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0011 MARCHANT AVENUE
I I �w� t@► I crr a nl ofIMME Town ofBarnstable *Permit # Fx Tres 6 months from issue date Building Departmelgf �, loFee IAENSTABLE, : Brian Florence,CBO -N8 9�A1 1b39 Building Commissioner p' �� � ECNIpt 200 Main Street,Hyannis,MA 02601 Nov www.town.barnstable.ma.0 �y Office: 508-862-4038 � � A�t♦� F x• 508-790-6230 11 S�ABLF EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press imprint Map/parcel Number !•►y J��►M. ' r (� Property Address �•+►A zoo IN A,(Q HJ att-uz1s }�}� Z22QO I g1 Residential Value of Work$ !jj;C>Qp Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address cydC �%a, 7 i Contractor's Name Telephone Number 21 • C]0�6 Home Improvement Contractor License#(if applicable) Email: Se�� � �gg } jl Construction Supervisor's License#(if applicable)�` �. CA ON q M ❑Workman's Compensation Insurance Cheek one: ❑ I am a sole proprietor ❑ I am the Homeowner \� I have Worker's Compensation Insurance Insurance Company Name 1AlD(Z:6_0Q_b 0A3W,(�.1 QAe��` Workman's Comp.Policy# �os Co O C���{ q!7'1 Q 7 ) 7 J 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side �® Replacement Windows/doors/sliders.,U-Value .31 (maximum.32)#of windows #of doors: *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 cop of the Home Improvement Contractors License&Construction Supervisors License is r fired. SIGNATURE: C:\Users\decoll ik\AppData\Local\Microsoft\Windows\tNetCache\Content.Outlook\9NNOKXY W\RESIDENTILONLYEXPRESS.doc 09/26/17 } 6 Town of Barnstable Regulatory Services Richard V,Scalb Interl►n nlrector Building Division Thnmm Perry.CAA Building Can)misslnaer Z00 Midn§irevt, Hymmk INIA 0.2,601 asavav,tma•n,hn rumtuhta,tua,ub ptlioes s"OR-tt(i5-�tttiti Eax; 3ttti-9�1ll-6a30 t Property Owner Must Complete and Sign This Section + If Using A Builder 1, CPJLI 10f 1169, &LDLL� ,tan owncr of the iuliject rropoto Nit,*authtariioT. Aogprs and. Marney _nuil.clera_ ...__ fir:aactonmybeial'f, in all.matere relark,to work aurliorirocl lay thii builcling permit appliv aci m for: i 1 l Pr 04 A N kz Jul Ue, (Aeleirnsn of Jab) signamro of yw n-Vt U*Xi o I 1A t,a '1<>,A W.C 6 C- print N-amv If Proparty Owner li applying for perntlt,plcasp complete the tlomenwnerF meense Exemptlon varm an the revarse aide. t Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-102999 Construction Supervisor GARY J SOUZA ` P.O.BOX310 _ . OSTERVILLE MA 02655 -•.1wr (.. Expiration: Commissioner 08/16/2018 Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement�Contractor Registration ; Type: Corporation ROGERS AND MARNEY, INC. i� _ t "a fF Registration: 164688 Expiration: 10/29/2019 P.O. BOX 310 , 1 OSTERVILLE, MA 02655 ' tom.; Update Address and Return Card. SCA 1 e';r 20M-05/17 - - Office of Consumer Affairs 9 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 164689: L 10/29/2019 10 Park Plaza-Suite 5170 ROGERS AND MARS NC Boston,MA 02116 Cie r GARY SOUZA * 445 WEST BARNS TABLE RD OSTERVILLE,MA 0 l Not Valid Itho SIg tuf@ Undersecretary AC40 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 1 09/12/2017 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: Krystal Doyle ROGERS &GRAY INSURANCE AGENCY INC PAIC,HONNo,E 508 398-7980 A//C No: E-DRESS:MAIL AD kdoyle@rogersgray.com " 434 ROUTE 134 INSURERS AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 . INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B ROGERS & MARNEY INC INSURERC: INSURER D: P O BOX 310 INSURER E: OSTERVILLE MA 02655 INSURER F COVERAGES CERTIFICATE NUMBER: 190895 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MMDD MM/DDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED - PREMISES Ea occurrence $ - MED EXP(Any one person) $ N/A / PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT PRO ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ - DED RETENTION$ $ WORKERS COMPENSATION X SPER TATUTE OERH AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNER/EXECUTIVE Y I N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? NIA NIA NIA 6S60UB4977P25217 01/01/2017 01/01/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Wd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 367 Main Street AUTHORIZED REPRESENTATIVE \ Barnstable MA 02601 Daniel M.Crc6)vv ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved... ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ROGER-1 OP ID: JK .4CORv- CERTIFICATE OF LIABILITY INSURANCE DA09/11/2017TE Y) 09/1112017 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 endorsements. PRODUCER CONTACT Matthew Paharik Northwood Ins.Agency,Inc. PHONE FAX P.O.Box 187 A/c No E>R:508-393-2455 A/C No): 508-393-2955 Northborough,MA 01532 E-MAIL ADDRESS: INSURERS)AFFORDING COVERAGE NAIC 0 INSURERA:General Casualty Insurance Co. 24414 INSURED Rogers&Marney, Inc. INSURERS: Gary Souza P.O. Box 310 INSURER C: Osterville, MA 02655 INSURER0: 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. ILTR TYPE OF INSURANCE INSD D POLICY NUMBER MMMIDD�EFF MPOM/LDICD/EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE a OCCUR CC10395621 03/20/2017 03/20/2018 AGE TO RENTED 100,00 PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,00 POLICY a EC LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 Ea accident A ANY AUTO CBA0395621 03/20/2017 03/20/2018 BODILY INJURY.(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED - - PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 10,000,00 A EXCESS LIAB CLAIMS-MADE CCU0395621 03/20/2017 03/20/2018 AGGREGATE $ DIED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y rN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDE OFFICER/MEMBER EXCLUDED? a N/A NT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION BARNSTA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 0211 4-2017 wwminass.gov/rlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Phlmbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Rogers & Marney, Inc. Address:445 Osterville West Barnstable Road City/State/Zip; Osterville, MA 02655 Phone#r: 508-428-6106 Are you an employer'.'Check the appropriate box: Type of project(requires!): I.q I am a emplover with'_emplovees(full and,or part-time)." ], New COnstrLlCtlOn '_ am a sole proprietor or partnership and have no employees working for me in ❑I - S. ❑ Re-modeling any capacity.[No workers comp.insurance required.] 3.❑I am a homeowner doing all work mvself.[No workers'com 9. ElDemolition p.insurance required.]' 10 ❑ Building addition 4.❑l am a homeowner and will be hiring contractors to conduct all work on my property. l will ensure that all contractors either have workers'compensation insurance or are sole l 1.❑ Electrical repairs or additions proprietors with no employees. 1�.❑Plumbing repairs or additions 5.7v I am a general contractor and l have hired the sub-contractors listed on the attached sheet. 13.❑Roof repair's These sub-contractors have employees and have workers'comp.insurance., 14�Otltzt 6.❑We are a corporation andits officers have exercised their right of exemption per�[GL c. Kl°:D.)1 � 152.§ll.4),and we have no employees.[No workers'COMP.insurance required.] "Any applicant that checks box ml must also till out the section below showing their workers'compensation policy infonnation. 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 provielina workers'compensation insurance for my employees. Below is the policy and job site information. . Insurancz- Company Name:Hartford Underwriters Insurance Company Policy-or Self-ins. Lic. -#:6560UB4977P25217 Expiration Date:01/01/18 Job Site Address: Opetl- u, 4 A& City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy nun er and expiration date). Failure to Secure coverage as required under ivIGL c. 152,§25A is a criminal violation punishable by 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 S'_30.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DLk for insurance coverage verification. I do her ehy certify tin r the trills id pe lalt of perjury that the information provided above is true and correct. Siu-nature: Date: 11 (21 1 Phone#:508-428-610 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#: Town of Barnstable rc , Permit#,6'a -/Y7 ires 6 months fro sue e Regulatory Services fee V !tU BARNSTi►s `mI'c� "u -Richard V.Scali,Director . t6gq. ♦� ' Building Division,. 4 ® _ Paul Roma,Building Commissioner' 1#Rl< 200 Main Street,Hyannis,MA 02601 JUN. 2 9 1 �r. www.town.barnstable.ma.us , Office: 508-862-403 8" TOWN U Sax:j508 g7 0-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ABU, Not Valid without Red X Press Imprint a r. Map/parcel Number ( Property Address ,� . � ' /J/T1� � ia��'J� n�� s 0 Minimum fee of$35.00 for work $6000.00 (Residential Value of Work$ � , Owner's Name&Address �iAea. ,�a(`'�1d' Contractor's Name. ,� i Telephone Number `` 0 e' / y Home Improvement Contractor License#(if applicable) ' s Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance . £ Check one: I am a sole proprietor, i ❑ I am the Homeowner.. PI have Worker's Compensation Insurance 3 Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ st(check bQ) ; "JRe-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) s Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum'32)"#of windows #of doors: Smoke/Carbon-Monoxide detectors 4 floor plans marked with red Sand"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 ofPermission:" j A Copy of the Home Improvement Contractors License&Construction Supervisors License is required: ' SIGNATURE. Q:\WPFILESTORMS\building permit forms\EXPRESS.d ' 06/20/16. _ ' r - The Commornreaitih ra,f Aaysadruse& Departmeut of 1'r dmoid Acddem& - ��of ITl1?V�shgatio71S ` 600 Wasl&wton S6—et - Boston,MA O211I iPrP'IL7l mmgvA1dia T�rlcers' CtmpensateunInsu>�UceAffidavit:SmlderslCrntracturs/ElectdciansJP'bmibers AprChcant Infarmation Please Prin E.e aly 0z . Phone rare you an employer?Cbeckthe appropriate bom Type of project(requir e4: I.