HomeMy WebLinkAbout0390 OAKLAND ROAD I�
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ALTERNATIVE
WEATHERIZATION
Date
Town of Barnstable
200 Main St.
Hyannis, MA 02601
Re: Permit# �lV
The insulation work at j �Q/3•)�
has been completed in accordance with.78.00MR:,'
performed work
w for
.. Agency o p ..-
Regards,.
Timothy Cabral, =
President . .. .
CSL-105454
58 DICKINSON STREET FALL RIVER, MA 02721 I (508)567-4240 I ALTERNATIVEWEATHERIZATION@GMAIL.COM
Town of Barnstable 10111u iling
�''x' ry�; air _ f 'r r �`rt' s .
iP,ostThis Card So That it.�svUis�bleFromthe Street Approved Plans Must be;Retamed on J.ob and his Card Must;be Kept ;
e
M' hosted Until Final Inspection HasBeen Made m}
fib � ,;..;; Permit
° Where a Certificate of Occu anc;pis^Requ.fired,such Building-;shall Not be Occupied§until°aFinal Inspection;has:been made fix.
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Permit No. B-18-856 Applicant Name: ALTERNATIVE WEATHERIZATION, INC. Approvals
Date issued: 04/18/2018 Current Use: Structure
Permit Type: Building-Insulation-Residential Expiration Date: 10/18/2018 Foundation:
Location: 390 OAKLAND ROAD, HYANNIS Map/Lot: 271-018 Zoning District: RC-1 Sheathing:
n. �. - X
Owner on Record: POPILLO SHANNON R&SIDRA M ContractorName ALTERNATIVE WEATHERIZATION, Framing: 1
ti INC.
Address: 390 OAKLAND ROAD 2
- Contractor License; b5683
HYANNIS, MA 02601
Chimney:
ojec
Description: weatherization �. Este Pr t Cost: $3,520.00
x Insulation:
Permit�Fee: $85.00
Project Review Req: g
Fee Pald: $85.00 Final:
,'.. a a•. a a
Date 4/18/2018
Plumbing/Gas
Rough Plumbing:
s _ CAS
Final Plumbing:
= pBuilding Official
Rough Gas:
s
This permit shall be deemed abandoned and invalid unless the work authorize by this permit is commenced within siz months after issuance.
Final Gas:
All work authorized by this permit shall conform to the approved applic�ionsand'the approved construction documents for whl' this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes.
' e ti Electrical
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. Service:
F
j � �; F
The Certificate of Occupancy will not be issued until all applicable signatures b y the Building andFiree Officials are provided on this permit. Rough:
Minimum of Five Call Inspections Required for All Construction Work.,,
1.Foundation or Footing Final:
2.Sheathing Inspection
3.All Fireplaces must be inspected at the'throat level before firest flue lining is installed Low Voltage Rough:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final:
6.Insulation
7.Final Inspection before Occupancy Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final:
Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department
`Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
Building plans are to be available on site
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
Application Number
MAE: Permit Fee..,:....... ........ .....Other,Fee......,,...........
...,..
Yb . .� .
TOWN OF BA.RNSTABLE MAR een?gpravalby,.,...
y1��1
TOWN O
BUILDING PERMITh�
Map ...........-Parcel.....D...................................
APPLICATION
Sectifln 1 �Owner's`Inforinat an and Project Loc on
Project Address 29 D 0ak f"d & 'Village 'S
Owners Name s P ;f!6
Owners Legal Address C31)2kl"d .
;city S State dip
Q
'Owners Cell# (�� �' 08 U E-mail i I 0 cJYI'1
Section 2 --Use of Structure
tJse Group ❑ Commercial Structure over 35,000 cubic feet
Commercial Structure under 35,000 cubic feet
Single f Two Family Dwelling
G
Section 3 -Type of Permit
Q New construction. Q Move l Relocate ❑ Accessory Structure Q Change of use
Demo/(entire structure) ❑ Finish:Basement Q Family/Amnesty ❑ Fire Alarm
i
Rebuild ❑ ° Deck Apartment ❑ Sprinkler System
Addition ❑. Retaining wall ❑ Solar
Renovation ❑ .Pool ❑ Insulation
Other— Specify - L'�-
Section 4 -yWork Description
itlf ` -i c)Yt;$ 1J�ota� i✓1 fG �Z,y` f tG
L so s8&serx ,door
Last updated:311-5/2018
Application Number....................................................
