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0286 MITCHELL'S WAY
��6 �,�s�;s wy / - -- - Town of Barnstable Building ? anna Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept "'p Posted,Until Final,Inspection Has Been Made. ° 1639. tiermt Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a final Inspection has been made. 1 Permit No. B-19-1388 Applicant Name: Henry Cassidy Approvals Date Issued: 04/26/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 10/26/2019 Foundation: Location: 286 MITCHELL'S WAY, HYANNIS _Map/Lot: 290-058 Zoning District: RB Sheathing: Owner on Record: WESTBROOK,CAROLYN OWENS Contractor Names ,HENRY E CASSIDY Framing: 1 Address: 1521 SOUTH COLLEGE ST Contractor License: CS-100988 2 TYLER,TX 75701 Est. Project Cost: $7,300.00 Chimney: tm Description: Insulation/ Wetherization Permit Fee: $87.23 { Insulation: Project Review Re 9 Fee Paid: 587.23 J q: " Date. 4/26/2019 Final: + Plumbing/Gas I q , Rough Plumbing: `\Building Official -'^ Final Plumbing: This permit shall be deemed abandoned and invalid unless the work a6thorized by this permit is commenced within six months after"issuance. All work authorized b this permit shall conform to the approved a lication and the approved construction documents for which this permit has been granted. Rough Gas: Y P PP PP PP All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. 3 j Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for,public inspection for the entire duration of the work until the completion of the same. , Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). �.,�F Fire Department Building plans are to be available on site r Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 4`� +` r Town of Barnstable *Permif#'C 6 Expires 6 monthMo e date Regulatory Services Fee 9 NAM �b Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint. - Map/parcel Number 2-9 Property.Address F VYi LT Lj pki-ofn jq IS M lA esidential Value of Work ;.5'e6 Minimum fee of$35.00 for work under$6000.00 Owner's Name&.Address C►=}lamyZ Owc4t Contractor's Name �frzt Telephone Number � _ E,i Home Improvement Contractor License#(if applicable) i41 C- 1-7/ $3 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance �Vk one: � � l"J .l am a sole proprietor. S ,P El am the Homeowner � �� ❑ I have Worker's Compensation Insurance JUL 1 (n, P. ? �� . Insurance Company Name ®. Workman's Comp.Policy# . olz BARNS 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) 2/Re-side r . "Awe-4e c` #of doors . ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows. 0 Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections:required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home provement Contractors License&•Construction Supervisors License is fired. �.. SIGNATURE: . I Q:IWPFILESVORWbuilding permit formsTY PRESS.doc Revised 053012 I July 18, 2012 Carolyn Owens Westbrook 286 Mitchell's Way Hyannis, MA 02601 Parcel ID: 290-058 Book/Page: 20832 261 To Barnstable building Dept. I authorize George Correiro of B and C construction to do repairs to wall shingles on my home at 286 Mitchells Way Hyannis any questions please call Thank You, Carolyn Westbrook 1521 South College Ave. Tyler,TX 75701 (H)903-592-3577 (C) 903-312-5987 { ALA s�xxsreer.E. ' ,0� Town of Barnstable Regulatory Services Thomas F.Geiler,Director. -'Buildings Division i Thomas Perry,CBO, Building Commissioner 200 Main Street, Hyannis;MA 02601 www.town.barnstable.ifia.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder Wxst YVD4 ,as,Owner of the subject property hereb authorize y auth CM-WIewt, (en s ZLTV1-s to:act on my behalf, , in all matters relative to work authorized by this building permit application for: (Address of Job) i Signature of Owner Date 0 Pt7 at Nani6 If Property Owner is applying for permit;please complete the Homeowners License Exemption Form on the reverse side. �AWPFILESTORMS\building permit formsTMRESS.doc Revised 051811 f THE 'own of Barnstable Regulatory Services BAIrrsre214 ' Thomas F. Geiler,Director Y MAsa: $ �°rEp ,•`e 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 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 wbo 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 persons)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\building permit formsTN'RESS.doC Revised.051811 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): reye, �.,.,wDPatc C rn i Rt?Can by" Address: Z C 7 j?r1 r T'eA2L5 r e1 • . cy2�1 City/State/Zip: -Om n i-S Phone M 5M 913 3k 1 Y 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.211 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp.insurance. 