 63 Eben Smith Road Cerdervllle,MA 02632-= THIS 18 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 THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 00 L7R TIP!or INSURAN11111 POLM NUMBER POLICY!►PECTM BATE POLICY EIVRATM DATE A WORKERSCOMPENSATION D EMPLOYERS'LIABILITY LIMITS E PROPRIETOR/ /UtTNERS/EKECUTIVE OFFICERS ARE: MICL o EUCL❑ 1 126104 1 8/0&2010 1 6/06/2011 TATUTORY LIMITS OTHER o6weppApolwtoMAOpwatlonsONy. MACCIDENT S 100.00 ISEASE POLICY LIMIT S 500, ISEASE-EACH EMPLOYEE 100 DESCRIPTION OF OPERATIO HICLMGPECIAL ITEMS i CERTIFICATE HOLDER CANCELLATION MWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN:BLDG DEPT EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE 200 MAIN ST WMTE THE POLICY PROVISIONS. BARNSTABLE, MA 02601 AUTHORIZED REPRESENTATIVE s " ,,,, ✓�e VJo�ri�no�rcueal�� a`..•lfa:uac�uael�i License or registration valid for individul use only Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: • Office of Consumer Affairs and Business Regulation Registration: .141225 �t 10 Park Plaza-Suite 5170 Expiration: 1122/2012 Tr# 291967 Boston;'MA 02116 Type:' "Private Corporation ROYCROFT&KUEHNE BUILDERS, INC. Sean Roycroft 65 Eben Smith Road �Q — Centerville,MA 02632 Undersecretary Not valid witho t `Massachusetts- Deparlincnt of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 83280 SEAN J ROYCROFT 65 EBEN SMITH RD k s' CENTERVILLE, MA 02632 Expiration: 11/29/2012 ('unuuisiunrr Tr#:-5237 oF� Town of Barnstable BAMWASM 039. Regulatory Services ,rD 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: 508-190-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, 'Fr ifG{. F fOy GL ,as Owner of the subject property hereby authorize :SeCc✓1 R 0VCr0-C l— to act on my behalf, in all matters relative to work authorized by this building permit application for: 16,0 -T—r yi► q Ay " ,jam %Ct.✓1V1 5 �O✓'f'� (v/ (Ad &ess of job) -- 3 cp ) a 4Signature of Owner Date/ Print Name Q:Forms:buildingpermits/express Revised 123107 - - 2a0YmIT oa +2 . NEW SItOSOO 3rx3r BARN B ° SASH NYSIYLE; A e LITE 2seA, .Ten i REPAIRED I NEW BHFoeoo GARAGE 3ri2r BARN NEW SASHHNYBTYLE XY BARN °LITE SASH NY STYLE e LITE REMOVE SST.WOOO; • NEW BROBCO POOK 70LET,SeK I - W,3r BARN B PAfORpN I, BASH NY87YLE e 11IE °H3r BARN - :3rBARrI E REPAIRED Ar °NFwwwwo AA SECTION REPAIRED GARAGE GARAGE A A , - w NEW BROSCO NEW BI°OBCO - 3r.3rSARN Wx3r BARN SASH NY STYLE SASH NY STYLE .. e LITE E - NEW ROOF CONST. - - •2 AO ROOF RAFTERSG IT en • - +?COXPLYWOODFWOP . - BHFATKNO W/QFS NEW12WxTVOHDOOR - -ASPHALT ROOF BANGLES •1SL8 FELT PAPER 2 SSL PSOSBDAFm .2. QI AL RAFTER ENDS GNEQiB -HCEj WATER SHIELD ATBOTTOM � � 'liT OF ROOF ' 2xn QlTe4 12 zlv i 1Ta'4 E70ST.2:4WALLSTO10MN ' xAes .Ten 1:BFASCNBOAf� GARAGE PLAN ' NEW SP.T:2Ae BHiW YO _ - 1Ae SOFFIT BOARD - .. wW 4 SHOE TSI FAB TOBONOOIBE NEWT COW-SLAB /SMPSON S.a ASA+S PO°TBASE REPAIRED NOTES: •. .. SOSf.2s4 WAL15TOREMN -.- rs rIBTAu OUROCIC eEHYFEEN eallonsse TO FORB SL NEW CONCRETE AB EDGES - GARAGE NEWW.C."JOESIONG 1.)CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS &DIMENSIONS IN THE FIELD - _ - NEW BEEMAM 2.)CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS, - NEW TcoNe.aAe M/H SI.S�ABI EH . DETAILS,&FINISHES IN THE FIELD WITH OWNER - 3.) ALL CONSTRUCTION TO CONFORM TO 780 CMR MASSACHUSETTS STATE BUILDING CODE,SEVENTH EDITION g 4.) 