i
Section 5—Detail
f
Cost of Proposed Construction VA N-D Square Footage of Project
Age of Structure .Dig Safe Number
# Of Bedrooms Existing Total#Of Bedrooms (proposed)
11 0 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design
Section 6—Project Specifics
Wiring ❑ Oil Tank Storage ❑ Smoke Detectors
f
❑ Plumbing ❑ Gas ❑ Fire Suppression
❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom
Water Supply ❑ Public ❑ Private
Sewage Disposal ❑ Municipal ❑ On Site
Historic District ❑ Hyannis Historic District ❑ Old Kings Highway
Debris.Disposal Facility: I am using a crane ❑ Yes ❑ No
Section 7—Flood Zone
Flood Zone Designation
Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ f
Section 8—Zoning Information
Zoning District Proposed Use Lot Area Sq. Ft.
Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site)
Setbacks Front Yard Required Proposed
Rear Yard Required Proposed
Side Yard Required Proposed
Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ 'No
f
Last updated:3/15/2018
Application Number...........................................
Section 9— Construction Supervisor
Nam Telephone Number - 7 ®?
Address a. LiS� City ��tvel- State Zip o?7�,
License Number /05L/-:S q License Type � Expiration Date
Contractors Email G�! '�^vr G F1'1/�W -�(,e�'i Za-f i'J71. Cell # 771/-6 y y-o: L/
I understand my responsi6 iti un er the ru14e and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Co e. I nderstand the construction inspection procedures,specific inspections and
documentation requir b 0 C d the T w of Barnstable.Attach a copy of your license,
Signature / Date -3 �0
Section 10—Home Improvement Contractor
Nam 444 a�!V e Mft'6)L Telephone Number '5o 2-
Address aZ L" S+ CityG�t State + Zip
Registration Number f 71(a 13 Expiration Date J S,e�2 _
I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780
CMR the Massachusetts State Building C de. I understand the construction inspection procedures,specific inspections and
documentation require 780 Cu d he T w of Barnstable. Attach a copy of your H.I.C...
Signature Date
jSection 11 —Home Owners License Exemption
c d M Cl Home Owners Name: sk' /� p
Telephone Number Cell or Work Number �a�'� �y'- ?9O
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. l understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable.
Signature Date
APPLICANT SIGNATURE
Signature Ot, U Date 91143 3
U r F1/'T
Print Name l_AuA41 046,^ea- Telephone Number)
E-mail permit to: a.LfWa1 6.!'t'Z-d4jt.i+l.
Fast updated:3/15/2018
Section 12 —Department Sign-Offs
Health Department 01 Zoning Board(if required) El
Historic District Site Plan Review(if required) El
Fire Department
Conservation ❑
For commercial work,please take your plans directly to the fire department,for approval
Section 13-- Owner's Authorization
7, S ► AAU10 , as Owner of the subject property hereby
authorize il�� to act on my behalf, in all
matters relative to work/authorized by this building permit application for:
oak [and-
(address of job) -
Signature of Owner date
Print Name
Last updated:3?15/2018
DocuSign Envelope 10:ODE 94128-OAF C-496&8733-03639363A6AO
Town of Barnstable
°-� Regulatory Services
0 sAa-IsTA x Richard V. Scali,Director
M&SS.
a63% •�� Building .Division
Paul Roma
Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
I, SHANNON POPIL.LO as Owner of the subject property
..............................................................................................................................................'............................................
hereby authorize n ` to act on my behalf,
...� -a
in all matters relative to work authorized by this building permit application for:
390 Oakland Road .Hyannis, MA 02601
....................
(Address of Job)
DocuSigned by:
- -----------E 3/7J2018 1 12:20 PM EST
.............._-------....................................................
............._.._.._....
Signature of Owner Date
SIDRA POPILLO `
Print Name
.If Property Owner is applying for permit,please complete the Homeowners License Exemption Form.
C:\Usen\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\L7U69LF2\E,XP121 SS(2).doc
01/25/17
I ,yam
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
a
1 Congress Street,Suite 100
Boston,MA 02114-2017
M www.mass.gov/dia
Wbrkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):ALTERNATIVE WEATHERIZATION, INC.
