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Home My WebLink About0234 MITCHELL'S WAY r,�� y !�;-�chells w r I fCAPE COD INSULATION # � '-f2 w,. � ��.-,a�; ®'fir,2 e��i ' 7 PIB[R OlA99 SEAMLESS SPRAT POAM $U9PENOED BATT9 GUTTERS INSUlAT1ON CfItIN03 �.F. uvTst•:�,,.:e..,r:::,y. Nwk±ter �+%''t n 1-800-696-6611 DIVI IQ II ! Town of Barnstable Regulatory Services . j Building Division ` 200 Main St Hyannis, MA 02601 Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit s application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village j� 1--� a a3y M'-�c�e\kS Insulation Installed: Fiberglass -Cellulose 'R-Value Restricted- Unrestricted �/ f Ceilings ( } ( /�) . Slopes f f Floors ( ) ( ) 09 ( ) ( ) i 1 Walls k3 ) Sin erely my Cas dy , President .1 ape od 1 ulation;Inc. 4 T J _ o- - 1 � c s,p• .;r k. , :WEBB : - eT' ,7 - Plan. o - _ 3�. 54. I - P yam• '" �r l1�R�"' CAPT: SNOW WIT+3, fA1vtILY.100M=,WINO; 4- GARAGE- - �oPYR16HT YDS C ONC=E E 200.'00 Sides': _ - _ 4 YDS CONCRETE -- - - c 4 00-4 00 T+'l�or c K — 1 F A'-M 1 LY . A DIN1_NG .D _ J O CQUNT�RY kITCMEN o - �i jHREEZE WAYS, t -7 1 =4 w IH . 1�.•: BEDROOM dI N` 1 12•t> w 12$ M1' - — — N A' "L um. CLOSeT LIVING ROOM d 13 9 x i5-1 RD M_ r BEDR00M*2 t - SLT.rL'n H•:IOx1i:8-. - OJ 16-0 14 O - 40-0 N I KERSON HOMES eriot t dimensions approximate } "• A"SUB$IOIARY OF NICKERSON LUMBER CO. 1n ORLEANS MAS'S.ACHU SETTS'02653 4 MANU'FACTURERS.:OF. QUALITY SHELL HOMES " 1.5M . , ,.,--Ass6ssor's map and lot number ...... Sewage Permit number .............. 7 SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIAN Z BJBHSTLDLE, i House number 23. Mitchell Wa.y WITH ARTICLE II STATE 90 NA eta...................................................... 39. SANITARY CODE AND TOWN< TOWN ' ,OF BARD hX' E s BUILDING` ?IrNSPECTOR • APPLICATION FOR PERMIT TO .....................................Build addition to present!;- House .. ...................... ......................................... TYPE OF CONSTRUCTION One 1) Car Garage .................. ..... .... , ..................................................... - .......JA?DAAArY....1.9...............1'9...79 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: t Location ..........Z3 ...Kit,chell Wavr.,.. Rarasit.able....0 unty.,...Hyanniz.,...Maszachusetts............. Proposed Use .............................Buibld a One (1 ) Car Garage onto the pre sent House ... ... .... ...... ... . ................ ..... .......... ....... ,. Zoning District F'isident "B" H annis ............................................................Fire District .......-..�Y.................................................................. Name of Owner. ....Erne.stL...Lee...J...r............................Address ...................................... ..... .Name of Builder ...............................................:....................Address ....,............ Name of Architect ................. ........................ ................Address ........:.. Number of Rooms One .W .............Foundation '� 6ncrete .:... ........................................................ Exterior ....Shingles - Standard Roofing ..........standard..shinape................................ FloorsCOT1grete Interior ..................:.........................................................::.............................................................. HeatingNOT1e...........................................:....:.......Plumbing .............................1!.Q11e........................................... Fireplace .................11.9?1e........................................................Approximate Cost ..........�... .............................. Definitive Plan Approved by Planning Board --------------------_-----------19--------, Area .�'. Diagram of Lot and Building with Dimensions Fee �Q '.V V.............. . ....... .. ................. SUBJECT. TO APPROVAL OF BOARD OF HEALTH j j q�tS O � A J . - 3`f iiJ . i x •..A. {+ ... j j I hereby agree to conform to I the.Rules and Regulations of the Town,of Barnstable, regarding the above construction: (. �-��" -. Name .�...........- ` .................................. ................................. Lee, Ernest_L. Jr. -21011 - add garage ,r110 ............:.... Permit. for .................................... to single family dwelling I ` Location ............234..Mitche1.Nay ................ Hyannis .............................. . .............. Ernest L. Lee, Jr. Owner .........:.:...................................................... , frame , Type of Construction .......................................... r ` Plot .. .... .. ....... Lot ................................. ° Permit Granted .............Febx:tlaPy-1.....19 79 Date of Inspection ...................... ...... .......19 0 r , Date Completed ..............:.. ...........19 Q `. PERMIT REFUSED ............................................................ 19 t ........ _ ... .... ............ .................•......... ..... ..... •...............................•. ................. •... ......... ...............................• •........ .. • .. ...... ........................ ......•...... Approved .............................................. 19 V ....- ..•.....• ..• { •................................................. - , - - ♦R --Assessor's map and lot number rI ypGTHEtp� Sefvrage Permit number � r ��P ♦� .. .............. f Z BARNSTME, S House number ...`.....:.........I..................................................... ' ,"b a �a �O 39• 0 a MIN a` TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO Build addition to or$s$ntl; 4ouse ............................................................................................................................. TYPE OF CONSTRUCTION ..................OI. .... iE .1 ). ......Cyr. . ...Garage..... . .. . .. .. ....... ............................................................................. :Tgminrr 1D...............19.. tt. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............. '. ..............'...17.....:14v:.......Rrlrng'r_zlh�lia...l`neirti-v txvnn-n .jaaQ.L3n'(1II-- aFf ....... Proposed Use ........................7L:`ld..a...`�ne (1 ) Car...Garage onto the Dresent;...'inus�..................:..... Zoning District F'`t'�C1E31�t t�c3n ..........Fire District ......fivannis ............................................................... ................................................................... .Name of Owner ....7:'"t1vz...t...L....T�.QL.. x..........................Address ..2..4 j'iitche1l 1,j.a:1........................................ Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms One t�.�........................Foundation Coficzrste ..................................... .............................................................................. Exterior i%F].�l.f`�.c'r3 -- -'tD=' dar .............................Roofing St;andard..:,hinr*7�................................ ............................................... ............................ Floors ....... ;n :L .......................................................................:c -' ;� '.Interior ........................................................ ........................... Heating ................... rtf1......................................................:.Plumbing ................................? ........................................... Fireplace ...................................................6.................................Approximate Cost .........:°...t.......if ...0..'.6............................ Definitive Plan Approved by Planning Board _____________________________19--------. Area r................................. Diagram of Lot and Building with Dimensions Fee '�� SUBJECT TO APPROVAL OF BOARD OF HEALTH n � { �.1 A I hereby agree to conform to all the Rules and Regulations of the Town,of Barnstable regarding the above construction. ,Name . ..?............................... , Lee, Ernest L. Jr;- A=290-121 Igo "`2101, 1, permit for add.,garage.... t.o...single family dwelling.......... . .... Location ...........234 Mitchell'JWaY................. .... ........ ........ ..........................Hyannis..................................... Owner Ernest L. Lee., Jr. „ .................... Type of Construction fr mQ.................... . ................................................ ............................... Plot ........................... at ................................ Permit Granted ..........FE.bruary...1........19 79 Date of Inspect„ion ....................................19 Date Completedi, ................19 PERMIT REFUSED ......... -+, 9 .......... . ................ ...........:"...............:�........................................ ............................................. Approved ................................................ 19 ............................................................................... 