110 MPH EXPOSURE B WIND ZONE,1.00 ASPECT RATIO - 5.) ALL LVL LUMBER/BEAMS TO BE 1.99 U480 LOAD 6.) FOLLOW ALL MANUFACTURER'S SPECIFICATIONS FOR INSTALLATION OF ALL NH:vv+raAoaNc. - NEw+r ou.can0. SIMPSON COMPONENTS SONOT+BE TO = SONOTBET047 _ - BELOW GRADE BELOW GRAM 7.) ALL CONCRETE USED FOR SONOTUBES,FOOTINGS&SLABS - TO BE 3000 PSI 9.) REMOVE&REPLACE ALL ROTTED&DAMAGED FRAMING.SQUARE BEAM DETAIL nSECTION @ REPAIRED GARAGE EXISTING FRAMING AFTER REMOVING ROOF&INSTALLING SONOTUBES - Al SCALE:12'-1'.W Q®COTUIT BAY DESIGN, LLC GARAGE REPAIR FOR: :� == a SCALE: DRAWING NO.: en.I�M,o.n".> 43 BREWSTER ROAD N.a sue.'MASHPEE MA. 02649 FLOYD RESIDENCE " DATE: Al PH.(508)2'14-111% � �� � FAX 508 539-9402 ��r�TM� e.,"A.eI�N"el�ll�e. c � 160 IRVING AVENUE HYANNISPORT, MA �"�" 4/18/2011 1s 17 e e� - NEW BODYGUARD FM �� ATOM � � - ao Mj NEWCARMAMS"E NEWOUTEDOMOR OADOOR,VEMFYWlt P"mE�T.DOOR WEST ELEVATION A EMW, SOUTH ELEVATION e,z -NEWASNNLTROOF M1 0 SINGMTOYATCH 12 E)OSTNG HOUSE S MEweaorawro faS FASQ1158gAif NEW SOOYW OM 7.5.. MEW BODYGUNWl e)7 x{Tlil Wl2-SLLAT ALL YYNDOWS NEW WA.SHDKI ESE)M r TOwEATHEIt NORTH ELEVATION EAST ELEVATION 8 Q® COTUIT BAY DESIGN, LLc GARAGE REPAIR FOR: --m a SCALE: DRAWING NO.: �°° x�x 1/4._V-0. 43 BREWSTER ROADQM A2 MASHFEE �nA. ozs4s FLOYD RESIDENCE TM �m1A� DATE: 66 FAX'c 508)539-9402 160 IRVING AVENUE HYANNISPORT, MA �,.� 4/18/2011 �ara+as 7zi4 1514 9-0 er F14 To Be NP ROOF ro 8 BB BOLT OVER B NBTALL NEW A7 HEADERSATALLDOORSLARDERHVRaaF Al aWNDOINSUNLESS OTHERWISE NOTED I 4� ti SLAB UNDER REPMED N� WALLS&WIEfEINOOD 4t1 RODEBQVID FLOOR WAS REMOVED N N 1 O I I I i REPAIRED A+ n I Al GARAGE I A p A A F Al SWALLOW" m I I �Or *O Np RODE CONNECTOR . NEW}P.T.2AS BEAM W M1� AT NVMD O OECOHMMT IIB.• 2 x4 SHOE FASM TO SONORIES - W/BBPB011 LLASUMPOSTSASE F. y F.T.4[4 FOSTS FRON {G. I BEAM TO TOP RATE *WALL SWOON HOP2 PASTEN TO BEAM W Ni COINER PLATEAT SBPSON Bp CAPA ASE. ALL CORNERS NEW$1 Wz11 h8 MHEAD6t NEW TUBETD011C. WRALLROM lTOBE MSTALLBWBOST To oI DEWW ORADE STRAP FROM POSE roeEAM emAP FRaM POST To lNA11 BELOW ONADE zd 17-M zr - FOOTING PLAN ROOF FRAMING PLAN .amw SCALE: DRAWING NO.: 8Q® COTUIT BAY DESIGN, LLC GARAGE REPAIR FOR: "°Nro"� 1/4 11-0N 43 BREWSTER ROAD MASHPEE MA. 02849 FLOYD RESIDENCE A� PH.(508))2Y41166 '� � FAX(5o 539-9402 4/18/2011 160 IRVING AVENUE HYANNISPORT, MA °'�""�'°�'°N" Town of Barnstable *Permit# Expires 6 month!,from issue date Regulatory Services Fee 9 .a Bnxxsrre� K"SS'1639. Thomas F.Geiler,Director Ep Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY / Not valid without Red X-Press Imprint Map/parcel Number /o 14 Property Addre4(100 =r v l r-O. 4Y�fn U(2 OLJ Win , 1v11 Q Residential Value of Work_/7 a® 0 Minimum fee of$35.00 for work under$6000.00 " Owner's Name&Address J`I �-C.i rfIO yZ Contractor's Name__6mn J. eOVCY-C ' Telephone Number 74'g36'6 6 24 Home Improvement Contractor License#(if applicable) Z�' Construction Supervisor's License#(if applicable) 3: � 4- REVS PE­0A far. ❑Workman's Compensation Insurance r OCT Check one: Gsa; ❑ I am a sole proprietor A TOWAI OF BARNS TABLE ❑ 1111n the Homeowner I have Worker's Compensation Insurance Insurance Company Name Gina jy)/ � I h S ur om ce {�U Workman's Comp.Policy# 02�p � 0,34 Y J Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof hurricane nailed (strippingold.shin les Al]construction debris will be taken to ►� d,Q�CI'S�e ( ) g ) ❑.Re-roof(hurricane nailed)(not stripping..Going over .existing layers of