Address:2 LARK STREET
City/State/Zip:FALL RIVER, MA 02721 Phone#:508-567-4240
1
Are you an employer?Check the appropriate box: Type of project(required):
1.�✓ I am a employer with employees(full and/or part-time).* 7. New construction
2.M I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No work!ets'comp.insurance required.]
1M I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 Demolition
0 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will .
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
14.�✓ Other I NSULATION
6.F�We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'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:STAR INSURANCE COMPANY
Policy#or Self-ins.2Liiee'.#: Expiration 00 Expiration Date:4/4/18
Job Site Address: y / 0 60849257
yw _�('dAL City/State/Zip: '
Attach a copy of the workers'compensation policy declaration page(showing the policy nuifber and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify unde th ins an a 'es p rjury that the information provided above is true and correct
Si mature: Date: L3
Phone#:508-567-42
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#:
,,...•..� ALTEWEA-01 SNER NHA
Di ATE(AATdfDDIYYXY)
CERTIFICATE OF LIABILITY INSURANCE 0512612017
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(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsemen s.
PRODUCER c.2WcT Christine Costa
Mason S Mason Insurance Agency,Inc. NCC N ,Exri:(78'1)523-0067 (a,No):
458 h Ave.
Whitman,MA 02382 RMS.,.ccosta asoninsure.com
i INSURE S AFFORDING COVERAGE NAIL tt
I IN SURER A:Evanston Insurance Co. '35378
INSURED (INsuRERa:Safety Insurance Company =39464
j Alternative Weatherization,Inc. INSURER c:Star Insurance Company 18fl23
2 Lark Street INSURER D
Fait River,IVIA 02721 i INSURER E
a,
INSURER F
COVERAGES CERTIFICATE NUMBER; AEVISION NUMBER:
THIS IS TO CERTIFY -HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
I INDICATED. NOTWITHSTANDING ANY REQUIREMENT., TERRA OR CONDITION OF ANY CONTRACT OR OTHERIDOCUMENT 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.
IN
SR ADOL SuBRPOUCY EFf POLICY ExP LIMITS
TYPE OF INSURANCE i wyD POLICY NUMBER 1
A ? X j COMMERCIAL GENERAL LIABILITY � j j ( EACH OCCURRENCE s 1,000,000
i CLAIMS i X OCCUR i i ;3C42088 ; 06107120171 06/0712018 1 DAMAGE1SfE TO a0 RENTED �5 100,flfl0
j MED EXP fAny oneperspi s S,OBO
I i i PERSONAL a ADV INJURY s 1,000,000
2,000,000
j GENERAL AGGREGATE s
GEN'L AGGREGATE LIMIT APPLIES PER:
i POLICY JPE'T LOC - i i ?PRODUCTS-COMPIOPAGG I s
2,000,000
i
5
OTHER: j CO�ABINE€3sINGLELIMIT 1 s 1,000,000
B AUTOMOBILE LIABILITY
ANY aura 16237702 j 04/08120171 0908/2018 I eoo1LY INJURY
'__7 OWNED — SC3-iEOULED I
!_s AUTOS ONLY X 'AUTOS BODILY INJURY(Per accident)i S
' 'H R NON VVNE s { i eOtetgtl 1pAMAGE i$
X AUTO ONL A &ONLY
I i
S iS
A ? UMBRELLA tJAB X i OCCUR i j EACH OCCURRENCE s 1,flflfl,flflfl
I X ExcEss Lwa CLAIMS-MADE j i [XOBW6619616 j 06107/2017 3 0610712018 1 AGGREGATE ;s 1,Ofl0,Ofl0
I ;
DED j ±RETENTION$ 1 1 S
PER-, 'OTH- ;
AND EMMPLOYE 7U BIL1rT?r 1, i X ; i
Y t N i 1VC 0849287 00 04104/2017 i 0410412018 600,000
' ANY PROPR)£TOR;PARTI:ERJEX'cGl71VE --: 1 I E.L.EACH ACCIDENT $
j rFICER'MEMB R EXCLUDED? Ni I N 7 A 3 ? ! so fl��
I �MarMatory)n N I ; E,L.DISEASE-EA EMPLOYE $ '
tf des,deswt>e under 508,000
1 ONsdR,PT,ON OF OPERATIONS ce?cw I E.L.DISEASE-POLICY LIMIT -S
i I I 1 1
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Remarks Schedule, attached It mars space Is required
;Action Inc.and National Grid USA,its direct and Indirect parents,subsidiaries and BMWates shall be named as addrttonal insureds on Commercial General
?Liability policy per terms and conditions of forms CG2010 and CG2037 and Commercial Auto Liability policy.per terms and conditions of form$CA 006(02
16).Forms Available Upon Request.