'x TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel pp w l A lication V 4/Health Division Date Issued V Conservation Division Y-Application F Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 23 Village R A t'i w S Owner J y r-A— LC-2 Address �3 M ��`S LAB-*V Telephone s 0T-- -7 7T- 0 Y7 Permit Request J A 2,e V &o0r-� �1�;r Sew 4 C. AW �Z30 AT) �'k►�S��e� � � +��L �q��He A�- ��(�e S Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation � 3 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:f 0 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 = M Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No 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 ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) .CV4jke_ CocSZ Tt SAA-tM&--) _ Name Telephone Number Address `�S S �/W f✓�c7J � t�k License# 10 Oq '� �1y�n.is MA , O'9—s (A Home Improvement Contractor# l Q S(0 7 Worker's Compensation # WQ)O O S IScl 0 I ALL CONSTRUCTION DEBRIS RESULTING FROM THISPROJECT WILL BE TAKEN TO DATE SIGNATURE r; t k FOR OFFICIAL USE ONLY 5 APPLICATION# DATE ISSUED _ ' MAP/PARCEL NO. . ` ADDRESS VILLAGE ' ' OWNER 1 DATE OF INSPECTION: FOUNDATION;' t FRAME 4 "i INSULATION ` f • FIREPLACE q ELECTRICAL: ROUGH FINAL , x PLUMBING: ROUGH FINAL t y �' CAS x"°' ROUGH S> FINAL "h f` J. FINAL.BUILDING : .DATE CLOSED OUT i; �� ASSOCIATION PLAN NO. ' ' T The ComrnonwealtlT ofMassach(csetts Department of Industrial Accidents 1 ' Office of Ifivestigations 600 Washington Street t Boston, MA 02111 -+ yy www.rnass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Elects icians/Plumbers AppLicant Information Please Print Ise itr bly Name (Business/OrganizatiorOndivi dual): CAM� _T/V SkI t' C.Y 't 1 0 �� C Address: ✓A , Q City/State/Zip: z Phone Are you an employer? Check th appropriate box:. Type of project(required): 1.(� I am a employer with—7,to—_ 4 ❑ I am a general contractor and I 6 E]New construction have h hired the sub-contractors , eiriployees(fills and/or part-time):' ._.._._....._.....__.... ........_ . . . _ 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 forme in any capacity. employees and have workers' 9 Building addition No workers' comp. insurance comp..insurance.$ 5. We, are a'corporation and its 10.❑ Electrical repairs or additions required.] ` 3.❑ I a homeowner,doing all work officers have exercised their 11.Q Plumbing repairs or additions myself. [No.workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.[] Otber Q�.} > > A t•h comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. . I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information 1 Insurance Company Name: 14 Policy# or Self-Ins, Lic. #: (u(A W rzs Expiration Date: �D 3G Job Site Address: y), , City/State/Zip: �V w Qvul�- p�c o Attach a copy of the workers' compensation policy d��ing 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. Ldo hereby certify tit e pa' and penalties of perjury that the information provided above is tr//ue/anrt correct. Signature: Date: Phone#: S O 7. � %y' f Official use only. Do not write in this area, to be completed by city or(own official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3, City/Town Clerk 4. Electrical Inspector. S. Plumbing Inspector 6, Other Contact Person: Phone#: �:��•., ',U L'hl tv: rlau'Lk l!' 9,1506'7705735 - kogers & Gray Irta. t'yOi;: 0i)3 Client#: 4597 CCINSUL Acor%`u- CERTIFICATE OF LIABILIWI-I URANC DATE(I'AINIDDIYYYY) 07/2112010 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:It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject le tilt:leans and conditions of the policy, Cer7ain policies may require an endorsement,A statement on this certificate does not confer ri ec cettiticare holder in lieu of such endorsement(s). gl s to the PRODUCER CONTACT Rogers S,Gray Ins- -So. Dennis NAfAE:_ Margaret Young 434 Route 134AIS PHONE 508-7604602 _ - FAx ---------.-..._:_.._-- Ac.No Exl, P.O.Box 1601 ADDRESS: RObUCER----- - ---- SouthDannis, MA 02660-1601 CUSToaIERIOL: —"'"— --- ---- - - INSURER(S)AFFORDING COVERAGE+. - NAIC II' INSURE LI - CiPO COd InSLllatlon:Inc INSURER Peerless Insurance 465 Yarmouth Road wsuaelia:Ohio Casualty Insurance Company Flyarims, MA 02601 INSURER :Atlantic Charter Insurance INSURER-0-Commerce Insurance Company 34754 INSURER.E: - -- INSURER F - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 7161S 10 CER'rIP, 1'HAT rHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR I-FIE POLICY PERIOD INDICATED.N(1T4V11''ri�;'I'ANDIIVG ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERI IFIC,SfE MAYBE ISSUED OR MAY PERTAIN,TFIE 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. l _ TR TYPE OF INSURANCE POLICY EFF POLICY EXP NSR VD POLICY NUMBERMIW/DOIYYYY =n1YYYY LIMITS A GENERAL uABaII v CBP8263063 0410112010 0410112011 EACH OCCURRENCE . 0,000,000 _ DAMAGE o�RE- LP o t(ltvl I'll.I(;IAI.CL NL FtAI l.lA1411 f IY _ hrlibn,L-5 f-a •, o :� $100,000 ]Cl iunl5 nV\L)L` ^XI Ot.l%UK 4 , ' 1 MCO EXP(Any ono pot„on) `. $5,000 - --.. - ------ fr% PERSONAL&ADV INJURY $1,000,000 - __ _-_--- GENERALAGGREGATE $2 000,000 T —.._. -_..L..