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Home My WebLink About0044 MIDWAY DRIVE Ll q t "LESS PERMIT -of t► rqy, Town of Barnstable *Permit a-Q L ` v� 5r2 - �,p� �'a ; Expires 6 months from issue date Regulatory Services Fee + BAaxereBLA • NAM Thomas F. Geiler,Director 9�A o FBARNSTABLE Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number i Property Address A 1 ot„ A4 WE a_n rz i,.� Residential Value of-Work 5-70-O Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address •�S V't"3�,la� Contractor's Name U%J y tL �� Telephone Number l<106 SO 41040 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ` `tot ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor F1I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. . Permit Request(check box) eRe-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going'over existing layers of roofl ❑ Re-side - #of doors ❑ ReplacementWindows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc., ***Note: Property Owner must sign Property Owner Letter of.Permission A copy of the Home Improveme Contractors License& Construction Supervisors License is ae:quired. SIGNATUR Q:IWPFILESTORMS\building permit forms\EXPR.ESS.doc Revised 070110 SearchResults Page 1 of 1 Search Results . Select the licensee name below for more information. (If your search produced more than one page, you may select page numbers at the bottom of this screen.) . Select the Search for a Person or Search for a Facility button to perform a new search. . Select the Preview File button to view a sample of the fields included in a file you can download. . Select the Download File button to download a text file of your search results at no charge. . Select Public Information Request Form for a form to order a data file. Name License License Type License Address Number Status KELLY CSSL- Construction Supervisor Active Yarmouth Port MA OLIVER M 099167 SpecialtV 02675 KELLY CSSL- CSSL-WS - Windows Active Yarmouth Port MA OLIVER M 099167 and Siding02675 KELLY CSSL- CSSL-RF - Roofing Active Yarmouth Port MA OLIVER M 099167 02675 1 0 http://elicense.chs.state.ma.us/Verification/SearchResults.aspx 8/21/20.14 �6ayy?4;d/t1vud ea144 12 Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration ` Registration: 128957 Type: Individual Expiration: 6/14/2015 Tr# 24090 Oliver Kelly - Oliver Kelly 8 Rhine Rd = Yarmouthport, MA 02675 Update Address and return card.Mark reason for chat scA 1 0 20M. it C'`Address f-1 Renewal, E] Employment Lost Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 128957 Type: Office of,Consumer Affairs and Business Regulation xpiration: '6i14/2015 Individual 10 Park Plaza.-'Suite 5170 Boston,MA 02116 Oliver Kelly Oliver Kelly - 8 Rhine Rd. Yarmouthport,MA 02675 Underiecretary Not valid without signature � ��it.1.ti:1TltuKti�-Di•Ifat•rnlent ur Palilit•�iefit; +Bruit d of Building RegMintill".%autl St:tad.0 ti ' • License_ CS SL 99187 Restricted to RFYM _ OLIVER KELLY a-RHINE ROAD . YARMOUTHPORT,AAA=75 Sze— -196 -- expiration: 822=13 Tr* Oft MWDMWM Aco CERTIFICATE 5/1/2014TE OF LIABILITY INSURANCE DA,>:` /2014 �/ 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: N the certificate holder is an ADDITIONAL INSURED,the po0cy(les)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsemenL A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ACT PRODUCER DOWLING&ONEIL INS AGENCY INC NAME: 973 IYANNOUGH ROAD PHONE FAX �. HYANNIS, MA 02601 &L INSURERS AFFORDING COVERAGE NAIC 9 INSURER A: LM Insurance Corporation 33600 INSURED INSURER B. OLIVER KELLY INSURERC: DBA KELLY ROOFING 8 RHINE ROAD INSURERD: YARMOUTH PORT MA 02675 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 20051017 REVISION NUMBER: THIS IS PTO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI: 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. lR ADD SUER POUC EFF POLICY EXP LIMA TYPE OF INSURANCE POLICY NUMBER MID MID COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ RENTEDDAMAGE TO CLAIMS.MADE 7 OCCUR ISES Ea ewnence $ MED EXP(Any oneperson) $ PERSONAL&ADV INJURY 8 GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F_�PRO- LOC PRODUCTS-COMP/OP AGG $ JECTOTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY accident) BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED ( BODILY INJURY(Per accident) $ AUTOS AUTOS l PROPERTY_DAMAGE NON43MF-D Per accident $ HIRED AUTOS AUTOS UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ g DED I I RETENTION A WORKERS COMPENSATION WC5-31S-338804-033 12/28/2013 12/28/2014 S AND EMPLOYERS'LIABILITY YIN00 ANY PROPRIETORIPARTNERlDCECUTIVE E.L.E EACH ACCIDENT $ OFFICERIMEMBER AM ED? FY N/A 100 (Mandatory in NH) E L DISEASE-EA EMPLO $ _ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 600 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space M required) Workers compensation insurance coverage applies only to the workers compensation laws of the state MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR OLIVER KELLY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOF JERRY WALSH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED I 110 KELL,EY RD ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS MA 02601-1990 AUTHORIZED REPRESENTATIVE LM Insurance Corporation V ®1988.2014 ACORD CORPORATION. All rights resen ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD CERT NO.: 20051017 CLIM CODE: 1329955 Didi Dangas 5/1/2010 9:36:27 AN (PDT) Page 1 0f 1 th o Massachusetts The Commonweal f 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 Aaplicant Information / Please Print Legibly Name(Business/Organization/In 'dual): Address: '1� City/State/Zip: 4etlt—OL�x � ®� Phone#: �� 4b(4`O Are on an employer?Check the appropriate box: Type of project(required): 1.9I am a employer with z 4• ❑ I am a general contractor and I 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.t �• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition _ working for me in any capacity. workers'comp.insurance. q• ❑Biding addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work 2 1(4),and we have no myself.[No workers comp. c ,§ 12.ff Roof repairs insurance required.]t 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp-policy information. I am an employer that is providing workers'compensation insurance for my employee& Below is the pohcy andiob site information. ff Insurance Company Name:t„Lasa "= t ' Policy#or Self-ins.Lic.#: t,�C,S �JaJ�3�5 ()�" o5� Expiration Date: Job Site Address: 1, i,�t City/State/Zi1 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 nder the pains and es ofpedury that the information provided above is true and c rrect. Si afore. Date: Phone it: Official use only. Do not write in this area,to be completed by city or town off Mal. 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#• c� snaxsrests, '""� i639. Town of Barnstable 9A ,0� 'Dp�a fir" Regulatory Services Thomas F. Geiler,Director Building Division M1 Thomas Perry,CBO ' Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.nia.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, 'Dewe Nco%AAC-1ID , as-Owner of the subject property hereby authorize (Duty to act on my behalf, in all matters relative to work authorized by this building permit application for: �)Iw (Address of Job) Signa of CYwner Date Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMSUilding permit formsEXPRESS.doc Revised 051811 �tHE Town of Barnstable Regulatory Services MAM ' Thomas F.Geiler,Director o39. `'� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION. ' Please Print DATE: Y° 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 accesso rY to.such_,use an&,-or faun 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 a'11such 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 personas 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\building permit formS\EXPRESS.doc Revised 051811