❑ lamaemployerwith 4 ❑I am a general contractor and I 6_ ❑New oon employees(andfor * ltavehiredthe sub-contracftws .❑ I am a sale "etor ar listed onthe att shed sheet. ?- 4ZR=bodeHgg l i?a l�� njese:=b-cmAractors have sb�p and have no employees ❑Dermaon :Forme in employers and have wo&zrs' �ytY- . nt,astrarc�r$ 9. .❑Buiitfsag addition[NO wodonw C=P.finustnce comp. required j 5. ❑ We are a corporatim and its 1 ❑Electrical repairs or adddiaus 3.❑ I ama hommuner doing all wow . officers have exercised their 1L❑Phnabsagrepairs or adifitions, mysdt[No workers'oamp. "right of a =pfion per Me-, try❑Foofrepaim. incur nceregnired.I f c.152, §I(4�andwe have no employees.LWovradoe ' 13-0tither cam-ksar=cz reTnn-j $Amyapg&eaaamtcbeds box RmostelanIMoit the swffmbdaw--&uviagftiry ke&camp—sat; PeRcyiafomud= Hameeamerswbasubs fins trffidngimfficatnz6eyaxedcfmgOvrc*sad&mhire64=&cmtxct=wust=Th=1new2fd2n&Cmdi—r such. ICozEtc CftM Bast checYtlds boot must wftr% sir sdrIiti®st sheet sbnei:ng the name of th¢SUj0-CCMtNCt3M fmd state Whether or not Vmse endtkshn-e mgib ees.Tftbe have empIoyws,dieyxmfst pmvide&w wa&eW to MP-FahcF"eL I am au euip�r that is prm*Mrg warkers'comgrensrdtan insurance for br azy empkya= $etoev is MapoUcy ardiab sfte irz,{ormrrtian. _ - t I�5auceComparlT- Natntr: Paficg or 1pisatiaaDe: Job Sate Addsessc;./I & U � ���' CitglStawZip:�� Aftach a-eopy of the workers'compensationpolfcy declaration page(showing the policy number and expiration date). Faite to semen coverage as r egmredunder Section 25A of MW-m 152 can lead to the imposition of criminal penalties of a fine up to$UOD OD ar d ror one-gearimpfism==3ik as well as rim penalties in fig form of a STRIP WORK ORDER and a fine of up to Moo a day against the violator. Be uh sed ihaf a copy of this statement saag,be fxvarded to the Office of Investigations of*e DL4 for imsorance coverage vedfic atim I do ff rm r cwt yy the pains and n a. FerJrce}'thatthe in orma€wiprinided abmv i;hm and correct Simmdum- .Dater e� R a,Okial sae only. Do mat Eats in figs area,to be cmnpTeted by city ortaocn ajoiciaL My or Town: Perarh ieense 4 Issuing Aufh-orfty(curie one): L Board of HwIth 1 I wIffing Degameat 3.C5lyfrowa Clerk 4 Electrical Fuspector S.Pjumbmg fnsgecter 6.Clfh4w Con#act Person: Phow#: 6 Eaformation and Instructions - mz&sar cft cret=al Laws c VfEr 152 rmlm=all e:gloy=b provide w=1M&=:aP=mtuan for f b ei£emplayees- Pm.-saantia this sty,an��y�is defined ash.every persdu in'he service of anatha under amy con Tact ofhi ° =p}ress orimpli.ec%oral orwrittn -" An EZnp dyer is defined as-au infvidnal,pMt2M Ship,associafran;carpor-dion or outer Iegal em ti f y,or airy two or more of the f ruing Magaged.is aJoint Mterpdsel and including the legal relnesetatives of a deceased employer,or the receiver or trustee of an mdmdnal,pm-fne hap,assomaiaon or otheslegal entity,eoxployMg employees. However the own=of a,dwelling Douse having not more tbm free apartments and who resides ffi=in,or the occag-mt of the - dweMag house of anon who employs pmsans to do maimfffiance,consL-az au or repair wow.on such dweIlmg boase or outhe grounds or buUdmgappurhmar¢thereto shallnotbecause of such employmentbe deemed to be an e�Ioyer." MQ,chapter 152,§25C(t7 also states fhat'e:verystate or local licensing agency shaII withhold fire issaauce or renewal of a ficertse or permit to operate a busimess or to construct buildings is the commonwealth for airy applicant Who has not produced acceptable evidence of compliance with the insurances cove)mge required" AddilionaIly,MGL chaptr_r 152,§25C(7)stairs�Feer rththe c=ma nor diy ofitspoIiiical subdivisions shall enter into any c me ract for the pmfmm=ce ofpubhr wm3cucLtI acceptable evidence of compliancewith the ins1ce MT3iMMets of this cbaptes have been presented to fhe confrading anfhozity-" Applicants Please fill oirt the wori=' compensation affidavit completely,by cbe�g$e bones aat apply to your situation and,if necessary,supply sob-canfractor(s)name(s); address(es)and phone numbers) along with.they=tifrcate(s)of msm-Emce. Limited Liability Companies(LEG')or Limited Liability Parft=abips CLEF)wifhno eauployces other than the members or partners,ala not mquired to cagy woke& compensation insurance. If an LLC or LLP does have employees,apolicy is regoi t4 Be advised-ffie this affxdaYitmaybe snbmittedto the Department of Industrial Accidents for confirmation of ismanoe covezage Also Be sure in sign and date the afdxVit The affidavit should be raged to ihe city or town that the