roof) LX, VRe-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: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is reguire - SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Win ows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 07211.0 71 e Con nromvealth of Massachusetts Departanerat of Indrtstrical Acciderds Of we of Investrg(ations ow 600 Washington Street. Boston,AL4 02111 n,mv.niaas&gov1di a Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers Applicant Information Please Print Legib -ly Name(Business/Orga=tionamimidual): © �1�}-'T'Z Tll,� � o? tiffs-cj ,J—K) C- Address:&-1 )�OCO SM 4f-1 City/StatetZi ol,1 62L5-'LPhone 4- —7-74-83<P _&&Z4 Are you an employer?Check the appropriate box: Type of project(required): t with 1.9"I am a employer er 4. ❑ I am a general contractor and I P Y : have hired the sub-contractors 6- ❑New construction employees(full andlorpart-time). 7. Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet ❑ g ship and have no employees Thy sub-contractors have. g ❑Demolition working for me in anycapacity. employees and have workers' insurance., ❑Building addition comP- [No workers comp.insurance required-] 5. We area corporation and its 1,0.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 LE]Plumbing repairs or additions myself[No workers'comp_ right,of exemption per MGL 17.❑Roof repairs insurance required.]b c. 152,§1(4X and we have no employees-[No workers' 1.3_❑Other comp_insurance required-] Any applicant dut checks box Rl tons also fill rout the section below showing Meer wwkers'compensation policy infornfftion- ?Homeomms who submit ibis affidavit indicating they are doing all wmk and then]rite outside contractors mast submit a new affidavit indicating sat b_ 'Cbntaccors that cbeck this box mast attached an additiond sheet showing the name of the sub-contrzacis and state whether or am those entities have employees. If the stilt-coutrsctots hwe employees,they must provide their workers'comp.policy number- lain an employer that is providing morkers'compensation insurance for my enapIoyees. Below is the pottcw mid job.site inforrrrntiom Insurance.Company Name: rojr)l h f/ v t a-+V --Li 1 iur Policy#or Self--ins_Lie. (0 f � 3 Expiration Date-EV(e L-2-6 t Job Site Address: .a AJcn wy QtylState/Zip:4V/Q!,)—r1),S ?—C)rt/ 'yG Attach a copy of the workers'compensation policy declaration page(showing the policy nu m eb .r and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 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 rrrtd r tlr ed na of peduty that the inforratntion provided above.is Mle and correct Si titre: ce Date: !���r •�0 t Phone#: Offleidl rase only. Do not trite in this areal,to be completed by city or town officiaL City-or Town: PermitiLicense€E Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Toum Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: '" ��c ' Orlriicrritu�Cr6ll/' ri�:-�rladrrc�aCe1� �. ® Board of building Regulations and Standards Construction Supervisor License License: CS 83280 — Birthdate:°11/29/1964 t Expiration: 11/29/2010 Tr# 5313 Restriction: 00 SEAN J ROYCROFT 65 EBEN SMITH RD CENTERVILLE•MA 02632 Commissioner i! ✓fe �o»m�iio�tuieal!/ a�' ltrxuarluaelta { r - Office of Consumer Affairs&Business Regulation License or registration HOME JMPROVEMENT CONTRACTOR' before the expiry ion date''If foundd for 'retur use only e d ? Registration: 141228 Office of Consumer Affairs and Business Regulation -` Exptratiah:. 