-..-�... cI N I Ac;cri c,a l r I IMI r AI r'I n s PrK PRODUCT S�COn1P)OP AG ^ $2,000,000 Pilo LUC i D AUTOMOBILELIABw1Y 10MMBCKVMK - 04/01/2010 04/01/2011 COMBINED SIIVGCE LIt411T ANT"U10 • - _ (Eaacudam) $1`000,UUU BODILY INJURY(Per person) b :\II UWlvl'n AlIIC1S � _-- X i\111 U:i _ - - BODII Y INJURY(Per amidenl) $ SCI IIUlll Cll _ PROPIf I-Y DAMAGE X 1uKI:urYUlO:; (Peiacclnenj X NUN CM'NI`.Li AiJI ta5 - '$ B UI'r1BNELLA LIAR X occuK . MEYAPP397725 0611712010 04/01/2011 EACH OCCURRENCE. $1 000 000 xt.ess L1Au cL.AINIti NWin. . AG-RLG -U ... $1 00U UUO Xj KEII-NI ON f. 10000 $ C worm®as COMPENSATION ERS'LiILITWCA00525901 06/3012010 06/30/2011 X. WL STlcru: nTI I AND Eh'IPLOYEI'tS'LIABILITY 1l'Y _I YIN _� _ ANY I NOPRIL IClKil AR'I'M RiE'XL-CUIIVt - E.L.EACFIACCIDENT - $500,000 011 t F h�nlLAllil h f:XCI UDL'D9 NIA - - (IYtID(iaHuyinNil) - II Yun.twxUba medal . . E.L.DISEASE FA EMPLOYEE $500,000- UESt:Ka'UDN 01:in"hRAHONS below - - E.L.DISEA SL-POLICY L411 $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Anaeh ACORD 101,Additional Runlatks Sahadelo,d more spacu is I'ugtwad) - - Workers Comp Information Included Officers or Proprietors (Sea Attached Descriptions) CERTIFICATE HOLDER CANCELLATION '10 Days for Non-Payment ` 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 P' (D1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 2 The ACORD narne and logo are registered marks of ACORD i1S54814tM53353 MEY OtJS INC 46o West 1�ai n Street iyannis, NAT 02601-3698 ASSISTANCE ENERGY & HOME REPA1t T (508) 7 71-5400 F (508) 7 90- ORPOPLATION 2425 HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN THISFORM IFYOU ARE THEAPPLICANT HOMEOWNER. I C I c- L hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation ( hereinafter referred as "Agency") on the property Iocated at: L..3 It t e-MAC�.S L,.)A`( 14 YA is, FAA T he weatherizati on work done wiII be based on programmatic priorities and availability of funding and it may include all or some of thefollowing measures: Weather-stripping& caulking of windows and doors, insulation of attics, sidewaUs& basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows. In consideration of theweatherization work to bedone at my home I agreeto thefollowing: 1. I give permission to the"Agency" its agents and employeesto travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The H ousing Assistance Corporation reservesthe right to inspect the fuel or utility bill for the weatherized unit on an ongoing basisfor no more than five(5) years after theweatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. H o m e Owner: (Signature) �T� L-c- L Date Agent: (signature) VAL;G a3 Date I-4_ c t. HAC approved Weatherization Company: C Cc�cQ ti��u Caliber Building&Remodeling Cape Cod Insulation [ Cape Save Creswell Construction Frontier Energy Solutions Lohr& Sons Peter Smith Resolution Energy Rock Solid Construction Sprinkle Home Improvement I.La-&l''•.`OP h :'•:R;iif Inmiii dn:;e,i,;. r 10 Park Plaza - Suite 5170 o Boston, Massachusetts 0211.E " Home Improvement Contractor Registration Registration 153567 ; Type: Private Corporation Expiration:. 12/15/2012 Tr# 206433 CAPE COD INSULATION,.INC HENRY CASSIDY 455 YAR M O UTH RD. ------- HYANNIS, MA 02601 ----- " - — - -- - -- — :'- Update Address and return card.Mark reason for change. Address_u•Renewal ( Employment ,[ .Lost Card s - 'S-CA1 is 50M-04/04-G101216 Office mer Affairs us ne ReguI tiori ,License or registration valid for irdividu!use n!y H . o � before the expiration date. If found return to Registration: 153567 Type: Office of Consumer Affairs and Business Regulation - � Expiration: 12/15/2012 Private Corporation ' 10 Park Plaza-Suite 5170 " 1- Boston,MA 0211E OD INSULATION, INC HENRY CASSIDY r 455 YARMOUTH RD HYANNIS,MA 02601 Undersecretary t alid ith t si ture. Nlassachutictls 0clrrrtmcnt uf.Pulilie )afcf� Board urBuildin- Regulation, dnd'Standarii, Construction Supervisor License 'P M. Llcegse:,-CS 100988 'Res tricted to: 00 k t �" a HENRY CASSIDY S--SHED ROW WEST YARMOUTH, MA 02673 15`" iration: 11/11/2011 G„roiui..iuncr Tr# 100988 06 / 65 FIRE, Town of Barnstable. -*Permit# O Expires 6 inonths from issue date Regulatory Services Fees M i + BARNSTABLE, ► 039. ,� Thomas F. Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 I aVV www'.town.barnstab le.ma.us � Office: 508-862-4038 �i�a�':rA�r'(IIQ0-623 0 EXPRESS PERMIT APPLICATION - RESID'ENTIAL ONLY ' C Not Valid without Red X-Press Imprint Map/parcel Number Property AddressCe/ C Residential - Value of Work J e 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name& Address �d/JQ ��`t? 3 a°u�� /-�"� r 3G�2� 3S'7s'c�' Contractor's Name ��,i� �� Telephone Number J d Home Improvement Contractor License#(if applicable) S SD Construction Supervisor's License#(if applicable) X �y ❑Workman's Compensation Insurance ChVf one: ,. ®'I am a sole proprietor ❑ I 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) Re-roof(stripping-old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going.over existing layers of roof) ❑ Re-side #of doors ❑ Replacement.Windows/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 Improvement Contractors License & Construction Supervisors License is required. SIGNATURE: Q:\WPFILESTORMS\buildingpermit s\EXPRESS.doc Revised 070110 The Commonwealth of Massachusetts 1 Department of Industrial Accidents Office of Investigations 1 t,I IR•U 1 600 Washington Street Boston, MA 02111 c w www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: f 3 � � C � City/State/Zip:_ D;� Phone #: 5 ,0 Are you an employer?Check the appropriate.box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I' 6 ❑New construction. mployees(full and/or part-time).* have hired the sub-contractors 7 2. I am a sole proprietor or partner listed on the attached sheet. $ . ❑ Remodeling ship and have no employees These sub-contractors have -8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repair's or additions required.] of 3.❑ 1 am a homeowner doing all work right of exemption per MGL IL E] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is,the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). - Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penaltie's 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 c rti 94-, under the pains and penalties of perjury that the information provided abov is true and correct. 1 Signature: Date: 2 Z cc Phone#: J b 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#: Z K 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." �P Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage: Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, lease call the Department at the number listed below. Self-insured companies should enter their P P YP P p 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 burn 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 Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia r 1 sro�,ti Town of Barnstable Regulatory Services t alwvsS& Thomas F. Geiler,Director 06 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 +. Fax: 508-790-6230 Property 'Owvrier Must Complete and Sign This Section If Using A Builder I N-/%� as Owner of the subject property ' hereby authorize �� o �i�rti1.` to act on my behalf, in all matters relative to work authorized by this building permit application for: Address of Job) w Signature of Owner Date Print Name ' If Propedy Owner is applying for permit please complete,the Homeowners License Exemption Form on the reverse side. -Q:F0R MS:0 WNERPERMIss1DN 1 l Town of Barnstable Hot"VKEr � Regulatory Services y � uxxszAsLF- Thomas F. Geiler,Director rt,-qs. {, t6sq ,0� Building Division PrFD I,a'�" Tom Perry, Building Commissioner 200 Main.Street, Hyannis,MA 02601 viww.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOrkIEOVNER 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. DEFINMON 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 consb7pcts 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)-f 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/sbe 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 ID9.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Hamcowner shall act as supervisor." Many homeowners who use this exemption are unaware that they arc 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 Mly aware of his/her irsponnbilitics,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.farm currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forrris:homccxcmpt > +� ."wiVl.istiuchusctts Dcpurtmcrit of`Public Safch Board of Building'Regulations and Standards Constructiori Supervisor_Specialty License License: CS`SL 99486; x Restricted to: RF,WS :m PETER SMITH ' 3925 MAIN STREET CUMMAQUID, MA 02637 Expiration: 11/1/2011 ('ununissiune'' Tr#: 99486 ✓die a.�r�.no�.uaP.al� o�✓�aaaaclzuaet7a r _ Office of Consumer Affairs&Business Reg ulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration , 150950 Type: Office of Consumer Affairs and Business Regulation i Expiration:' 5/8/2012 DBA 10 Park Plaza-Suite 5170 max- Boston,MA 02116'PE ER J SMITH.N�ME MPROVEMENT pnii F = ' PETER SMITH 3925 MAIN ST. CUMMAQUID, MA Undersecretary kv 'dhout signature a r