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Home My WebLink About0016 LINDA LANE i Town of Barnstable *Permit o 01 Etipires==da" Regulatory Services Fee Richard V.Scali,Director 5 Building Division NOV o 6 2�� Tom Perry,CBO,Building Commissioner NW ®� BARNS-�pg�E 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us ToOffice: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address �� t r�,QR [Residential Value of Work Minimum fee of$35.00 for work under$6000.00 i Owner's Name&Address P CVASSQi�� Contractor's Name 01 1 Telephone Number --C<3W. Home Improvement Contractor License#(if applicable) t � Email: /CC.00AO C Construction Supervisor's License# if applicable) (p [rorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 2',have Worker's Compensation Insurance Insurance Company Name �A r--�D � Workman's Comp.Policy#� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) / Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to W ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 equired. SIGNATURE• -0 0(] 4 C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Interne Files\Content.Outlook\2PIO1DHR\EXPRESS.doc Revised 040215 KELLY ROOFING INC MA CSL #99167 PH 508 509 46+40 8 RHINE ROAD. MA HIC #128957 YARMOUTHPORT MA 02675 kellyroofing@icloud.com August 24'2015 Proposal submitted to Mr. Wayne Chasson of 16 Linda Lane, Hyannis MA We propose to supply all materials and labor necessary to remove and replace the existing roof at the address above. All debris to be removed to town-transfer —. _ 8"White aluminum drip edge to be installed on all eaves. Ice and water damage protection membrane to be installed on the first three feet of a eaves,in all valley areas and around all protrusions. Remainder of deck to be covered with#15 Felt Paper. Lifetime limited warranty Architect style shingle to be installed, (Color to be specified) All shingles to be storm nailed. (6) Bathroom vent pipe boots to be replaced with new. Repair/Replace all flashings as necessary. Install Shingle Vent II Ridge vent on all ridges with Hand Nailed Caps. Protect all walls, windows, decks, plants, shrubs, etc. during roof strip. Complete cleanup of area during and after procedure including all nails and cleaning of gutters. Obtaining of Town Permit. At a Total Cost of$7900 Payment schedQe;50% due at project start, balance upon completion. 1 1 Respectfully Submitted, Oliver elly. Proposal accepted b ; Date AN-/ /2015 p P Y, l If acceptable please si and remitloe copy to the address above, keeping a copy for your records, this prop s valid for 45 days from date above, please call to verify thereafter. I The Cotm,>tirmoniveath of Massachusetts Department of Industrial Accidents Offwe of Investigations 600 w'Qsliingtorx street BostonMA 02111 mv►stntamgmldio Workers' Compensation Insurance Affidavit:Bu'dders/Ck4ontractnrsiEEkectriciansfl'lumbers licant Information Please Print Lezibly Name ok sines owuizationlindividoal): LLV E:L Address_-?)- City/s telzip: AQgoo-T e� Ij� CQW5 Fiume 6087 S C;)9 4&4,1O AFJ.an employer?Check the appropriate boa. T)T a of project(required): 1_ m a employer with 1 4- ❑ I am a general contractor and I employees(full.andlor part-time.)-* have hared the sub-contractors 6. ❑New v construction. 2_❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling ship and have no employees Uese sub-contractors have S. ❑Demolition working for me in any capacity- employees and have workers' [No workers'comp_insurance comp_insurance.X 9. ❑Building addition. requited.] 5. ❑ We,are a corporation and its 10.❑Electrical repairs or additions 3_❑ I am.a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions if o workers' right of exemption per MGL�`� � - 12. oof repairs insurance required-]l c. 152,§1(4), and we have ono employees.[No workers' 13.0 Other comp.insurance required.]; ;Any applicamt that cfiecks box r?1 mast also fill oru the section below shovdng their erot err'compensati uv policy informticaL Homeowners who submit this af&hmit itedicating they are doing aU lean$and then hire @ride contractors toast subink a new off davit indicating.such. kontracmts than check this bctx most attached an additional sheet showing the name of the sub-ccamctors sad state whethu or not those entities have earployees. If the sab-cominctntsSane employees,they moistprovidethem warkers'camp.policy number . dam art empla;r th at is prov ding workersp cosupensssalion insurance for vtv empjoy m& Below is the policy findjobsite information. Insurance Company Name: �� Policy It or Belf-ins-IIc.