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions myself. [No workers' comp.. right of exemption per MGL 12.❑ Roof repairs insurance required.] t a 152;§1(4),and we have no employees. [No workers' 13.E�JOther s toe-U)'Wa.. comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy 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 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 certify the pains d penalties of perjury that the information provided above is true and correct. Si ature: ( Date: T 1 �t--y .Phone#: 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#: t Office�Con�roer ffairea °;ness egu a'o License or registration valid for individul use only. HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: P1. 1536- Type: Office of Consumer Affairs and Business Regulation Expiration: :.ji2,V2P14 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 G GE L.CORREIRO GEORGE CORR —INEZEt - 257 MITHCHELLS Vi/AY r' HYANNIS, MA 02601 = Undersecretary _ rY Not valid.without signature Massachusetts- Department of Public Safetj Board of Building Regulations and Standards Construction Supervisor License .. License: CS 92253 GEORGE L CORREIRO 257 MITCHELLS WAY. - HYANNIS, MA 02601= Expiration: 1/25/2013 = ' ('unnnissiuncr . Tr#: 9306 i OFIm r� Towla of Barnstable *Permit D q,. Expires 6 months m issue date Re gulatory Services Fee - 9 039 ��� Thomas F. Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 ' www.town.bamstab.le.ma.us i( rn QS E ' li Office: 508-862-4038 EXPRESS PERMIT APPLICATION - RESIDENTIALONLY `Nsq; zo Not Va[id without Red X-Press Imprint . Map/parcel Number d 5� rResidential Address d e � OS Value of Work ®' — Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address P$ roo Contractor's Name Jose (/ �� Tel hone Number_So G9�f� Home Improvement Contractor License#(if applicable 8 3 3 y tr uction Supervisor's License#(if applicable)rkman's Compensation Insurance Check one: ❑ I a sole proprietor 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} N, VReplacement de © #of doors 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 re SIGNATURE: Q:IWPFILESIFORMSIbuilding permit forms EXPRESS.doC Revised 070110 The Commonwealth of Massachusetts ,- Department of Industrial Accidents Office of Investigations 1 , 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): GTvI Address: ODD .-66-7 -5-19-P- City/State/Zip: (_altuk -3 o5 31 Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.rA I am a employer with go 4. n I am a general contractor and I 6 N construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working :for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers comp. insurance ,r ,. comp. insurance. t.required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. _ I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Q Expiration Date: 3 - Job Site Address: �,q6 City/State/Zip: NAwIPA r Attach a copy of the workers'compensation policy a-ration 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 certify under ' s and penalties of perjury that the information provided above is true and correct. Sip-nature: Date: (/ C Phone#: Jed g ' [ _ 6 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 1. Building Department 3. City/Town.Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: 7 ® DATE(MM/DDIYYYY) A�® CERTIFICATE OF LIABILITY INSURANCE 02/21/2011 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 1-404-995-3000 CONTACT _— -- -- Marsh USA, Inc. PHONE FAX AIC No,Ex) —_--- A/C No: ---_-- - _ homedepot.certrequest@marsh.com E-MAIL ADDRESS: —___— Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURER(S)AFFORDING COVERAGE Atlanta, GA 30326 NAIC# Fax (212) 948-0902 INSURER A: Steadfast Ins Cc 26387 INSURED INSURER B: Zurich American Ins Cc 16535 The Home Depot, Inc. New Hampshire Ins Cc 23841 Home Depot U.S.A., Inc. INSURER C: P 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Cc 23817- Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339. INSURERF: Illinois Union Ins Co 27960 COVERAGES CERTIFICATE NUMBER: 19834682 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. rLTRA ADDL SUER - POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDIYYYYGENERALL LIABILITY GL04887714701 03/01/1 03/01/12 EACH OCCURRENCE $ 91000,000 X DAMAGE TO RENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ _ CLAIMS-MADE1�1 OCCUR M_ED_EXP(Any one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL BADVINJURY $ 11000,010 X OF SIR: $lM PER OCC _ GENERAL AGGREGATE $9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9,000,000 X POLICY PEO LOC $ B AUTOMOBILE LIABILITY BAP 2938863-08. 