CERTIFICATE HOLDER CANCELLATION
t
I
I - i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES.BE CANCELLED BEFORE !i
I ! THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
National Grid I ACCORDANCE WITH THE POLICY PROVISIONS.
40 Sylvan Road
1 Waltham,MA 02451
I nUTHORAZE a REPRESENTATIVE .
ACORD 25(2016/03) O 1088-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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Office of Consumer Affairs and Business Regulation
i
10 Park Plaza - Suite 5170
Boston, Mass,9chusetts 02116
Herne lmproveme a tractor Registration
5 Type: Corporation
ALTERNATIVE WEATHERIZATION,INC. 0 Registration: 175683
2 LARK ST
Expiration: 05/28/2019
FALL RIVER,MA 02721
� a
H Update Address and return card. dark reason for change.
�;A I r, 2e;1A-esr,
_.._.. ._ .._ ,,.... .... _._...,.__....__.._.,._.:._,.. L:•.ir�iE3S_��+s„i+<�uaa!, rh a a
•, I>r>,.�r�rt'is,r:.y{t{.i'ral/�r� ,;��ia��tr�rt�c1(^, ,.
- 1:r Office of Consumer Affairs&Business Regulation
=; HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Corporation before the expiration date. If found return to:
Big ,Ion. 92S8: I.Bi3 Office of Consumer Affairs and Business Regulation `4
<.: 1-756W 05/2812019 10 Park Plaza-Suite 5170 r.
ALTERNATIVE WI=ATf-I6I7A ION,INC.. n,MA 02116
TIMOTHY CABRAL, ,Q-
2 LARK 5T
FALL RIVER,MA 02721� Undersecretary Ot V G Si alturE:
' Y
I_
ov1HE Town of Barnstable *Permit#
Expires 6 months rom issue date
Regulatory Services Fee
tARNSMBL.E; + .
9tb ,6 9. 1$� Thomas F. Geiler,Director
�rED Mp'(b
Building Division PRESS
PER
Tom Perry, CBO, Building Commissioner IWIT
200 Main Street, Hyannis, MA 02601 a �
www.town.barnstable.ma.us %011
Office; 508-862-4038 TQWN OF B p� -, ���30
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY IV•�)
Not Yalid witlrout Red X-Press Imprint
Map/parcel Number"
Property Address O A 1\ L A of
❑Residential Value of Work' Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
L356 OrsrLAA i2 �
Contractor's Name ! Ir(.J Piz D /Z�n A C.CG fit Telephone Number/ 3 qz✓yZ J�
Home Improvement Contractor License#(if applicable) 1qe 56z 5
Construction Supervisor's License#(if applicable) '76093
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ lam the Homeowner
'01 have Worker's Compensation Insurance
Insurance Company Name n?AC k C
Workman's Comp. Policy# W G
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)
L7 Re-side
#of doors
Veplacement Windows/doors/sliders. U-Value t (maximum .44)#of windows I
*Wh ere req u ired: Issuance of this permit does not exempt compliance with.othei town department regulations,i.e.Historic,Conservation,etc.
'Note: Property Owner must sign Property Owner Letter of Permission.
A coy the Home Improv ment Contractors License& Construction Supervisors License is
u' d.
SIGNATURE: .16211
QAWPFILES\FORMS\building permit fDrmsIEXPRESS.doc
Roviro.7n^lnl to
a ;n
The Commonwealth of Massachusetts
Department of Industrial Accidents
;,1 r 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):
Address: s
City/State/Zipl'WO,Boi2 m ✓�_ Phone 4.-
Are=aUm
employer?Check the appropriate box: Type of project(required):
1. employer with T 4. ❑ I am a genera]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'. $ ?• ❑ 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
required.] officers have exercised their 10.❑ Electrical repairs or additions '
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. (No workers' comp.. c. 152, §](4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ 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 anew affidavit indicating such.
IContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy inforiation.
I am an employer Mat is providing workers'compensation insurance for-my employees. Below is the policy and job site
+ information.
Insurance Company Name: �C�IN +t
Policy#or'Self--ins. Lic.#: WC �G 5-1 17`/ Expiration Dater
Job Si
te Address: /V d A'ta,r- 2 A lk-as /7 City/State/Zip: 06S
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-yearr 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 er t e pains and p alti s of p jury that the information provided above is true and correct
Signature: Date: 2_1
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):
3
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.-Plum bing Inspector
6. Other
`z
f —+"4 n,._..,.,.. Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written.
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or,to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary,supply sub-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,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the-affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner-or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e, a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations'
600 Washington Street
Boston, MA 02111
Tel. # 61,7-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
try Town of Barnstable
a
Regulatory Services
�, Thomas F. Geiler,Director
o; 8 Building Division
Tom Perry, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Owrier Must
Complete and Sign This Section
If Using A Builder
I, It A, as Owner of the subject property' .
herebyauthorize / l�cw"lr4i`GL to act on my behalf,
is all matters relative:to work authorized by this building permit application for.
(Address of Job)
r
S CO,
Signature,of Owner. Date
Print Name
If Property Owner is applying for permit pleas e complete. the
Homeowners License Exemption Form on :the reverse side.
i
Town of Barnstable
�ofTHE ray
Regu ato'ry Services
Thomas F. Geiler, Director
hLl4C .
163g. ,� Building Division
PrEO µp't s'
Tom Perry, Building Commissioner
200 MaiiiStre _Hyanais,MA 02601
R�wsv.tofrn_b arnStab l e_ma.us
Officer 508-862-4038 Fax. 508-790-6230
HOMEOWNER LICENSE EXEKMON
Please Print
DATE:
JOB LOCATION:
number stract vi l lagc
"HOMEOWNER":
name home phone# work phone#
C[TRRE>rNT MAILING ADDRESS:
eityhown state up 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.
DEFTNMON OF HOMEOWIIMR
Person(s)who owns a parcel of land on which he/she resides or intends to reside, an 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 constrq}cts more than one home in a two-year period shall not be considered a bomeowner. 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)
Tl,e undersigned "homeowner"assumes responsibility for compliance,with the State Building Code and other
applicable codes, bylaws,rules and regulations.
The urndcrsigned"homeowner"certifies that.he/she.understands the Town of Barnstable Building Department
Unum inspection procedures and requirements and that he/she will comply with said procedizcs and
requirements.
Signature of Homeowner
Approval of Building,Official -
Note: Three-family dwellings containing 35,000 crbic feet or larger will be required to comply with the
State Building Code Section 127.0 Constriction Control.
HOAaO WNER'S E7CEMP n b)q
The Code states that: "Any homeowner perfomning work for which a building permit is rcquiT=1 shaD be exempt from the provisions
of this section,(Section 1 D9.1.1 -1 iccnsing of construction Supervisors);provided tha t if the homeowner engages a person(s)for hire to do such
w orlc,that such Homeowner shaD act as supervisor.
Many homeowners who use this cxarnption arc unaware that they arc assurrung the responsibilities of a supervisor(sec Appendix Q.
Rules&Regblations for Licensing Construction Suparisors,Section 2.15) This lack of awareness often trsults in serious problems,particularly
` when the homeowner hires unlicensed persons. In this ease,our Board cannot proceed against the unlicensed person as it would with a licensed
Supcvisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,ns part of the permit appication,
that the homeowner certify that hchhe understands the responsibilities of a Supervisor. On the last page of this issue is a,form currerrt)y used by
several towns. You may care t amend and adopt such a form/ccrtifieation for use in your Community.
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Board of Building ]tegn.la(ions :and 5T���c��r1 ;l;
CONTRACTO
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. 15/2011
ype: : uplemer;t Card
NEVVPRO OPERATIN.