+9: Expiration Date: S-(0 1sot lO Job Site Add> :h ( ,-I aA ' City/State/Zip- Zcol Attach a dopy 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$1,50D.00 and/or one-year imprisonment,as well as civil penalties in the fbrm 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 cerlal.6,rater the pains andpen a f 6hat tl'te irtforindionprotidedabove is trite and correct e:. bate: Phone#: Official arse only. Do not write in this area,to be zourpkRted by city or totter official: City-or Tows: P'ermitf tense 9 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#: Massachusetts Department of Public.Safety ; Board of Building Regulations and Standards j License: CSSL-099167 Construction Supervisor Specialty OLIVER M KELLY�� 8 RHINE ROAD , YARMOUTH PORT MA 02875' ' t Expiration: Commissioner 09/284017 m - , �-, �l'GQi ��Zt�l�(�� t2 /��:i E� �•t'.Yit�'0!i/Gl/.�Q/��UJ� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration - Registration: 128957 Type: Individual Expiration: 6/14/2017 Trlf 266936 Oliver Kelly Oliver Kelly 8 Rhine Rd = _ - Yarmouthport, MA 02675 _ Update Address and return card.Mark reason for change. SCAT a 2oM-osn1 �{ Address r1 Renewal [ Employment ❑ Lost Card _ —_Office of Consumer Affairs&Business Regulation License or registration valid for individul use only 10ME IMPROVEMENT CONTRACTOR before the expiration date If found return to: 1 egistration: - 128957 Type: Office of Consumer Affairs and Business Regulation 457 Expiration:= :61-i41201T; Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 Oliver Kelly Oliver Kelly 8 Rhine Rd. _ Yarmouthport,MA 02675 Undersecretary Not valid without signature CERTIFICATE OF LIABILITY INSURANCE DATE IMM/ignis; YI TWL%rvER'nFICATE 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 he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: DOWLING&O'NEIL INS PHONE FAX 973 IYANNOUGH RD (A/C,No,Ext): (A/C,No): E-MAIL HYANNIS,MA 02601 ADDRESS: 22LGR INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY KELLY ROOFING INC INSURER B: INSURER C: INSURER D: 8 RHINE ROAD INSURER E: YARMOUTHPORT,MA 02675 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 REOUIREMENT,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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MIMDD\YYYY) (MM\DD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED $ CLAIMS MADE OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT❑LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident)PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X FWCITSSTATUTCRYEMPLOYER'S LIABILITY Y/N UB-2E901371-15 05/06/2015 05/06/2016 ANY PROPERITORIPARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? F1 N/A E.L.EACH ACCIDENT_ $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 D DESCRIPTION OF OPERATIONSILOCATiONSNEHICLESJRESTRICTIONS✓SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. r CERTIFICATE HOLDER CANCELLATION MADELINE MASON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 42 CENTER STREET BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV D IN ACCORDANCE WITH THE POLICY PRO SOUTH YARMOUTH,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP(TRA11 zr rlg is reserved. DIME Town of Barnstable *Permitilo 4o gg Expires 6 month o i sue date K ~' Regulatory Services Fee i s + BABN3TABLE, MA 9' Richard V.Scali,Interim Director 1639 Ado 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 0911 8 — 1�o n Property Address c cC, [residential Value of Work$ ��AIJ� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address - Contractor's Name Telephone Number `!50 7-7 0119 (o Home Improvement Contractor License#(if applicable) w Email- < �e��P i7G Cep Construction Supervisor's License#(if applicable) ' ❑Workman's Compensation Insurance Check one: El am a sole proprietor- T NOV 12 ��1� ❑ I am the Homeowner 1 O WN OF BA RI have Worker's Compensation Insurance - USTABLE Insurance Company Name Workman's Comp.Policy# ( 1/f'y t jc� 100_0 465 !Y/ Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) +Soug)q& Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to, ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) D6 Re-side SQURR Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 reZ' ed. SIGNATURE: ,. T:\KEVIN-D\Building Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313 • snxxszne�.E, MAM 1639 Town of Barnstable 9Q i63� A Regulatory Services Richard V.Scati,Interim 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 ;a�s�,wwner of he subject property 1 p p tY hereby authorize d to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) S &A �f Signature of Owner Date l -Yd Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. TAKEVIN MBuilding Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313, TIICRIGIITCHOICE i---------- ----- Since 1971 I Office Use Only I ceans�de= JOBNUNLBER .restoration = 217Thornton Drive,Hyannis, Mass,02601 508-771-3110 800-464-3318(MA.Only),774-470-2211 Fax ASSIGNMENT AND AUTHORIZATION TO PAY The undersigned, herein called claimant, has authorized and ordered from Oceanside, Inc . , the materials and/or services requested. Undersigned hereby assigns to Oceanside, Inc. any unpaid proceeds due or to become due, under the claimant ' s policy with the insurance company to