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HomeMy WebLinkAbout0031 PAINE AVENUE V -Fcx;l n e- 8°� - IIci -oat t� ..J App ication number.:.... ...... ............ �........................................................... DAWMAO ' Building Inspectors Initials.... ................... BUILDING DEP 3 rr- '. Date Issued................... . 2020 MAR 13 Map/Parcel.. .... .... .....:.......�..' .��.:................... OW �"44QF' BARNSTABLE SCANNED EXPEDITED PERMIT APPLICATION: MAR 1'6 2020 ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: ?C,� t C', V1 rL( NUMBER STREET f VILLAGE Owner's Name: V 1 C�K.1 1M G C'�) Phone Number -3(0c), Email Address: V ko5 e_ 6�1 CCU Yletell Phone Number (' - (09'5-`A3 I S Project cost$ L GQD Check one Residential ✓ Commercial OWNER'S AUTHORIZATION As owner of the-above property I hereby authorize to make application for building permit in accordance, th 780 CMR Owner Signature: C�/1 Date: � Lr/ TYPE OF WORK. 0 Siding Windows (no header change)# �` `: 'Doors (no header.change)# 2-- DInsulation%Weatherization 0 Roof(not applying more_than I layer of shingles) 0 Commercial Doors-require an inspector's review Construction Debris will be going to © Certificate of occupancy with no construction(complete below) Occupant/family relationship or business name or Existing amnesty apartment(attach a copy of recorded comprehensive permit). CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# ��C1 ? (attach copy) Construction Supervisor's License# S V�e (attach copy) _ Email of Contractor ,..1_ one number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR/F THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER................................................,........... - *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X ,,.: X Additional tent dimensions can be attached on a separate piece of paper. P i ose of Event rtrCheck�one: this event is a: for profit non-profit event t , ,.yt Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 201bs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes ' No , if yes, a gas permit is required.. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/ AL/PELL CO ET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature _ jhem Date ,/& APPLICANT'S SIGNATURE &Sr natur� V r 1 at� -tX--z All permit applications are subject to a building official's approval prior to issuance. - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia a Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleciricians/Plumbers Applicant Information / ePlease Print Legibly Name-(Business/Organization/IndividuA _ al): Address:.. 1/v �1� C City/State/Zip: �itfl/ Phone#: Ar`u an employer?Check the appropriate box: Type of project(required): l. 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.❑ 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 in an capacity. employees and have workers' g Y P tY• 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ 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 I.❑Plumbing repairs or additions myself. [No workers'comp. - right of exemption per MGL 12.FOth repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13. er, r r comp. insurance required.] GVL 0 �� *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: G " Policy#or Self-ins.Lic.#: �(�6�,0/ � Expiration Date: L�7 G Job Site Ad'd ess:� 6 v City/State/Zip: G �� �` Attach a copy of the workers' compensation policy declaration page(showing the policy num er 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 an penal 'es ofgeQrjurythat the-information provided above is 7tr ;d c rrec�Si GG _� '� Da te 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#: of r I o , matron 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-contractors)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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or.licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture .(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 0mce of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4400 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Division of Profe'ss�onai Licensuse y ® Soarl of 8 ldmg Regulafions'and Standards GoristruGttbri StSper�isor CS-009055 ^ -�ri €-spires '08t17t2U20 ; MARKA WENZEI & ; 45 WHIDAH WAY, Y; CENTERVILLE MA 02632 ''x; r Y ; G'ornmissloner Office of C.onsurner.Affairs and Busriess Regulation. " a ' 'One.Ashburton Place- Suite 1301 . . Bostdri, Massachusetts 02108 r Home Imp..rovement:Contractor'Registration' r - Type Corporation WENZELFRAMING,,INC R. i tfation 100285 �,. Expiration-. 06114/2020 45 Wkl!YAH WAY , .CENTERVILLE MA<028,32_ _ .,, ,�.,. , •.'. rt a 4dafe;Address and Retam Card.. • r%/re��.::itrrltrr eralf/rr�^jl�ii�.i�cf�,:,��f/ y •.r. Offiee:otConsumeP-Affairs&Business Regutat�on ' • , HOME IMPROVEMENT CONTRACTOR:. Registrabon`.valid for individual use onry c ' TYPE:Gorooration' r before the,expiratlon.date. H found.retum.td- Registration Emiration ,• Office of Consumer Affairs and_Busines4 Regulation . 