application for the permit or license is being requested,not the Department of ; TT�l A�adents- ShDnld you have airy ques-tions regatdmg tine law or ifyou aim recpfed� obtain a wormers' comp,Satire,poficy,please call thzDeparimentatihermmbeali<st below. Self-fimuedcompani esshould r#liea self-i sa=Ce license=mber an.the appnTriate line- City or Town Of L - Please be sr¢a fhat the affidavit is complete and.priated legibly. The Deparimenthas pro-vided a space of file bottom of the affidavit for you to fill out in the event the Of ofIuvestigations has to contact you regarding the applicant Please be sure to fill in the pen/i ice nse nu nber which will be used as a refer nee number. In ad dition,an applicant mat must submit multiple pc='/Ticam,ce applitati ns in any given year,need only submit one affidavit indicating==3t policy information Cif necessary)and under`rlob S`$e.Address"the applicant should wz>$"aU locx�ns n (may or town) "A copy ofthe-affidavit that has been officially stamped or marked by the city or to may be provided to the bL- applicant as proof the a valid affidavit is on#tie for 531= permits or licenses. A new affidavit must be f Iled out ea z year.Where a home owner or citizen is obtaining a license or permit not related in any bn7esc or commercial a dog license or permit to bum leaves etc.)saidpmrsou is NOT requRrdto complete tliis affidavit The Office of Investigations wouldh1m to thank you in advance for your cocperation and should you have any g3=fi . please do not hesitntm to give us a call. The Depart nenfs address,telephone and fax number: Of MzssaCh Dep33JM=t of�Aocidenta - . la MA Ol I11 Ta#617- -49Wwt406w1-977MAS A " Faz#617 727 7M Reviscd¢24-07 - - v Town of Barnstable Ms Regulatory Services ` saAse. ` Richard V.Scab,Director " Building Division Paul Roma,Building Commissionerel 200 Main Street,Hyannis,MA 02601 " www.town.barnstable.mams Office: 508-862-4038 j '` Fax: 508-790-6230 Property Owner Must , Complete and Sign This Section ' *`. If Using A Builder ; T .. ( %y, 1c 72:)M ./TZ✓�11,0 cll ,has Owner of the ro subject P Pe�tT hereby authorize J� i"%- C -," to act on my behaliy in au matters relative to work authorized by this builduig permit application for:" '* (Address of Job) **Pool fences and alarms are the responsibility of the applicant'Pools, -� are not'to be filled or utilized before fence is installed and all final inspections are performed and accepted. - y Signature-of Owner .; Signature of Ap}}+"licant ' e , , -Print Name Print Name .. '. e �' .. �• .. r fry p' ¢ a).. G 4 - I Date J QYORMS:OWNERPERMSSIONPWI S I Town of Barnstable Regulatory Services dF Richard V.Scali,Director Building Division RARNSTAJIM Paul Roma,Building Commissioner PAAM 039. ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: ciWwwn state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building hermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family 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 homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided-that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shalLact as supervisor." Many homeowners wbo use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing-Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. . Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 AC V CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/30/2016 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; Kathleen Geddis NORTHWOOD ESHBAUGH INSURANCE AGENCY, INC. PHONE Ell: (508)771-1632 ac N„ ADDRESS: kgeddis.north24@insuremail.net 540 MAIN ST. INSURERS AFFORDING COVERAGE NAICA HYANNIS MA 02601 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER 8: DAVID COX INC INSURERC: INSURER D: PO BOX 401 INSURER E: S YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 65978 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 LTR TYPE OF INSURANCE ADDL SUBR - POLICY EFF POLICY EXP POLICY NUMBER IMMIDDIYYYYL (MM/DDfr.YYILIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RE T D PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECT �,LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY - EOMaB NNdEDISINGLE LIMIT - ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident $ AUTOS AUTOS ) NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Par accident UMBRELLA LIAB OCCUR - EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000, A OFFICER/MEMBER EXCLUDED? N/A N/A N/A 6HUB91OX742215 - 07/16/2015 07/16/2016 - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.g6v/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of BarnstableACCORDANCE WITH THE POLICY PROVISIONS. 236 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel M Cro rney,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD: • I f - 1 i Massachusetts Department of Public Safety µ Board of Bailding Regulations and Standards License: CS-063537 Construction Supervisor DAVID R COX PO BOX 401 ' SOUTH YARMOl1TH R 2 Expiration: ' Commissioner 10/16f2017 I I1 '.