1/22/2012 Tr# 291967 g n 10 Park Plaza-Suite 5170 TYPe Private Corporation Boston,MA 02116 ROYCROFT&KUEHNE BUILDERS, INC. iSean Roycroft 65 Eben Smith Road. Centerville,MA 02632 Undersecretary Not valid witho t snnxsTna�.E, * " 59. Town of Barnstable 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 Owner Must Complete and Sign This Section If Using A Builder 14- ( �DG ,as Owner of the subject property hereby authorize y �f LJAf k)n1f-.) to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) / AD�� Signature of Owner Ddte Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 I� .,�� ss7 �x`1'+� ro�ef;*1' i'',xxk' $, Y •^" �3fm'.� °�`' °'� +c= x fat-4.w�,.,4 .�"�"v�, 'r'm v t j a fr y - !Yu�,•s'.rL�1°" '0.7a 'a'ri�'xv� . '"t v � - �.R" t# 7 ` z -d Hi8 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED Y THE POLICIES BELOW.TH18 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUING INSURER 8 AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. ' MPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(hm)must be endorsed. If SUBROGATION 8 WAIVED,subject to the terns and conditions of the policy,certain policies may require and endorsement A statement n this certificate does not confer ri hts to the certificate Holder in lieu of such endorsement PRODUCER Southeastern Insurance Agency 641 Mein St Hyannis,NIA 2801 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Roycraft&Kushne Builders Inc 85 Eben Smth Road Centerville,MA 02632-0000 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING 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 THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 0111 i TWE OF NSURMN FOLM NUMBER FOUOTEFFICM DA1E FOUCT 1110 iATION DATE A WORKERS COMPENSATION D EMPLOYERS'LIABILITY LIMITIS E PROPRETORI ARTNERSIEINCUTIVE OFFICERS ARE: IIcL o EKcL o 126104 8/06/2010 1 8/06/2011 ATUTORY LIMIra OTHER owapaAp0IwtoMAOpwdcnaOdy. CM ACCIDENT S 100,00 INUB POLICY LIMIT S 500, I E-EACM EMPLOYEE S 100.000 DESCRIPTION OF OPERATICNSNEHICLMSIBPEIG"nrEIIAS CERTIFICATE HOLDER ANCELLATION TOWN OF BARNSTABLE $MOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN:BLDG DEPT EKPRATKIN DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE 200 MAIN ST WIITE THE POLICY PROVISIONS. BARNSTABLE. MA 02001 AUTHORIZED REPRESENTATIVE 1� EVE ro Town of Barnstable T *Permit oe Expires 6 months from issue date Regulatory Services Fee;J1 y K BARNSCABLE. MASS. Thomas F.Geiler,Director t639' 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 - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 4 �112 Q Property Address I -Residential Value of Work #b jr o `w Minimum fee of$2 . 0 for work under$6000.00 Owner's Name&Addressac Contractor's Name—!Ono o (11a,Qn Telephone Number �&13-395= Z Home Improvement Contractor License#(if applicable) (t{'G 1 7 Construction Supervisor's License#(if applicable) „�rj " ❑Workman's Compensation Insurance k one: c< am asole proprietor' m S ' � t ❑ I am the Homeowner JUN W1. 1 2003 I have Worker's Compensation Insurance Insurance Company Name SOWN OF BA NSTAS. Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. 