100285 '; ... 06)14/2020. One Ashburton Place=Suite 19.01 0 WENZELFRAMING-INC. Boston,.MA 62109 x P MARK A.W ENZEL 45 WHIQAH CENTERVILLE,nnA o2s32: Not Vdild.withoutsignature Uridersecretary s r S of ' ' • ♦ - WENZFRA 01 ACO KULICK CERTIFICATE OF LIABILITY INSURANCE DA712 `... THIS`'CERTIFICATE'IS ISSUED AS A MATTER OF INFORMATION ONLY'AND CONFERS NORIGHTS UPON THE CERTIFICATE HOLDERrTHIS` CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER"THE COVERAGE-AFFORDED..BYTHE POLICIES BELOW. THIS CERTIFICATE'.OF INSURANCE DOES T:NO :.GONSTITU NT TE.A CORACT BETWEEN THE ISSUIHG INS URER(S),AUTHORIZED REPRESENTATIVEOR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H.the.certificate holder Is an ADDITIONAL INSURED;the_poiicy(ies)'must have ADDITIONAL ED INSUR provisions or tit endorsed: ` If SUBROGATION IS WANED,subject to the to ms and eondiiiohs of the poficy;leertain pollciea may re_qulre an endoisemerit A statement.on thls:oertificate does not confer B htslo the CiMlcate.holderin 11eu ofauEh endorsemen s .PRODUCER License 1111780862 HUB tntemaDonal New.England • , : 508:945-0446 _._. FAx�:508 9459138 266 Orleans Road North Chatham,MA 02660, 9t4 INSURERS AFFORDING COVERAGE -NAit 9 INSURERA-Trevelers:Ci"aity iris urance imipa of America:19W6 . - 18489 WsuaED 2 " iwsURERe:AssoCiatedMutual Int. Wenzel Framing Inc, INSURER C:. 46WhidahWay .. L" a WsuRERo.>, ._., Centerville,MA 026J2 'IN SURER Ft':. COVERAGES CERTIFICATE NUMBER: REVIS ON NUMBER . THIS LS HE POLICIES. NDI OF INSURANCE LISTED BELOW HAvE BEEN 7SSt1ED T07RE INSURED NAMED ABOVE FOR THE POLICY PERIOD .TO CERTIFY THAT T NY INDICATED. NOTWITHSTANDING A REQUIREMENT;TERM OR COTION'OF ANY:::CONTRA CTiDROTHERDOCUMENi\NRH WH RESPECTTOICNTHIS CERTIFICATE MAYBE ISSUED OR.MAY:PERTAIN,.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN:(&SUBJECT TO ALLTHE?ERMS; EXCLUSIONS AND CONDITIONS OF SUCH... CIES:.LIMRSSHOWN MAY.HAVE BEEN REDUCED BY PAID CLAIMS:: W Sp ADDL SURR POLICY EFF POLICY E1CP .._ LIMITS a TYPE OF INSURANCE POLICY wUMBFR .., - A X .COaUdERCIAL;GENERAI LIAHILITY - - `EACH OCCURRENCE ., 1 000 000 CtlUanSa+ADE ,:ocGUR 803A20272J; 7111FA19 .7/1112020 70RENTEO S OOO 30D • iA. MEO EXP IAny one Rersmr • ::PERSONACS:ADV INJURY:... S .... GEWLAGGREGATE LIMIT APPLIES PER- � „2,000,000 # GENERALA GREGATE S X PC �� � •..PRODUCTS_COMPJOP AOG S 2,000,000 _ .OTHER: ,a .,. '; BODILY INJURY er MxUTO AUTOS ONLY - Nry�po�NN$VWU�LNNEEEOpp , i. :HRORDLLY ITNyJl1RY er acadenl E E. _ . . AUTOONLY � j `..DPedRrlent S ;AUTOS ONLY -UMBRELLA UA8 1. j OCCUR EACH OCCURRENCE 'EXCESSLIAB :CtAI{dS44ADE '- " .`AGGREGATE. :..; S. ....... DIED ,RETENTIONS.... S .,.., B WORKERS COIAPENSATION _ - ANDENPLOY RS'LIABILRY 'vJN 5018977/ ,r 7N7/2019 -711112020 E.LF1acHACCIDENT 500,000. ApNFY•ICPRRO�PNRI%ETRO�RpIPIXCTUDEER CUTIYE❑;NIA ,. SOO,ODo E E DISEASE EA EMPLO 8 If ae�dosafbe finder= - EL.DISEASE POLICY LIMIT 5D0,000 D S RIPTION OF OPERATIONS do - .:.._. .: ... - •• , OESCRYPTION OF OPEMTIONS I IOGATI0w5 f VENICIES COR0:101 Add nai Remmka SWeAole nmY 00eOcohed a,more} b ropu§ed) 44 �a Certlflcate holder 1;;listed as AddiOonei Insure for General Liability when required by written eoIf CERTIFICATE HOLDER -:.._, CANCELLATION.. SHOULD ANY OF THE ABOVE DESCRIBEGPOLICIES BE CANCt71EDBEFORE. THE DJPIRATION DATE -THEREOF,.NOTICE WILL amsta BE'DELIVERED IN TO"of Bbie zr ACCORDANCE WITH THE POLICY PROVISIONS. _ $67:Main Hyannis MA 02607; M1 .` AUTHDRRED.REPInttE/S(E�N(TATNE? M r ACORD 25{2096H13) ; ®1988-2015 AC, fits reserved. ORD CORPORA710N Alt rig The ACORD name and Iogo are registered marks'of ACORD a 1. Y Divisiony:of Profcssronal Licensure` ' Boad of Buiidmg Regulations and Standards �onstrtictlbnSfipervisor • 'GCS'-009055� �;�' � �� ; ` 4E�PIres'0611712020 '. 4 MARK:A WENZEL s 'Gommissloner,,,; , O fice of Consumer Affairs and Business Regulation One Ashburton Place- Suite f801 - ` Boston, Massddhusetts 02108 Home. Improvement Contractor Registration ; type': Corporation. . Registration:' 1002135 WENZEL FRAMING„INC:. Eiratlon: 06/14/2020 t 45 W IDAH.WAY CENTERVILLE MA.09039, i... Update:i4ddress:and"Return Card_,. SCAT €.• 20M 65117,' , rJ://fl C�Crii:9r26�n!••et7l/j n�^!f'.. _ - y -.� .. _ -_ ._,1 ._ -^ -.. .'.- �•y. . '....., - _ .-. .. - '- . Officaof Consumer Affairs&Business Regulation" 5 HOME IMPROVEMENT CONTRACTOR. .£ Registration valid for individual,use only" TYPE::Corooration before the explretian date. tf found retumto: Reaistra#ion it "o' Office of Consumer Affairs and Business:Regulaton ;,100285 �` O6/14/. 020' ;. One Ashburton Place=SuRe"i301 ., WENZEL FRAMING,ING 4 Bos4on,MA 02108 MARK A.'W ENZEL „ 45 WHIDAH WAY CENT RV MA 02632: " Not valid without.signature y Undersecretary ., ,