03 O1 1 03/01/12 COMBINED SINGLE LIMIT 1 000 000 Ea accident �.• __• X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED - BODILY INJURY(Per accident) $ j AUTOS AUTOS ---------.._..- ---- NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS - Per accident X SIR AUTO P Y $ -UMBRELLALIAB OCCUR EACH.OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $. DED RETENTION$ - $ C WORKERS COMPENSATION WC061967352 (AOS) 03/01/1 03/01/12 X WCYTATU- OR AND EMPLOYERS'LIABILITY D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N/A WC061967354 (FL) _ 03/01/1 93/01/12 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? WC061967353 (CA) - 03/O1/1 E (Mandatory in NH) 03/01/12 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Workers Compensation WC061967355(XY,MO,NY,WI, p3/01/1 03/01/12 F TX Employers XS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/lM E Workers Compensation WC1192378 (QSI) 03/01/1 03/01/12 SIR 1M DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION j SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT.U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY.ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 r ' USA l ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD jfiero_hd 19834682 -�JZ:� �✓l??Yii:Fi.i2:c i:.�: ".�. f�is�:;!.::'-:5..."�L- =�. {f3,/.�P,i�of Ccrsu.:��:�ffar �: Bssiuess Rce:�ta:io� a / Registration: 126893 Tyre: Expiration: a02012 Suaptenent: The Home Depot At-Home Services DARREEN DEMERS 2690 CUMBERLAND PARKWAY S - "(�APJ�f`�,, GA 30339 Undersecretary License or registration valid for individul use only before the expiration datte. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 ;ard Boston, 4IA 02116. Not valid without signature i i • The Commonwealth of Massachusetts Department of Industrial Accidents 00ce of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApoUcant Information ell- I Please Print Legjblv Name(Business/Orgaaization/Individual): Address:' n City/State/Zip: A ® 4(9— � Phone* ®� 11� Are you a employer?Check the appropriate box: 1.❑ I a employer with 4. ❑ I am a general contractor and I Type of pro t(required): ployees(full and/or part-time).• have hired the sub-contractors 6• ❑N construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' 8' ❑Demolition [No workers'comp. insurance comp.insurance.! 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their . I I,❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required]t c. 152, §1(4), and we have no 3a.❑ I am a homeowner acting as a employees.[No workers' 13.❑Other general contractor(refer to#4) comp.insurance required] 'Any applicant that checks box#1 mast alw lilt out the section below showing their workers,compensadod policy information. t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such =Contractors that check thin box must attached an additional sheet showing the acme of the and state whether or not those entities have employees. if the sub•aontrsctors have employees,they must provide their workers'comp.policy li number. I an an employer that is providing workers'compemadon hunrance for my employees Informadon: Below it the pollry and Job site Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach s 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 S 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 herby cerdJj► the pa and pe of p wy at the/n adon provided abovr!s and eonvelt MEL- c -�� Phone#: Offle a!use onl)R Do not write In thk area,to be completed by city or town o/yleial City or Town: Permit/License# issuing Authority(circle one): 1.Board of Health L Building Department 3.ChyfTown Clerk 4. Electrical inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: 1 t Information and Instructions • ompeaeadon 15< c3enacst Lean chapter 132 cequices all