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 [t -Replacement Windows. U-Value aximum.44) �"dt 6-4 (/tz-4s et, —t- *Where required: Issuance of this permit does not exempt comp)lance with other own department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. g Home Im ovement Contractors License& Construct Supervisors License is required. SIGNATURE: 'Q:\WPFILES\FORMS\E ress\EXPRESSPERMIT.DOC Revise06O4O9 PERMIT PAYMENT RECEIPT TOWN.OF BARNSTABLE BUILDING DEPARIMENI w; 200 MAIN S(RELI HYANNIS, MA 02601 DATE: 06/11/09 TIME: 08: 9 -- -- -__ .-TOTALS----------------- PERMIT $ PAID 25.00 4 T NDERED: 25,00 IED: 25.00 .00 ER: 200902642 CHECK 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 Please Print Ledbl_y Name(Business/Orgmization/Individual): spx'14-3 `M"4.(a •Address: lo%, (o B City/State/Zip: nv14' 0 Z� Phone.#: 509-31:l�5 G z Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4• ❑ 1 am a general contractor and I 6. ❑New construction epopyees(full and/or part-time).* have hired the sub-contractors 2: a sole proprietor or partner-' listed on the attached sheet. 7. .❑Remodeling ship and have no employees These sub-contractors have g,'❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'-comp.-insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.ElI am a homeowner doing all work officers have exercised their 11.❑Plumbing repair's 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 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. tContractors 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 ployers,they must providt 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 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 tip 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'Off-ice of Investigations of the DIA for insurance coveraze verification. I do hereby certify under the pains-and penalties ofperjury that the information provided above is true and correct Si e: f2 Date: Ph one#4 SOO -395" ���?� 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): I.Board of Health '2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all cmployers 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 engag in a�omt en rpns` e,.i mcluR g the leg representa�LiiTeb'�f- de�ased�empiuy�r, 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 inramce 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, it necessary,supply sub-contiactor(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 permittlicense applications in.any given year,need only submit onp affidavit indicating current policy information(if necessary)and under"Job Site Address" the appicant 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 pitizen is obtaining a license or permit not related fo any business or Commercial venture (ie.a dog license or permit to bum 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 CornmonwWth of Massachusetts Department of Industrial Accidents 4ffitce of Iavestigations 600 Washington Street Boston,MA.02111 TO. # 617-727-4400 ext"406 or 1-977-MAS-SAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia ij .ram- �. •a TT �. Town of Barnstable Regulatory Services 9 $, Thomas F.Geiler,Director F 619. 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstabl e.