pay direct to Oceanside, Inc. or to include its name on a check or draft, for all requested work. In the event that Oceanside ' s claim herein is not covered by, or paid by, an insurance company, claimant agrees to pay Oceanside, Inc . within sixty ( 60) days after work has been completed. Claimant understands that Oceanside, Inc . is working for them and not the insurance company or the adjuster. Payments remaining due and payable after the claimant has received payment from the insurance company shall bear interest at one and one- half (1-1/20) percent per month. In the event that there is a breach by the claimant of any of the conditions of this agreement, Oceanside, Inc . shall be entitled to recover, as additional damages, attorneys ' fees, costs and any other collection expenses reasonable and attributable to said breach. I'f payment is not received within 60 days, collection action will commence without further notice to the claimant . LOSS/DAMAGE ADDRESS 1(p t t 6,64 1,� 4Y 1,-K-,To5 m-A C� o f MAILING ADDRESS (BILLING) CITY STATE ZIP CC'C- i�S r 6C �� S e his t�rh2�C�,Q, INSURANCE ADJUSTER' S NAME/CO . LOCAL INSURANCE AGENCY NAME (XN �l)6 lid / .5 U (/ f" `� C /4 /Z L A Cy l Z Z PRINT ME j INS . CARRIER/POLICY UNDERWRITER DATE: aL 1 CLA IS SI ATURE PHONE: 5-0 g— EMAIL: r �eantrrconrruea�t. &waclrc�n/t PR, iee of Consumer Affairs&Business RcguiatiouMEIMPROVEMENTCONTRACTOR gistration': pg1 Y Expirafiorl`_="_...._,-_.; ,: Type: r,= ,szia�s_. OCEANSIDE INC,.' SupplementC, STEVE TESSIER ss3- 217 Thornton Dr Y MA 02601 CluderwereNry Massachusetts-Department of Public Safety ~` Board of Building Regulations and'Standa_rds Construction Supervisor License: CS-055571 STEVEN M TESSOR 18 DEE BEE Ci[R MWDLEBORO KA ' ow,off a MY " Expiration Commissioner 09/17/2016 -r i i License or registration valid for indtvidut use only before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 -)rd Boston,MA 02116 JNAotvalid without signature i t . i w , i . A& Client#:586925 20CEANSIDEIN ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 07/3112014 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($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed,ff 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 Ileu of such endorsement(s). PRODUCERNTACT ME: Dowling&O'Neil PHONE Insurance Agency E AINj,°E"t:508 775-1620 AIc No):5087781218 973 lyannough Rd., PO Box 1990 ADDRESS; INSURE 9 AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:Arbella Insurance Company INSURED INSURERS:Everest National Insurance Comp Oceanside,Inc. INSURERC: 217 Thornton Drive Hyannis,MA 02601 INSURERD: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DL UBR POLICY EFF POLICY EXP LIMITS LTR IN SR POLICY NUMBER MMIDDM MMIDDIYYYY A GENERAL LIABILITY 8500061423 0110112014 01101/2015 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY FpREMqI E T RENTEDPREMISES Ea occurrence $100,000 CLAIMS-MADE 5XI OCCUR MED EXP(Any one person) $5 000 PERSONAL&AOV INJURY $1 00O 000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY .lF LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNEQ PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident 5 ( $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESSLIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ B WORKERS COMPENSATION CF4WC00045141 1/01/2014 0110U201 X WC STATU- OR AND EMPLOYERS'LIABILITY - ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $1 00O 000 OFFICERIMEMBEREXCLUDED? 51 NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1 00O 000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE l 01988-2010 ACORD CORPORATION.All rights reserved,` ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1349821M134981 LS1 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 Legibly Name(Business/Organization/Individual): 0r-en.,,'>1 16 Q =hC-1 Address: I)b 1)P City/State/Zip: �—k Ck n i7!4_s Itid 0:Z&,)j Phone#: r~ - 's Are you an employer?Check the appropriate box: Type of project(required): 1.91" / 4. ❑ I am a general contractor and I am a employer with� _ 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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.I 9. Building addition 5. We are a corporation and its 10.❑ Electrical repairs or additions required.] ❑ 1P P q � 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 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 my employees. Below is thepolicy and job site information. Insurance Company Name: _ J-e re,'T- - N a'((orx-6 _!_D-\<SUr-a,c)C'—e (2-6 l'Yl a-3- " Policy#or Self-ins.Lic.#: L� �- �� U 0�J Expiration Date: 1 .1 Job Site Address: 14 ZINOX 4 IMAWA V4 City/State/Zip: imA4 J 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 certi u er h a and penalties ofperjury that the information provided above is true and correet. Signature,-' Date: Phone#: �� 1 Official use only. Do not w to in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Realth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel - Permit# `le I fo Health Division Date Issued Conservation Division 1• o�H `� Fee • Tax Collector Treasurer �t,ct_ . Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis 'Project Street Address AlIP/1/,5- ' Village Owner ��,� SG C5—j Address � � V-eS sue , Gov%��Lf 4 rz� Telephone :7/ _ 7 Permit Request •P,�/�a0�� /✓��/I�� rOD,D Cc/l�c��r �Go� �,t/°.L,t�I,,G��S��. Iva Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Tota�w Estimated Project Cost D Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 'el Two Family ❑ Multi-Family(#units)- Age of Existing Structure J�� '�� Historic House: ❑Yes 62 No On Old King's Highway: ❑Yes O No ~ Basement Type: 8 Full ❑Crawl : .❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new `l/OL1J, Half:existing new tio � Number of Bedrooms: existing new /V Total Room Count(not including baths): existing new, /ZI First Floor Room Count . Y s Heat Type and Fuel: 3 Gas ❑Oil ❑ Electric ❑Other Central Air: ®Yes ❑ No Fireplaces: Existing New &0o Vij' Existing wood/coal stove: ❑Yes 4�i No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size O 104 1Shed:❑existing ❑new size /1/466 Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use sS"i/eS-&_ /�'�y`!/1�' !0�/ &/�roposed Use �5/1�4L / ��L.Y �� 1�'✓% BUILDER INFORMATION Name �o ,�= 6-2 Telephone Number Address �License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY _ 4.,'•E a J. �,. s' CC F' .. 'R` i J t _ , PORMIT NO. w DATE ISSUED .K MAP/PARCEL NO', � •� •` ,. - - » � • � ', " . .. #� k, .Nye i • - • t " w { ' + ; i , , , ... ', t . ..• t #•,t ADDRESS, , VILLAGE 1" OWNER ,.- : � , t -� ,, . .�. , , '... "t �» � •� a' 07 ` DATE OF INSPECTION:' FOUNDATION FRAME. « _ e E INSULATION FIREPLACE , ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH I FINAL GAS: ROUGH FINAL FINAL BUILDING fi Ea p t r i ' x DATE CLOSED OUT ASSOCIATION PLAN NO. a ` ` , e own oi itsarnstaDie • e�erw� _ 9 ►`�� Department of Health Safety and Environmental Services Eo Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Buiiding'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. ' I Type of Work: G� /��® �� Estimated Cost Ll z Address of Work: Owner's Name: 1,7 _ Date of Application: Vz I hereby certify that: Registration is not required for the following reason(s): Work excluded by law [3Job Under$1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the o er. �p✓1- ' 7 Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav The Commonwealth of Massachusetts Department of Industrial Accidents 600 Washington Street Boston,Mass 02111 Workers' Compensation Insurance davit name: l . ) C 9 zaje5e 12-,0/d2r C L y location: c.0 �6 city phone# ❑ I am a homeownerf.. performing all work myself. proprietorI am a sole ❑ I am an employer providing workers'' compensation for my employees working on this job. com nnv name: address: VV city: phone#: insurance cn. C-� �/ olicv# 6��e C ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the folloning workers' compensation polices: company name: address: dtv: phone#t . . ...:... ..... msurnnre ca. ... . oirty# comnanv name: address• city: ... phone#� .. .. ........... .......:;,:.•:,.:::.:..:;:::<•>..>.. Insurance co. olicv /G//O / Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a flue of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage veriIIcation. 1 do hereby certify under the pans and penalties of perjury that the information provided above is true and correct Signature Date _ Print name Phone# o fficial do not write in this area to be completed by city or town otIIeiai permitNcense# QBullding Department ❑Licensing Board ediate mponse is required ❑Selectmen's Office 011eaith Department phone it; ❑Other (tented 9M P1A1 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any coat— 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 c: 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renews: 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,neid=.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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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. mgmixt City or Towns 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 applicand. Please be sure to fill in the permitilicemse number which will be used as a reference number. The affidavits may be returned io the Department b mail or FAX unless other ememts have been made. eP Y �g The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax mimber. The Commonwealth Of Massachusetts Department of Industrial Accidents Of Ice of Ilwastloadons 600 Washington Street Boston'Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat 406, 409 or 375 Y' ` 4iyti •� H w Co N i.il IIg I s� c `e �'�' 4419 NagZ as'4 Tf� 7'1` -.t. '4 cn' _ w s-► � � '3�'�aq�f�� 'I' ci �z O 1 �• � ' rtl m r.�j. T t0 m i