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Home My WebLink About0160 MARSTON AVENUE (4) Lao m a_y-,4o,n l�a-rb�w- Y i 14(, t Application number.... .................. Fee ........................6.................... . . Building Inspectors Initials... ....... .. ................. JAN 25 20g TOMMF BARNSTA6LE Date Issued.............. ..it.�5. ..�. .......................... Map/Pa rcel... ..� d....111P..:........... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET VILLAGE ' U Owner's Name: lLS'/ Al 5�-r-� Phone Number_ Email Address: Cell Phone Number Project cost$ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ❑ Siding ❑ Windows (no header.change) Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris'will be going to CONTRACTOR'S INFORMATION Contractor's name PO Box 52 Home Improvement Contractors Registration(if applicab*J men i s� Jgtach copy) Cell (5115) 280-6964 Construction Supervisor's License# CSL-58633(atHMGcWP393 . Email of Contractor Yn CCc Phone number, ALL PROPERTIES THAT HAVi STRUCTURES OVER AS YEARS OLD OR IF THE SUBJECT PROPERTY.IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED: APPLICATION NUMBER........................................................... �. h *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one:this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or>Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date "//AYPLICANT9 S SIGNATURE Signature Date I All permit applications are subject to a building official's approval prior to issuance. VII z gf.:'[HB Town of Barnstable _ s CY :. tsnRVsrn Building Department Services AISS` Brian Florence,CBO p Y639 0 opAT� p�Ar a~ : Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office:508-862-1038 Fax: 50&790-6230 , Property Owner Must Complete and Sign This Section If Using A Builder 1, Kay Nordstrom , as Owner of the subject property hereby authorize l`� L, ��,�--;- to act on my-behalf, in all matters relative to work authorized by this building permit application for: 160 Marston Avenue Hyannisport (Address of Job) Si a of Owner Signature of Applicant Print Name Print Name Date �; \✓ 7l/G � \�/�/�V44'4iJtiL'�i'7(/�L.�L'Li/, Office of Consumer Affairs ark Business Regulation 10;Park Plaza-Suite 5170 Boston*.. %;tu 'et s 02116 Home lmprov ` ractor.Registra#ion �+. ._ Indlvidtfai MICHAEL MCCAATHY Registr oret; 1 i83 P.O.BOX'52 neon: Daft �2019 WEST DENNIS,MA 02670 ti. '. 1 S�Nf Update Address and retum card. Mark reason tor'aliarige. SCA 1 8 20ht-05/i f -- �J Q� ��/ // __r __..�_.n.Add ress 3AsnAwat t'1 mpteymRnt C1L not Card amadweA office of ConeumerAffaire&Busineae Regulation HOME.MPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:lndMdual before the eXpirstlon date. If found return to: i=lMftn Office of Consumer Affairs and Business Regulation 06/15/2019 10 Perk Piaza-Suite 5170 MICHAEL MCCA ,11 gi ;y Boston,MA 11 Yi•.�.,. MICHAEL F.MC , a RANGLEY LN. SOUTH DENNIS,MA 02880 Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Profession.al Licensere 11"1ae�� mcc�t�y Board of Building Regulations;and Standards Co rig - t ,y Constt oe �rvlSor Has s s#ul. 66M letsel>li�e Na anal FlE CS-058633 i COMM Training Course - T ices 04f i'.Ql2020 , 231d dilly ofAUgust2011 MICHAEL J AkCA ` PO BOX 62 WEST DENNIS'A q .. t�Flftft eoms'F4w. i f��P,.,� .,aFV..,,1E+..V.oVGaY+ehseVw„ .. /• .. CornrPissioner - OSHA R558712. . r :. A U.S.Department of tabor Siikblfre as Occr►pational-Sa a fety end Health Admiiustratioh § Michael McCarthy has suc saruFr c rnmetee a lw+our oocvpatwnatSatety ar,a Freanh *. .gA=tsa[dr MY Trainug Cotase fn ' 3�Ftouts;ofdas3lTjne 'boun;otfield'tirge oaltFt:: The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia I-Vorlcers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 7�� *, Please Print Le iblV Name{Business/Organizadon/Individual): Mehael mccarthvGrS�}r..��'v�r. Address: PO Box 52 City/State/Zip: we3t rani- A -- - ---- -. ne Are you an employer?Check the appropriate box: Type Of project('required)' 1.[E]I am a employer with `�. employees(full and/or part-time).* 7. [J New construction 2. I am a Sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.]. 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.FJ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am,a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.! ��•• 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required,] *Any applicant that checks box dl 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 anew 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. lam an employer that is providing iporkers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: N�'�fon� L J,;k 4-i } f w,,'C T,c Policy#or Self-ins.Lie.#: V J kJ C : `I 3 5-h Expiration Date: i'a ►S'�I�j Job Site Address: City/State/Zip Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. . I do hereby certify Wj"Ignaldes of perjury that the information provided above is true and correct Signature: Date: 13-'rf�I F Phone#: Rk) ;Ito-C 76�> Official use only. Do not write in this area,to he 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: MCCART9 ACORO' DATE(MMIODmyY) CERTIFICATE OF LIABILITY INSURANCE TE(MMI DIYY 019 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 have ADDITIONAL INSURED provisions or 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 508-398-6060 C NTACT Bryden 8r Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-398-6060 FAX 508-394-226T of Dennis Inc. =No,Ext: ac No 485 Route 134,PO Box 1497 E-MAIL So.Dennis,MA 02660 Bryden&Sullivan Insurance INSURERS AFFORDING COVERAGE NAIC# INSURER :Ma fre Insurance 34754 INSURED INSURER B:National Liability&Fire Ins Michael McCarthy Construction Inc.PO Box 52 INSURERC:Western World 13196J West Dennis,MA 02670 INSURER D:Evanston Ins.Co. 35378J INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TO TYPEOFINSURANCE ADDL SUB POLICYNUMBER POLICY EFF POLICY EXPIM LIMITS C X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F_X]OCCUR NPPIS03635 10/0712018 10/0712019 DAMAGE TO RENTED $ 50,000 MED EXP(Anyoneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY PRO- ❑LOC PRODUCTS-COMP/OP AGG $ 2'000'000 Je- OTHER A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea ccidentlANYAUTO RS0871 07/0512018 07/05/2019 BODILY INJURY Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY Per accident $ X AUTOS ONLY X NON-OWNED ONLY PROPERTY acciGenDAMAGE $ D UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE XOBW7740818 07/19/2018 07/19/2019 AGGREGATE $ 2,000,000 DED RETENTION$ B WORKERS COMPENSATION X I PER STATUTE OTH- ER AND EMPLOYERS'LIABILITY V9WC747574 12/1512018 1211512019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YIN - 'E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED( Y❑ N/A (Mandatory in NH) - E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Michael McCarthy as elected to not cover himself for Workers Benefits CERTIFICATE HOLDER CANCELLATION HOMEWOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Homeworks Energy ACCORDANCE WITH THE POLICY PROVISIONS. 101 Station Landing Suite 110 Medford,MA 02155 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. 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