emPlaYds it�sayke of� another under rnp can" otlyic0. punuaot is this statute,as ape Wlq»r is defined a",..every Pruners expres at implied,oral or written. As tsylsyw is defined as"as m� PuuwsWP►"Soc'sdo4 corparatiaa or oths l"d aft'of my two s deayted m4ioyer, of mat a oiet and iach�sfi ms k repraeata�� or the of the tarefralofi anfasd j ' associados at orbs tepl entity.empbyia�employes• Hamm the r wnw o s Orestes of �Pd�dm� and who resides of do of tie onset ota dweilios . dwelling hawse of another who s as of do conshrwadM of repsk work os such dwelling house 9UMM th---Shen not because of such UV&gm w be deemed to be an®tployea:" or os the pcoumds or brwildiat ,MGL chsptir 132. ¢uC(6)alto SWO that""ay stsa W'seaa llCHOWS apsey abd wld&U do isausa sr at resew of a trews err Permit to°Pena s badness or ts ee--An-el boddlsp IS the as awweaitr flar any sppiteast wM hos sat pre ON&weptabit"Wanes of eempils sse with der loom""averep rOgmk » Neither the normyo(jimpoliticalImbdivisiostshell, pddidoosny.MOL cbaptsr 132,12XM Sbf t fb acaptahls evidence tcompliasee with iwance requken aft of this cbspesr boo bow Pessubd w dw coubsoft 140 AppUeasls Ptesse fill out the woclaere'eoenpwados of ldevi<compleftly,by cbeckles the boxes that v*to your Simsdos wad,it ec�(a)ash addtes wr m(es)and pho nu m(s)alone with their cesd&ate(n)of inrmaoe� Lindled f l ►Caaw*snib(Lt.C)at Limieed Ll.bility i�rme*shipe( vs q°P10 other then th. nrsmban of PWUM%w not os cWqwo •eosapsmados iweasoa if as LLC or UY does heat an4bS► a pommy is wed' Be advised that this a8fds it away be submitted to the Deperhowd of industrial Aaeidesli fits conflramdaa of innwrasct covangs Alan be me is alp and deft the stndavit The affidavit Should be retusnsd m air city or lbws that the applicedon fbr tbs Pumb err ibesea is bsie fi eegaated,set d OapMOMeat or . Indpee�•1 Aoeidewea Should yore hpe any graadoas reprdhwn the taw err if yo.nee required es obtain a worbn• conopensadaa poliep,plow cad aloe Depa un"ct the comber lasted below►. Sd�iwed caaapamaa Should eafat tbsir selsFiareeasot Rogow number os the upeng HoL City or Two Ofmdals Please bed Surf that the at�v�i•the everwt the Ottfce of hWesdooss to contact yet Nowdin fi the aPP� plan the a e we for yea to fin r which will be used a a mfereaet no h r fs addido%an q%Acaa Ptew be art to fin is the pe:milllleaw atioos it inn Yes.need�snb@*oat affi6vit h dicsdsi cuumd that meat sdtm>rt msldpV Pa*�Me M policy iafbramdm(if nscmwY)and uNder"lob Sits Addreser•air apPlicast SbonW wrilt Own locations yp o _(slay or pipV A copy at tbt aflldsvit that bes ben o®cielly Stamped err meshed by the c*a mry►lot provided t the appliiaast r proof that a valid sfiidavit is os file fbr fiw am permits a licamea A sew affidavit must be filled out eaeh year.wine a hone owssr at cide s is obtaining a license of permit Got mhftd ft any busima of consmeial ven"* (i.&a dop Bees or Venn&to bum team nee.)said Feriae is NOT requited to conip' I-this affidevk The Ofiles of invesdgadone would low to thsat you is"vas=flor yawn cooperadoe and should you have any quadoado plew do act hedu is tat pipe us a aLL I7ta Deperttemt's addtes4 telePhOw and fiat Gvmbsc The Comnanwealth of Nftwchosetts Depmmne d of Industrial Accidents OMO of w9wrtde" 600 wear Sh9d Boston,MA 021 It Tel. A 617-727-4900 Cd 406 oar 1-971-MASSAFE Fit►a 617-727-7749 Revised 11.224)6 www.num v/dia JAW Qom . office of Consumer Affairs and i�uiness Regulation 10 Park.Flaz:: Suite 5170 Boston,MassacY��.tsetts 02116 Home Improvement C�n�tractor Registration - - - Registration: 132349 'jig Type: Partnership Expiration: 1/1172013 Tr:s 207392 Expiration: J &J Remodeling Joseph Duarte 15 Fall St. Wareham, ma 02579 - Update Address and return card.Mark reason for change- D Address D Renewal ❑ Employment Lost Card )P$.CAI 0 (Oy{406.4/012/6 , Q,,,, �, 16- �a i License or registration valid for indi return to only Otttca o oe m a rs Enos cg before the expiration date. U found return to: kqHOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation Registration: -:•132349 Type' 10 park Plaza-Suite 5174 Expiration: :jlt1/2013 Partnership Boston,MA 02116 jsmodeling;: Joseph DUa►te 15 Fall St. �� � nature Wareham,ma D2571`.