�'/�N (;"nY�a!/!nirrl erlt1tle O,r"lLriJ.frr[�ilelr./YJ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only k I€IOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 100497 Type: Office of Consumer Affairs and Business Regulation yyExpiration: 3/25/2018 Private Corporation 10 Park Plaza-Suite 5170 s,s' Boston,MA 02116 DAViD COX, INC. David Cox i 19 LAVENDER LN W, YARMOUTH,MA 02673 Undersecretary Not valid without signatu .. r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �- � Parcel d Application # Z Health Division Date Issued Conservation Division 2Y Application Fee Planning Dept. - Permit Fee - Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address Villager � y Owner /L//I/ � /� �cece< Address c .3 S-v/ Telephone Permit Request _ ' OC 7,34 1-1�WOIIY6 fro Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio 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 Q.Electric ❑ Other fir; 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 ❑ C) Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Telephone N tuber d Name i u Address /.,! , License # CS Is Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 4_0G1145z_ DATE //— -. �'� FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED }f MAP/PARCEL NO. ADDRESS VILLAGE OWNER - DATE OF INSPECTION: . H FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH r r FINAL GAS: ROUGH FINAL FINAL BUILDING F - . a DATE CLOSED OUT ASSOCIATION PLAN NO. ,r � ry t The Commonwealth of Massachusetts DepartmW of lndusMal Accidents Office ofbm►estigaaons 600 Washington Street Boston;MA 02111 Workers' Compensation Insurance Affidavit: Sande s/Con A hcant Information tractorsXlectricians/Plmmbers , Please Print Legibly Name (BBsmess/organization/Fndividnal); Address: City/Star mv:�/i l� �/ G' ! Phone#: Are you an em to er? P Y Check the appropriate bar, _ 1.[] I mm a employer with 4. ❑I mm a general contractor and I Type of project(required): employees(full and/or part-time).*. have hired the sub-con nstructian 2.X1 am a sole Ti or tractors 5, ❑New co Prof partner- listed on the attached sheet. 7. ❑Remodeling slip and have no employees:. Thes6 sub-contractors hav e working for me m any capacity, employees and have workers' 8' (]Demolition [No workers'comp. incrrrrr,De:.. comp,msuiance. 9. ❑Building addition 3.❑ required.] 5. [] We are a corporation and its I�. , I am a homeowner doing 0 work officers have exercised their Electrical repairs or additions .. myself [No workers' c 11.❑Plumbing repairs or additions camp. right of exemption per MGL iastrance required] t C. 152, §I(4), and we have no 12 0 Roofrepairs t employees. [No.workers' 13. Other omp.insurance. . re e Any applicant that checks box#I mast also fill out the section below showing ties workers c d] t Homeowners who submit thus affidavit indicating they are ompensation policy infnrmalion #Ceatractnrs that check this box mast attached as additional eII work and then hire outside contractors must submit a new affidavit indicating such. �ploYem If the sub-contractors Dave to sheet showing the name of the sub-contactors and state whether or not those entities have �p Yam,they most provide their workers'comp,policy cumber, • I am an employer that is prvvidiitg workers'cvarpensation insurance oT inforrrraz�on• f my employees. Below is the poFicy and job site 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(shoaling.the po,hcy number and + Failure to secure coverage as required under Section 25A of MGL c: 152 can lead to the ' ezgu-ab°n date)` fine up to$I;500.00 and/or one year�o imposition of�imal Penalties of a Of up to $250.00 a der a �� well civil penalties in the foan of a STOP Y against the vio}ator. B WORK ORDER e advised that a Copy of this ststeinent may.be forwarded to the Offi f d a fine .Investigations of the DIA for incrT.�„ce cov erage verification. Jr der hereby certify under the pains and penaffiea o • fPeflu►y that the inforrnalion provided above is true and carrecL. Si 6'G > Phone Official use only. Do not write in this area to be completed - ��OT tpwT!O,�Cla( City.or town: PermitUcense# Issuing Authority (circle one): L Board of Health' 2.Building Depart ineat 3. City/T`own Clerk 4.Electrical 6. Other Inspector 5.Plumbing Inspector Contact Pwsou: Phone#: Town of Barnstable t Regulatory Services * UWWA=, . MASSThomas F. Geer,Director i639. il - •. . Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 0260I www.town.barnstable.maxs Office: 508-862-403 8 Fax: 508-790-6230 . Property Owner Must Complete and Sign This Section If A Builder as Owner of the sub1'ect P ro . P hereby authorize to act on my behalf in all,=tatters relative to work authorized by.this building permit (Address of Job) #Pool fences and alarms are the res onsibili of P tY the applicant. Pools are not to be filled before'fence is installed and pools are not to be utilized until all find inspections are performed and accepted. r Signature of.Owner Signature of Applicant i��✓ %J Print Name Print Name Date QFORMS:OWNERPERMISSIONPOOLS IME Town of Barnstable Regulatory Services NAMUDISSMAIK"Z4$ Thomas F.Geiler,Director MAK 059. Building Division prEp�� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4088 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: t+ city/town state , 7 _..:ap.code Y+`"*.~\ 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'tlie owner acts as supervisor. " _ DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. 'Such "homeowner"shall submitto 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"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official - Note: Three-family 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 homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that ifthe homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly` >when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware ofhis/her responsibilities,many communities require,as part of the permit application, that.the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt • I I Massachusetts Department of Public Safet} ' ! Board of Building Re"a lations and Standards 1 C Consfi•uctipn Supervisor License �. I -,License: CS 15834 � ;HOWARD W,WOOLLARD �«I ` ,PO BOX 263/3219 MAIN:ST � - �BSA,RNSTABLEE,iWA 0263i7 .r F Expiration: 10/30/2013 " Contniusiu�ier". T,r#: 5947 Office o1` on um°�a airsiness ega a o0 HOME IMPROVEMENT CONTRACTOR I {{ Registration: Al 15 Type: { t Expiration:, `7/2412012 Individual RD W.WOOILAR ;� IR- Howard Woollard�� 236 CENTER STREET— 1 tea✓ " YARMOUTHPORT,MA 0,25Q:' Undersecretary a47o 780 �tIH*E r Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee _ t anxNsrast g Thomas F.Geiler,Director Mass. c�S 9�b i63� ,•� Building Division 2 ArED�,l A - 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 Property Address Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number, 5:1-,Y/Z Home Improvement Contractor License#(if applicable) v(Workman's Compensation Insurance Check one: . ❑ I am a sole proprietor ❑ I am the Homeowner -PRE h ffI have Worker's Compensation Insurance 99 Insurance Company Name f� lc ,5 AUG 1 4 Zoos Workman's Comp.Policy# Zld 275 2 TOWN OF SARN STABLE.. Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken toi4i?/'l/�Z ' ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum Al *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 Fnm Kathy Geddla FaXIU NorThw*OC M$L:rance -eye c v,c „_ ,c •ate ACQRp CERTIFICATE OIF LIABILITY INSURANCE OP IDDAV - °RT°`"a''D4/0 DAVZD2 07 14/p9 PROWCER THIS CERTIFICATE IS ISSUED AS A MATTER cF INMIIRW ION ONLY AND CONKERS NO RIGHTS UPON THE CEPTIFICATE Nortir000d Sn5. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR 540 Main Str®et, Suit® 9 ALTER THE COVERAGE AFFORDED BY THE POUCICS BELOW. Hyannis HA 02601 Phone:508-771-1632 rax:509-393-2955 }INSURERS AFFORDING COVERAGE NAICK �N NsuREu A. Travelers Insurance Co. YNSL'RER� Ttavala!rs Snausaac�coupany�. i 4Vtid COx/ C. INSURER' S Yarmouth MA 02664 m;;rf jRe;;_ COVERAGHS ,Utr iACf.:T, E ' KF .E0O TW • tE POlC\PcRiOD f? !rATEO NCTw ITHSTad^IaG! STE ; F Fs 6 +tQUIR. T Rfr�*:::.tlaUitK11E GF At1Y,� NTRACT 4ri Ji HE:'.L'^CUfAEN7'h'.M kc`aFt_'•C-T.:\1hUC4-H:S!�Ri{F!CF1E I:•l+:'r K IJSI'ED 0P n+.Ky PFPTA!N,T e L'JSURN,,CE AFF::'RCW BY THE ROL G ES✓E5CF:i5E0-!EREIn i c:�J3.1EC--G ALL?tE-=_RM'5,ct•C_U51:A ;,C,C,hNC!iT!:N&r`F SLICE Plv:i44iC,3 MAY HAdE REV F XZ-,Ely PAID CLAMS. . WOK tTR Tl'FE Cf 1PSWRAAICE POLICY NUMBER GA i •GD/YY1 I GATE tMN1G •1 Y) L'Imrs I �10ENER"AIL, L!ABIUTY II EA'H0a:CURRENCE �ooaoao A CCNNv1ERCi.4.XNEzLJ IUTv a-6$0-14$123796-^,Off°-0902/14/09 03/14J10 $ 300000 Ct.411aS!v1ADE !}{ 'nr•CUS 1 I MED EJ(?i.ny cna PFrio') cl ,5000 �"•- 1 F�?; AAD'CrrrVRy `' 2000000 - � Business OWd'iHBrs 1 _ I OErEAtA!scRECrs;rE 52000000 I '0[N':Av'?nCCtF.TEUMITAPF-IESPEF'. I ?ROGUCTB- 2000000 r.A,CY r� LO': i i crs. ! 2000000 j AI:T0K4fLE L,M LPIY OZ-w!\Z)E>IK',LE 0,1I7 I (Es 9,,cA ) 1 i I ,i:•L'?\vVEC'PtTJt• � 1 � �DODIL"av„U4Y �q IPa,How! ! SCHHOU(.EG'r«JTC3 ____ j WiR°D Pi.?OL I t j 8000l!:"0J,'•l(_•_ I it I (Ptr acc!Uamj I--1I i I I 'PP.OP°FIIY y`,F+fyACiE �S �•— ip•r accideni! OARAOE UA9 L+TY AVTC C'NLY-EA A,^,CIDEVT 5 ` I I ANY HtJ-O i I OTHEG THwJ cA.a:: {---it I AVEC JhkY' A G I 111 ! i fiXCE88IV0116REtLA LIAgy IT)e EA:H O^.:URRE!JCE S _ �I C•EDLICTIBLE i PEtENY''ON 6 •S I WORKERS COWBNSAnONANG I I TCRYLIMIT$ ER B p a'r 'RCS IEi. 'F'sR'fntEo/ehECU;/E I OUT u%Z, raLL u rr.cmt co 1 07,r 15/08 I 07/15i 09 =L !•s 100000 cs:CE�ntSM6E�EYCLL,1'.1-C" WZN 5 DAYS 07/13/0.9 07/15/10 'E1. 