TOM ' PEACOCK
M 26 CEDAR ST.
`NOBURN, IAA 01801
i
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?� Qualffled In all zones
NEW PRO MANUFACTURING
eNFRPCNEIWPRO 2000 DOUBLE HUNG
C
PICTURE WINDOW
Kom Cellular PVc frame,Triple glazed,
Natlonal Fenestration Low E coating (e=0.034,52&5),
Rating Council Krypton]Argon/air filled
DEV-K-28-00015-00001
ENERGY PERFORMANCE RATINGS
U-Factor(U,SA-P) Solar Heat Gain Coefficient
0.
1 U.28
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance Air Leakage (U,S./(-P)
0.42
Condensation Resistance
72
Manufacturer stipulates that these ratings conform tD applicable NFRC procedures for determining whole
product performance,NFRC slings are determined for a ftred set of environmental conditions and a
spec flc product slie.NFRC does not recommend arty product and does not warrant the sultabllltp of arty
Drodud for eny specfAc use.Cwwft manufacl mes Iltembire fa otherproducf performance IMermaw".
www.nlrc.erg .
s
�1
BIERGY
in Highlighter C -ialified
I Regions
N N W"010 4iw
® -- qualified In all zones
NEWPRO MANUFACTURING
rvFttC SERIES G NEWPRO 2000
DOUBLE HUNG
�� ,
Cellular PVC frame, Triple glazed,
National Fenestration Low E coating a=0.027 S2&5)
Rating Counclim
Krypton/air filled
D EV•K-27.00030.00001
ENERGY PERFORMANCE RATINGS
t
U-Factor(U.SJI-P) Solar Heat Gain Coefficient
0, 17 0,24
ADDITIONAL PERFORMANCE RATINGS
t Visible Transmittance Air Leakage(U.S./I-P)
0w40 0 A
Condensation Resistance
70
ManufacWrer sdpuletes that tlreee retinge conform to epplkahie NFRC procedures for deormIning whole
produq performance.NFRC retlnge ere Rd
for a @red set of emlroemental candifons end e
3whIc product elze.NFRC does not recommend ury product end dace tat werreM the eulte6111ty of arty
product fat anY eDeclllc we,Ceneuf!menufechrror e I niuro for elherprodUct performance 6rformellon,
www.nfrc.org
,
DclMartll)6)t 0t' Public S�rfct�
Buildi-Wr Regulations ,incl Stancia.1-ds
Construction Su {..
C t�.n Supervisor License p
License: CS 96093
-tricted to:, 0
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2/14/2011 11:29 AM FROM: Mackintire Insurance TO: 17919320860 PAGE: 002 OF 003
4 DATE(MMIOOM'VV) "
�TM CERTIFICATE OF LIABILITY INSURANCE 02/14/2011
PRODUCER 508.366.6161 FAX SOB,366.5202 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION —
.Mackinti re Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
11 West Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND EXTEND OR
Westborough, MA 01581-1931
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
-
INSURERS AFFORDING COVERAGE NAIC#
INSURED Newpro Operating LLC INSURERA: Peerless Insurance Co. 24198 _
26 Cedar St. INSURER B:
Woburn, MA 01801 INSURER C: —
INSURER D: }
INSURER E:OVERAGES
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. Cy RRAA
IL7R N C TYPEOFINBURANCE POLICYNUMBER pLICY EFFECTIVE PDATE�MIM N LIMITS
GENERAL LIABILITY CBP 8588370 12/31/2010 12/31/2011 EACH OCCURRENCE $ 1 000 000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $PRFMIRFS(FA AM IrAnm) ZOO OOO
CLAIMS MADE O OCCUR - MED EXP(Any one person) $ 15'OOO
A PERSONAL&ADY INJURY $ 1,000,000
GENERAL AGGREGATE S 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY PRO LOC
JECT
AUTOMOBILELIABILITY BA 8584174 12/31/2010 12/31/2011 COMBINED SINGLE LIMIT $
ANY AUTO (Ea accidents 1,000,000
ALL.OWNED AUTOS \ _ BODILY INJURY
A X SCHEDULED AUTOS (Per parson) $
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accldenl)
OARAOE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $ .
AUTO ONLY: AGO $
EXCESSIUMBRELLA LIABILITY CU SS82578 12/31/2010 12/31/2011 EACH OCCURRENCE $ 5 OOD OOO
OCCUR CLAIMS MADE AGGREGATE $ 51000,000
A $
HDEDUCTIBLE $
x RETENTION $ 10,00 $
WORKERS COMPENSATION AND WC9645074 05/01/2010 05/01/2011 OTH-
EMPLOYERS'LIABILITY
A ANY PROPRIETOR/PARTNER/EXECUTIVE , E.L.EACH ACCIDENT S 500,000
OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYE $ 500,000 .
H yes•descnbe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS -
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
' - BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATNEB.
Town Of Franklin AUTHORIZED REPRESENTATIVE
.,Timothy Mo na h
ACORD 25(20011013) FAX: 508,520.4906 ®ACORD CORPORATION 1989
r
_ r
04-01-'11 14:25 FROM-Newpro-Wheeling Ave, 1-781-932-0860 T-832 P0001/0001 F-117
r mt,y+r+rovac 10 !� c 11 (�
. RI Reg#26463 1 6 JL 9 58
Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 (F)781-933-N26,www.newpro:com
THIS CONTRACT MADE THE ;day of 20—AL between
(Hoge Owners) - (Home Phone) g
a hone /
of -t U6.1�ICi�(�`� � C I W
(Address) (City) (State) (Zip)
the"Owner"and NEWPRO Operating, LLC, "NEWPRO". The job address is a condominium.
NEWPRO hereby agrees that it will for the consideration hereinafter mentioned,furnish all labor and material necessary to install the following
described work at the premises.located at
Job Address "
(E-MWO for proprietary use onry
TOTAL Additional Model TOTAL
Windows Purchased NEWPRO Work Number Qtv CASH - O
Window Color In: Out: Sliding Glass Door PRICE i b�J
Capping Color ` 1 -� Steel Security Door
W r for in: ut: DEPOSIT
Model Name Model Number(s) Qty Sidelites WITH 2
Double Hun New Construction Unit ORDER �� S00
Picture Window Storm Door BALANCE
Casement ---, Obscure Glass TOP IIOT;6M DUE AT
2 Lite/3 Lite Slider Screens A -F:bM INSTALL ft v
gat/Bow Frame I Please initial,
I
Roof U soffit.12 Customer understands that NEWPRO®does not erniT.-Ielf
Garden Window � do any painting or staining. (ie:when removing Valance paid t at ir�tallation
Awning or replacing interior stops or trim)
Hopper NEW PROO is not responsible for conditions or
Shaped circumstances beyond its control including con- FINANCE
Other densation resulting from or due to pre-existing Bank completion form signed at inewistion
GRIDS olo I —EtlR17 conditions,
DESCRIBE WORK: — KPIM ZI Aft
Est.Start Date: —(.S- 3.1)Ii Customer understands this is an"estimated date" tn.-6
Est,Comp.Date: L
Initials ustomer understands all steel security doors will have a 3/4"aluminum threshold installed over existing threshold.
it shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement,as the Owner's Agent. The Owners who seara their
own construCtiOn-related permits,or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC,142A, All Home
improvement Contractors and Subcontractors shall to registered by the Director and any inquiries about a Contractor or Subcontractor relating to a registration
should be directed to; Director,dome Improvement Contractor Registration,One Ashburton Pr,Room 1301,Boston.MA 02108,(617)727.8598. if the
Owner is obtaining financing by way of a Retail Installment Sales Agreement,such Agreement shall include a time schedule of payments to be made under
said contract and the amount of each payment stated in dollars,including all finance charges. The Retail Installment Sales Agreement shall be incorporated
herein by reference. If the Owner is obtaining a revolving credit line to pay,in whole or in part,for the contract amount herein,the terms of the revolving
line of credit including interest rate and payment terms,shall be dearly set out on the credit application. The portion of the credit application referencing
a time schedule of payment,to be made under this contram and the amount of each payment stated in dollars,including all finance charges,shall be
Incorporated herein by reference.
NEWPRO represents that it carries Workmen's Compensation and Public Liability Insurance in the amount of$100.000-$300,000.