•,:` Uadcraccrctary ?n of v d without sig :►,::►chu:ett�-Depxr�mcnt ut•Public Safct} 11 1 Masrtl of Bui'dimm Red2ul:uiun:ant'St.u+d:trd% BilaConstruction SuPe(vt80t License license: CS 70077 JOSEPH C DUARTE 15 FALL ST 02571 WAKKAM,MA _ Expiration: 1?13orAt2 ,. Tr#: 7048 _ - Z9L656Z EG:TZ TTOZ/ZO/TO TO 3Jdd ACORD,, CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDOIYYYYI 03/23/2011 PRODUCER 508.295,4440 FAX 508.295.5864 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Paul B. Sullivan Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 2'870 Cranberry Highway HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Y g y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0, Box 551 East Wareham, MA 02.538 INSURERS AFFORDING COVERAGE NAIC# INSURED 7 8, ) Remodeling INSURERA: Vermont Mutual Insurance Co. 26018 1.5 Wilson Way INSURERS: Middleborough, MA 02346 INSURERC: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYYYY DATE MN.IDD!YYYY LIMITS GENERAL LIABILITY BP110205ZO 03/22/2011 03/22/2012 EACHOCCURRENCE $ 11000100 X COMMERCIAL GENERAL LIABILITY PREMISES Ee occurrence) S SO,OO CLAIMS MADE OCCUR MED EXP(Any one person) $ S.1000 A PERSONAL S ACV INJURY S .11000,060 GENERAL AGGREGATE S 2-,000,,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,000 POLICY PE4 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT AN"AUTO (Ea accident; S ALL OWNED AUTOS BODILY INJURY $ S�HEDULEDAUTOS [Pei pelsoi) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS peracdden:) $ PROPERTY DAMAGE S (Peracddew) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ AN"AUTO OTHER THAN EA ACC S. AUTO ONLY: AGG S EXC ESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATi $ $ DEDUCTIBLE $ RETENTION $ - $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNEPJEXECUTIVE(--I LL EACH ACCIDENT $ OFFICERIVEMBER EXCLUDED? 0 (Mandatory In NH) E.L.DISEASE•EA EMPLOYE' $ N yyes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMITS OTHER ( DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS HD At Honte Services, Inc and the Home Depot are included as additional insureds ith respects to general liability linsurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSLR2ER WILL ENDEAVORTO MAIL 10 DAYS WRITTEN THD At Home Services, Inc. NOTIC E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUY FAILURE TO DO 80 SHALL 3200 Cobb Gal l eri a Parkway IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Suite 200 REPRESENTATIVES. Atlanta, GA 30339 AUTHORIZED REPRESENTATIVE ,o Edward Sullivan/MARIE ACORD 25(2009/01) FAX: 508.7S6.8823 ©1988.2009 ACORD CORPORATION. All.rights reserved. The ACORD name and logo are registered marks of ACORD it f DOME IMPROVEMENT CONTRACT PLEASE READ THIS — ` Sold,Furnished and Installed by: Branch Name: Boston Date: ? -/- - L / THD At-Home Services,Inc. —1J d/bla The Home Depot At-Home Services 345A Greenwood Street,�Unit 2,Worcester,MA 01607 Toll Free(800)t57-5192;Fax(508)756-8823 Branch Number:31 Fcc r ID#75-Zbssa60;ME Liu#C 02419;RI Coni_Lic,P 16427 CT Lic#HIC.0565522,MA Home Imprdverwnt Contra for Reg.#t26893 . Installation Address: r t� City 43 State Zip Parclutser(s). Work Phone: Home Phone:: Cell Pbone: IV I Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updatt s): ❑I DO NOT wish to receive any marketing emails from The Horne Depot Proiect Itnforanafaon: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,Inc. ("The Home Depot")agrees to furnish,deliver and arrange for th4 installation('1ustallation")of all materials described on the below and on the referenced Spec Sheet(s), all,of which are ineorpiXated into this Contract by this reference, along with any applicable State Supplement and Payment Summary attached hereto and ally Change Orders(collective "Contract")., Job#: opu avlRcav=-1 Spec Sheet(s)#: Project Amount ❑Roofing ❑Sidin Windows El Insulation - $ 93ZO ��t�f C ❑Gutters/Covers []Entry Doors ❑ ❑Rooting USIding LJ Windows ❑Insulation []Gutters/Covers []Entry Doors ❑ ❑Roofmg ElSiding Windows ❑Insulation y ❑Gutters/Covers []Entry Doors[] _ []Roofing Siding []Windows'[]Insulation $ ❑Gutters/Covets []Entry Doors Ll Main 25%Deposit of Conrad Amount doe upon evewfim of this am t & Total Contract Amount $ Maine Purthasm may not deposit more than oxtbd"of the Contt'aetAmmmt Customer agrees that, immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The home Depot reserves the right to issue a Change Order or terminate this Contract or any individual