015EA;1E-FAFl 0 !V pat,Wsonbe undte FRCVISICt:SUIO i El GI EAX•F;?Li•_,U'J ;500000 UT ER ' I 09SCRPMN OF 01011171102 1 LOA.WrCN81 V CLI EXCLUSIONS ADDED BY ENCORSEM NT I VliaAL PR VI CERTIFICATE HOLDER CANCELLATION TOWNBAA BHOULC ANY OF TWABOVE DL'3CRIBED POLICIES BE CANaL69D SEFORB THIE EXPIRATION r. DATE THEREOF,THE 01;VING INSURER WILL ENDEAVOR TO KNIL 10 DAYS'NRiTTEiv NOTICE TO THE CBRWWATS HOLDER ROM TO THE LIFT.OUT FAILURE TO 00 50 54ALL TOM OF HAMSITABLE 367 HAIN S1'Ri10ET IMPOSE NO OBLIGATION OR LABILITY OF ANY kttll) PaF!U THE WSUR@R,ITS AWNSS OR HYAMIS HA 02601 REPRESENTA"S. AUTH;p� . ACORD 25(2001108) 0)ACORR CORPORATION 1988 The Commonwealth of Massachusetts M. Department of Industrial Accidents Officiof, Investigations 600 Washington Street Boston,MA 02111 H 6'`� . I www.mass.gov/dia c Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):� � � �%' Address: City/State/Zip:p: e2zkAel. : Y-11,7S �horie.#: Are you an employer? Check the appropriate box: .Type of project(required): l ❑ I n to ljth 4 0 I am a general contractor and I ees p Yye ,� 6. ❑New construction employees(full.a d/or part-time) *. " have hired the sub-contractors ~ .2: I am a sole proprietor or partner listed on the attached sheet. 1 •7. Q Remodeling ship and have no employ These sub-contractors have,. 8. ❑'Demolition workingfor in an capacity., employees and have workers' Y t 9. ❑Building addition [No workers'-comp.:insurance comp. insurance. re uired. 5. We area corporation and its 10.❑ Electrical repairs or additions 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 7 12.WRoof repairs , 4 insurance required c. 152,.,]t � �. ` , §1O,and we have no.: � employees. [No workers' 13.El Other comp.insurance required.] "Any applicant,that checks box#1 must also fill out the section below showing their workers'compensation policy infomiation. ` 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 employees,they must provide their workers'comp.policy number. E' 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 #: 'L � ,�'- L Expiration Date:y : p• Job Site Address f� fC/ ` 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 25.A 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`agaipst 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. y certify p p f p ry f p ided above is true and correct I do hereby certi under the ains and enalties o er'u that the information rov Sign,ature:,-- Date: `Phone#: r Official use only. Do not write in this area,to be completed by city or town official. City,or Town: Permit/License#'z Issuing Authority(circle one): 1.Board of Health 2.Building Department. 3 City/Town Clerk 4.Electrical Inspector,°5.Plumbing Inspector 6.Other - Contact Persom 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 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-contractors)name(s),-addresses)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department.has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in -_(city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.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 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# 617-727-774 Revised 11-22-06 www.mass.gov/dia t OF ' ti KE O ' Town of Barnstable r RUMSrABLE, s MASS, r Regulatory Services 'O�En►�'�a 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 as Owner of the subject property hereby authorize ✓ ham �/d� to act on my behalf, in all matters relative to work authorized by this building permit application for." (Address of Job) Signature of Owner ate Print Name QA)ATFILESWORWbuilding permit formsEXPRESS.doc Revise020108 �t Town of Barnstable Regulatory Services BMM�,�� . Thomas F.Geiler,Director � t ,�� Building Division AlEO fV1Ar� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family 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 homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC Dard of But m _ u ,,,,,,�� g ation�and At= a n + . on Bards ^ stru� c6on Supervisor License I r iY License: CS 63537 { r BirthdateNl0/15/1953 Expiration 10/162009 Tr# 6313 IRestriction 00., i DAVID R COX p t F / PO BOX 401 S YARMOUTH, MA 02664 `' ] Commissioner ✓/. Vi omimoauuPa�C� o��aaaac uae�b j ` Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: !` "` Board of Building Regulations and Standards ` RegistraiiQnl, 100497 One Ashburton Place Rm 1301 Ex iration 6%.18/2010 Tr# 268012 l P{ 117. Boston Ma.02108 (. Type Pnvate Cprporation ; - t 'DAVID COX,INCH David Cox Y ,19 LAVENDER i Not valid without A nature �W.YARMOUTH,MA 02673 Administrator, s' `k * blTown of Barnstable Permit# 8680 oft►,e ram, Ex Tres p _. .. _.,. 6 rnonihs fr is date e_..__ __ •_ . ,.. . -=•..,..... -=Re ulator Sem—lees .... _ Fee-- BAMSTMIAW Director BuildingDivI on Perry, Build mPRESS ing Commissioner I .