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property O nerMust Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize �\,A&n,�o to act on my behalf, in all matters relative to work authorized by this building permit application for. 146 -( dress of J ) Signature of Paty 1h D tON Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 0:F0RMS:0 WNERPERMIMSION ;Y n Town of Barnstable 4L Regulatory Services Thomas F.Geiler,Director �bs¢. Building Division PrED a Tom Per ry,Building Commissioner 200-Main-Streeter Hyyaffiir,-hvbk-02tiU1 — _.._. . . _._.._..... www.town.barnstable-ma.us Office: 509-862-403 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: cityADwn 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 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 undersigned"homeowner"2sst3ITres responsibility for compliance with the State Building Cods and other applicable codes,bylaws,rules and regulafions. The undcrsigncd."homeowner"certifies thathe/she understands the Town of Bu_ stabIq,Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and rUn ts. Signature of Homeowner Approval of Building Official Note: Three-fancily dwellings containing 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 bomeowner perfoming work for which abuilding p=nit is required shall be exempt from the provisions of this section(Section 1 D9.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a parson(s)for hire to do such work,that such Homeowner shall act as supervisor... Many homeowners who use this cxecrption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Rules&Rcgulations'for Licensing Construction Supervison,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 es Supervisor is ultimately responsible. Tomnn-e that the homeowner is fully aware of his/her responsibilities,rruny communities require,as part of the permit application, that the homeowner certify that�dshe understands the responsibilitics 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 curb a form/eettificaEon.for use in your community. Q:forTns:homccxcmpt i a Boa Dep:r rtrttent()t-p r't1 of Buildin« uhlic S;tietj' Construction Rc�rilation and Standards License: CS 66658 Supervisor License Restricted to: 00 JAMES R MEDEIROS 696 RT gA x, YARMOUTHPORT, ,. MA 02675 "ufl}nl iS.Sij' � Expiration: 4/16/201, __—__ —--- Tr#: 5104 ' � �ie �omirreo�.zuea/� a�.GlcrQaact rtucae%a� .. Board of Building Regulations and Standards,' HOME IMPROVEMENT CONTRACTOR , License or registration valid for individul use only t, before the expiration date. If found return to: Registration\ 140157 Board of Building Regulations and Standards Ezpirafjof g%�9/2009 -Tr# 133523 One Ashburton Place Rm1301 " "�rtjC Type'x Individual Boston,Ma.02108 JAMES R MEDEI'RIIO.Sti. �r c JAMES MEDEIRbS 696 ROUTE 6A q YARMOUTHPORT,MA 02675 v Administrator Not valid without signature " cFt"�rati Town of Barnstable *Permit# ?a Ys ? Expires 6'nq0thsjr0M issue date iURNMBIA = Regulatory ServicesMAM Fee D 9 1639. `0$ Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 X®PRESS PERMIT Fax: 508-790-6230 nn �22 EXPRESS PERMIT APPLICATION - RESIDENTIALrT 9 2003 Not Valid without Red X--Press Imprint TOWN OF BAR N S TAB L E Map/parcel Number ��`p—�� 7Z Property Address hUO A2Vd A!C A- [Residential Value of worklp 0r OJ Owner's Name&Address �Q , \T �1� 3/Ln Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ElWorkman's Compensation Insurance -p Check one: Iam a sole proprietor am the Homeowner 0 I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to Au 6 ek Y ou-j"p kTrot.5 , ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows.�U-Value (maximum.44) *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***No Property Owner must sign Property Owner Letter of Permission. (,,,,Home Improvement Contractors License is required. Signature Q:Forms:expmtrg Revise053003