If the Owner refuses to permit NEWPRO to proceed with the work herein,or in the event of any breach of the Owner of this agreament,for any reason
whatsoever shall cause the owner to pay NEWPRO a sum of money equal to thirty-three and one-third percent of the price agreed to be paid,as fixed,
liquidated and ascertained damages,and not as a penalty,without further proof of loss or damage,
NEWPRO shall not be held liable in damages for delays in the performance of this contract due to causes beyond Its reasonable control.
Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the owners to enter
into this agreement.
This contract represents the entire agreement between Owner and NEWPRO and cannot be changed except in writing signed by both the Owner and
NEWPRO,
You are entitled to a copy of the Contract at the time you sign. Keep it to{protect your legal rights. We,the
aforesaid owners,certify that immediately after the signing of the aforesaid agreement,a copy was furnished to us.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the
seller,which may be his main office, or branch thereof, provided you notify seller in writing at his main office or
branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day.
following the signing of this agreement. (Saturday is a Iegai business day).-Sri the attached notice sir�ancs=tlatiot: -
form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Y,The owner has seen"sample"warranties that will be provided by NEWPRO upon i talta' n. $am le warre 'es provided to®corer.
IN WITNESS WHEREOF,the parties have hereunto signed their names this l2 ay of 20 s i�
t C IfwMAqQn EIN# Signed `
IAG �
Marketing Representative Printed Na a Owner
Accep NEW orating,LLC
By S; row Cal
Owner
CORPORATE OFFICE WARWICK BRANCH OFFICE
26 Cedar St 2d Minnesota Ave
Woburn,MA 01801 Warwick.RI 02888
(P)800.242.9974(From NE) (P)800-3563312(From NE)
(F)781-933-0717 (F)401.732-1371
WHITE: Branch Copy YELLOW: Customers Copy PINK: File Copy GOLD: Finance Copy
us-is
Rome
�E TTown of Barnstable
of The
Department of Health, Safety and Environmental Services
,,Y,?=AB E, . Building Division
9 K"SS' �� 367 Main Street,Hyannis MA 02601
1639• 1
AlfD MA'S�
Ralph M.Crossen
office: 508-790-6227 Building Commissioner
Fax: 508-790-6230
Home Occupation Registration
Date: March 22, 2001
Name: Michael D. Rego
Phone #: 508 790 4303
Address:
390 Oakland Road Vlage:_� annic MA n2tini
Type of Business: Transportation/Liyery SPrvicP Map/Lot: R271-018
INTENT: It is the intent of this section to alloly the residents of the- Ba t oydittancbl a provided that the aeon
within single family dwellings,subject to the provisions of Section 4- of the g
activity shall not be discernible from outside the dwelling.th ethan a re shalles no
ontialluusec o increase m traffic ab in noise or odor-,no ove normal
alteration to the premises which would suggest anything
residential volumes;and no increase in air or groundwater pollution. won shall be permitted as of right subject to the
After registration with the Building
Inspector,a customary home occupation P
following conditions: -------
The activity is carried on by the permanent resident of a single family residential dwelling unit,located
within that dwelling trait.
• Such use occupies no more than 400 square feet of spacer �buildin ,and
• There are no external alterations to the dweIIingwhich are not customary in residential gs
there is no outside evidence of such use.
No traffic will be generated in excess of normal resi
dential volumes.
The use does not involve the production of offensive noise,vibration,smoke, dust or other particular
matter,odors, electrical disturbance,heat humidity or other objectionable effects.
,glare, explosive materials,in excess
There is no storage or use of toxic or hazardous materials, or flammable or
of normal household quantities.
Any need for parking generated by such use shall be met on the same lot containing the Customary Home
• Occupation,and not within the required front yard.
• There is no e-.terior storage or display of materials or equipment.
• 'There is no commercial vehicles related to the Customary Home Occupation, other than one van or one
pick-up suck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot containing the Customary Home Occupation.
• No sign shall be displayed indicating,the Customary Home Occupation.
• If the Customary Home Occupation is listed or advertised as a business,the street address shall not be.included.
No person shall be employed in the Customary Home Occupation who is not a permanent resident of the
• dwelling unit.
J agree with the above restrictions for my home occupation I am registering.
1, the undersigned,have read and