• •200 Main•Street,•Hyannis,MA 02601 S E R 1 2 2005- Office: 508-862-4038 _ Fax:'508-790-6Z30' TOWN OF BARNSTABLt...r..,.. _.. -° +EXPSS; ERIGII'T:A 'I' YOA�'TON RESIDENTIAY,ONLY. Not Valid without Red X-Press Imprint lap/parcel Number 'roperty Address Residential Value of Work �P Minimum fee of$25.00 for work under$6000.00 owner's Name&AddresyZ _ P ,,�� ,,��ll; 4kAzZ Y� Contractor's Name � �.b Ji Telephone Number Home Improvement Contractor License#(if applicable) JT tl 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 1A WoOman's Comp.Policy# t' Copy of Insurance Compliance CertificitWimusl be on file. Permit Request(check box) eRe-roof(stripping old shingles) All construction debris will be taken to �,L,7W ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maxdmu**+.44) *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. Home Improvement Contractors License is required. Signature Q:Forms:expmtrg Revise063004 Board of Building Regulations and Standards i r-.<. .. HOMEIMP OVEMENT CONTRACTOR Registrati�nt 10049% 8�2006 p - to Corporation DAVID COX,IN David Cox } s 19 LAVENDER LN r W.YARMOUTH, MA.02673 -' � - Administrator —— r o Town of Barnstable of �� , ' Regulatory Services T,homas F.GeUer,Director 9� ��� �.• Budding Division '°1FD MAi TomPerry, Bufldlug Commissioner 200 Main Street, $yaanis,MA 02601 www,town Barnstable.ma.us, Fax: 508-790-6230 Office: 508-862-4038 Property Owner Must Complete and Sign This Section If Using ABuil.der as Omer of the subject property .to-act on mybehalf; :hereby authorize r application for. in au�.tters relative to work authorized by this building permit r ,Z�rl�illt/1J /�1/ d �P/ (Address of Job) 4 Signature of Owner ate Print 1*�ame I I Crai Ole Lj Beach Rd. `_j: I e w w w wz 4"X4"P.T. POST(TYP.) Ir osnn I o PROPOSEDO NN 2"X4"RALINGS X46 ON4 1a POSTS Q 00 l a- PROPOSED WALK REMOVABLE STAIR = a p 0 ROPOSED - SECTION TREADS � 31 m 'LL Op LANDING W/2"X2(CLEATS) I I PROPOSED Locus 7 1/4"RISER W/ I PROPOSED CONCRETE 11 1/2" TREAD (TYP.) I i STAIRS (TYP.) STONE Nantucket REMOVABLE STAIR SECTION i STEP (TREADS W/2"X2" CLEATS) 16 16- Sound jk 14 14- I 12 12- BOTTOM POSTS JETTED& DRIVEN (NO CONCRETE) 8 I 10. 18- LOCUS MAP 6 6 SCALE 1"=2000't 4 4 - if 2 ° ° 2 - ASSESSORS MAP 286 PARCEL 26 0 ° ° 0.- #11 MARCHANT AVENUE LOCUS IS WITHIN FEMA FLOOD ZONE V10 (EL 14) AND ZONE C AS SHOWN ON - -- COMMUNITY PANEL #250001 0008 D DATED A Saale:1"='1O' A B B 7/2/1992 ° 5 '° 15 20 25 FEET OWNER OF RECORD HARDEN, DAVID E & BABCOCK, ANN H THE FAIRWAYS MCCONNELLESVILLE, NY.13401 REFERENCES LC CERT# 87915 MITIGATION LCP# 13920A ` PLANTING NORTHERN BAYBERRY (25 SF) MYRICA PENSYLVANICA (TYP. OF 8) [#3 SIZE) #14 MARCHANT AVENUE EVANS, DAVID C& TUTEN, MARGARET E LAWN -MITIGATION 128 ASHWOOD RD FENCE PLANTING � FENCE - J VILLANOVA, PA 19085 #28 MARCHANT AVENUE STONE STEP (50 F) KENNEDY. ROBERT F GE of g Rchq 114°7 C AIINBRIDGE RD 9: W o 'yT 11 MCLEAN, VA 22101 MITIGATION // j �i0 '�V� PLANTING Z (120 SF) EXISTING VISTA W ,y TRIMMED VEGETATION Q n Q $j Q #27 MARCHANT [l^ •T— � z - UJI AVENUE a < Q #11 MARCHANT AVENUE COLEMAN LMTED (TYP. OF BENCH TOPIOF COASTAL BANK -A/ n PARTNERSHIP' n LP #4 #3 625 WEST LYON PROPOSED ' 1 V FARM DR _ LANDING --- -- N GREENWICH, CT --FRS p 06831 j4 (REMOPr) ENE C 4 - o 5 PRgtJOSEO 8 , RAISED ALK TO _---- - /- TOP OF STAIRS / i _ - EXISTING OPEN RISER _ CW�'iAL-BAN= #61 DALE AVENUE 0) STAIRS 7 (TYp,) MCOUADE, EUGENE M &PEGGY J 50 DOWNING ST ' E GREENWICH, RI 02818 .j ? 1 SNOW PROPOSED 4 i STAIRS W/ I - ------_ _ / RAILINGS ,e1 D REMOVABLE S HERE r11c�KEr SOUNDHANDRAILS& POSTS / - ►VAN pop'\-) W a TO REMAIN IALL YEAR B COASTAL BEACH, Z/ I < �/ o Scale:1"=80' _--- _./ 0 40 80 120 160 200 FEET / M.H.W STAIR PLAIN 1,4 NAVD88 DATUM IN 2 LW SEAC" D HYANNISPORT, MA .,VSnNC ROCKS fX/snNC ROCK �A SO R£V£7M£NT !� VV (TIDAL) PREPARED FOR ' Scale:;"=10' ANN H. BABCOCK a�pS�y`SpCHU� . R.G �5 10 15 20 25 FEET Qe`y c , I DATE: MARCH 25, 2010 REVISED: APRIL 28, 2010 :� NOTES: off 508-362-4541 YZ"N `r`' I fox 508-362-9880 1. VERTICAL DATUM: NAVD 88;„ os m�� downcape.com Il T 2. THIS PLAN SPECIFICALLY FOR THE PERMITTING OF THE down cope engineefing, 14C. STAIRWAY TO THE BEACH AND NOT TO BE USED FOR LOT DATE ANDREW R. GARULAY, STAKING OR ANY OTHER PURPOSE. s„oFSHOFsso civil engineers Mss r� qy 3. THE EXACT STRUCTURAL DETAILS OF THE STAIRWAY ARE TO DANIEL � land surveyors DANIELA. A. BE PROVIDED TO CONTRACTOR MUILDING DEPARTMENT UNDER y oJAla OJALA u SEPARATE COVER, DESIGN N01 TO BE UTILIZED AT ANY OTHER 939 Main Street ( Rte 5A) CIVIL No.40980 SITE OR IN ANY OTHER ARRANGEMENT WITHOUT WRITTEN Na 46502 Ao �� YARMOUTHPORT MA 02675 po�Fs ors �° CONSENT OF DOWN CAPE ENGINEERING, INC. ( sr ©2010 DOWN CAPE ENGINEERING, INC. ALL MATERIALS DATE DANIEL A. OJALA, P.L.S. PERMIT SET - NOT FOR CONSTRUCTION 09-249BABCOCK.DWG a