ProduLt(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Contract_ Pa.Eftnt Summary: The Payment Summary # 0 , included as part of this Contract, sets forth the total . Contract amount and payments required for the deposits and anal payments by Product(as applicable): t NOTICE TO CUSTOMER You are entitled to a completely filled-inn copy of the Contract at the time you sign. Do not sign wCompletion Certificate(note; there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Rome Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO 'r.HE HOME DEPOT FROM THE DEPOSFF PAYMENT OR OTHER PAYMENTS MADE, WITHOUT t.IMITING THE HOME)DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Atcentance and Authorization: Customer agrees and understands that this Agreement is the Entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. I� pp6wpt : Wow Wd3t�:9 e00Z 9 '-tdd tZZZZ9260S: 'ON XdJ Town of Barnstable *Permit# ti0 Expires 6 months am issue date Regulatory Services Fee MASS s,�xrtsrns�, 1639. Thomas F. Geiler,Director �prEO MA't a Building Division Tom Perry, CBO, Building Commissioner' 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 5 08-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY of Valid without Red X-Press Imprint Map/parcel Number C1 Property Address 4 eV z W ' s ❑ Residential Value of Work 7l<b 6 Minimum fee of$35.00 for work under$6000.00 Owner's Name &Address.. �G-✓' y 4/ l/i/,e.j �` 1,7 r."5 b eK ill i t-r-6 C//-1, �.y Contractor's Name S�l Telephone Number' Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: R ESS, PERMIT El I am a sole proprietor I am the Homeowner S E P- 7 2C11,11 I have Worker's Compensation Insurance r i.R ±ABLE 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:IWPFILESIFORMSIbuilding permit formslEXPRESS.doc Revised 070110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly tName� /Organization/Individual): `C&yc ` - welv' 6y d 6 Address:v cy5 / 4 tC"""L %v 1 a VC—ity/State/Zip: -` P{ /VIUi5, hone #: (5 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 employees (full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g; Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp,insurance. 9. 0 Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3 I am a homeowner doing all work officers have exercised their g 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that 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 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 under the pains and,pelnalties of perjury that the information provided above is true and correct iff f—Date :3 Phone#'" `3J l 02. - �✓ �' 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#: �TNE i Town of Barnstable Regulatory Services mm&rnsr.E, Thomas F.Geiler,Director 9 MAM. `bp i639• �•� Building Division TfD IV1A't A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstabIe.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION a Please Print -- �� DATE: 7 JOB:LOCATION:"7""r.'t (� —[ ! Fi`1.� yV Il/N�✓f /� jf �6 number street � 9 ' / village "HOMEOWNER'.'.' l��[j;��I/je/!-I i'V !/U•�S Jd�6d f� a 3 3l07 name home phone# work phone# CURREN_T_MAILING-ADDRESS:___ /_. c��( ✓ d (9 GLSL city/tow6 state zip cod 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. P s d The homeowner actin as g Supervisor is ultimately P y 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:forms:homeexempt - �IHE h�.� Town of Barnstable ' BAx►vsTeec.E. Regulatory Services MASS. �, Thomas F. Geiler,Director 1639. n . Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 50 - -8 790 62 30 Property Owner Must Complete and Sign This Section If Using; A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted.. , Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&O WNERPERMISSIONPOOLS Town of Barnstable *Permit# R-56 5 I rrsr O,� Expires 6 *0whs from issue date • Regulatory Services XAM%63 as F ssresr�, ee �' Thom F.Geller,Director !M't�`0 Building Division Tom Perry, Building Commissioner 200 Main Street,.Hyannis,MA 02601 �Ij� Office: 508-862-4038 Fax: 508-790-6230 ®, tA EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid%*hout Red X-Press Imprint L 4ap/parcel Number 'ro erty Address Residential Value of work Ael atia a O-d Minimum fee of•$25.00 for work under$6000.00 ?wner's Name&Address --ontractor_s_Name Telephone Yome Improvement Contractor License#(if applicable) ,onstrnction Supervisor's License#(if applicable) OWorkaun's Compensation Insurance Check one: _ ❑ I am a sole proprietor 4R I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Worktnaa's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will betaken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows. U-Value (maximum.44)- *Where required: Issuance of this permit does not exempt compliance with other town department regulations,Le,Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement`Contractors License is required. Signature * 6 QForms:expmtrg Ravisc063004 r The Commonwealth of Massachusetts r . Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Q Nagle (Business/Organization/Individual): • _ L,' n 16LS _ 0 Address: ;2 g(a City/State/Zip: Yl c S Phone#: xr' Dg-- '776� 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 employees (full and/or art-time .* have hired the sub-contractors p 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- _ listed on the attached sheet ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp.insurance. . 9. ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions- requized] officers have exercised their Tight of ex exemption per MGL 11.❑ Plumbing repairs or additions_- 3�I am a homeowner doing all work ' �P p - c. 152, 1(4),and we have no myself[No workers' comp. § 12'�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. =Contractors 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—ob'site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: SLim�city/state/zip: Attach a copy of the workers' compensation policy declarat pag (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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Dater Phone#: 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#: 1 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, expr. or implied,oral or written." n employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more A A the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the of recaiver 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 nstruction oesides rrer air,or the occupant of the wo k on such dwelling house dwelling house of another who employs persons to do maintenance,co eP „ ant thereto shall not because of such employment be dedirr�d-W-be }oY or on the grounds or building appurten � IvI;rL chapter 152, §25 C(6)also states that"every state;or local licensing agency shall withhold the issuance or permit tooperate a business or to construct buildings in the commonwealth for: renewal of a license or 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 perform comp liance with the insurance ance of public work until acceptable evidence o requirements of this chapter have been presented to the contracting authority. Applicants Please 00 ut the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if Flea ssary,supply sub-contractor(s)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 orLLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Also be sure to sign and date the affidavit. The affidavit should Accidents for confirmation of insurance coverage. application for the permit-or license is being requested,not the Department of be returned to the city or town that the regarding the law or if you are required to obtain a workers' Industrial Accidents. Should you have any questions 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 or future permits or licenses. Anew affidavit must be filled out each applicant as proof that a valid affidavit is on file f 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#617-727-7749 Revised 5-26-05 Www.mass.gov/dia f r r OF SARNSTAKE Town of Barnstable 2045 MAY I I .PM 2; 44 Regulatory Services Thomas F.Geller,Director 3 a�xxsr�z�. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.townbarnstablema.us Office: 508-862-4038 Fax: 508-790-6230 PERAM# " FEE: $ SHED REGISTRATION 120 square feet or less Location of shed(address) Villag wt Sot 7 1 ao3 Property owner's name Telephone nuznber Jnx JQL Size of Shed Map/Parcel# - x �s Sign a Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District-Commission jurisdiction? V— Conservation Commission(signature is required) PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN _..................... al F MAP , 2 9?3, 86 P 2 c:\conservation.dgn 3/28/2005 9:36:52 AM