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HomeMy WebLinkAbout0005 PEACOCK DRIVE -Peet cock '�r, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map / U Parcel Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Feed Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street Address n-lc-D C,� Village Owner-D&V C a yc I 1 le-r Address P�-e_C c_ng_ Telephone TO i Permit Request 13 u -� r C!-2 �� -` G 3 b S cV. Square feet: 1 st floor: existing proposed �3(,2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation.%000, 0-0 Construction Type LUAU , Lot Size_ !_3i SA Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family �' Two Family ❑ Multi-Family (# units) Age of Existing Structure C5 Historic House: ❑Yes 0 No On Old King's Highway: ❑Yes R No Basement Type: UrFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) (0 Basement Unfinished Area(sq.ft) S41, Number of Baths: Full: existing new Half: existing new Number of Bedrooms: 7 existing —new Total Room Count (not including baths): existing —new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil UP electric ❑Other .Central Air: ❑Yes klo Fireplaces: Existing g New Existing wood/coal stove: ❑Yes CB-P�o Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: Ifexisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: e Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# t w Current Use - Proposed=Use h APPLICANT INFORMATION �� (B/UILDER OR HOMEOWNER) Name �A �--�" $ S 6-N Telephone Number �a Address �`� r t(�f V_ S 'f License # C 2 0wI J — Home Improvement Contractor# 1 2- ��2-5 Worker's Compensation # w& Z'3( S-3 2y 0 Zg--o z D ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L." A a SIGNATURE DATE FOR OFFICIAL USE ONLY `APPLICATION# DATE ISSUED i} MAP/PARCEL NO. k a • ADDRESS VILLAGE OWNER i DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING } DATE CLOSED OUT - ASSOCIATION PLAN NO. a I er r Town. of Barnstable Regulatory Sermes i�usregr Thomas F. Geiler Directoz` 1 Building Division Thomas.Perry,CBO,Building Commissioner " 200 Main SfYeet, Hyannis,MA 02601 www.towh.bamsta b9e.wa:us Offices 508-862 4038 Fax:_ 508-790-6230 ,. PLAN RE VIL W Owner: �, F C V AL /� Map/Parcel:" �-"�� :�6`t Project Address S'r Pia Cos/c • Builder: The following iteza' s were noted-on reviewing: - c b Reviewed,by _�ei'-7�t Date: v N _ f M di It k A X a. ax , n , �Q �� 4: �. Bo%o ul mg. egu a gods n an ar s License or registration valid for�ndividul use only { MOME"IMPROVEMENT`CONTRACTOR ; before the'�xpiration date If found return o: > Board.of Building Regulations and Standards Registrat n. 128528 l s One Ashburton Place Rm 1301 i ^,o r z Expiration 4/1 512011 ' Tr# 284326 Boston,Ma.02108 , Individuaf rlLE i s; � PAUL N.CRO N if PAUL CROS..SEN l t 317 MAIN ST. �� ;` vali without si gnature ,tom ��°� Not HAptWICH,MA 02645'w��-'", Administrat or. } i • Massachusetts- Department ol•Public Satcti Board of Buildimi Regulations and Standards=Construction•Supervisor License " License: CS 74174 �1 -Restricted to: 00t _1 l y r PAU.L N CROSSEN 317 MAIN STt • • " HARWICH, MA 02645 c� -•��. �c� Expiration •12/14/200 Paz ('ununissiuncr fW,9.006. The Common-we"Ifff ofmassachusetts -Deparfinenl of 11,dustlejTJ Accidents Office of rnvesdOzions 600 War h.nHVOn Streef Boszon, A64 021J] wy .trtrzss.goWdia Workers' Compensation Znsaran.ce Affidavit: Builders/Contractors/EIectrjcians/?lumbers Applicant In.formattori Plea se_Print LP-E zblY j�aTlle (BusincsslOrganizationlfndividusl): CRA ( S S I AdrJress: 3l'1 L�, s'-�-' City/State/Zip:Yt t r VVIc� OL-fp Phone.4: 4`� Arne yo.0 as employer? Check the appropriate box; Type of project(required): 1. a cmployct with 4. ❑ ram a general contractor and T 6. ❑24ca, contraction cmplayecs (full an part-.me).* have hi e sred th nib-contrac 7 tors . J. Remodeling listed on the aitachcd sheet ❑ 2.❑ I am a'sole proprietor or par acr These sub-contractors have g, ❑ Demolition sbip and bavc no ctnployoes working for mein any capacity. employees and bave workers' 9 B>lilding addition -camp. insurance.$ [No workers'.coiap,•insurancc 10.[]-Electrical repairs or additiot rbgnircd ] 5. [] We are a corporation and its 3.FT I am a homeowner doing all work officers have exercised tbcir 11_[�.Plumbing repairs or.aAditio> myself. [No workers' comp. right of exemption per 1v1Gr, 12.El Roofrcpairs c, IS2, §1(4), and we have no insurance required.]t. 13.�Other �.2 employees. [No workers comp, instn-ancc required_] Arty applicant that checks box#1 rnuA also fill out the section below showing their workers' compm a4on policy information. t HomtoWnCTk;who submit this a$tdavit indicating thcy m doing all work and that hire outside cantraetors musi submit anew affidavit ndi_caiing each. xConlraeinrs that check t ffih4 is box must atfachcd an additional sheet showing the name of fhc sub-conla�ttbrs and sta{c whether yr not those tnbdrs have employees. Lt at sub tnrx have errtployccd,they mutt proyidh their workers'comp policy numbs, earn art cmproyer that isprovidingtvorkers'coinperlsati.Dn iluurancefor my employees Belatu Is the policy ttrtdjab site info rm at[on lasutancc Compmy 1 fa.mc: O Z$ ' O 20 Expiration Date: .Policy# or Self-.ins, Lic:#: �e- � 3« � 32$ _ • lob Sitc A-ddress: -e a Cn �Y\ V� City/Stervzip: ti G�r• \ Attach a cope of the workers' cotnpet�sation policy declaration page (shouting the policy number and expiration date). Failure to secure covcrago as rcquircd under Section 25A of MGL c. 152 can lead to-the imposition of criminal penalties of a Eno tip to S.1,500.00 and/or one-year imprisonment, as well Offic as civil penalties in the form of a STOP WORK ORDr and at the violator.�Bc advised that a copy-of this statement may be forwarded to the r, of of up to $250.00 a day agains Invcsti ations ofthc JD A for insuramc covera c verification X do hereby certify under the pains•and pertallzes bfperjury tJc,al the irrformalion provided above is true ana'col rec>; Date; 3 I d — Si ature: Phone Official use only. Do not write in th r area, to be com feted by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2, 13uilding Department 3. City/Towm Clerk 4. Electrical Inspector 5. Plumbing Ynspector 6. Other information and IIIStr'U.0 I chusetts General Laws chapter 152 requites all employers to provide wockocfsanotb p ndtrOa Y contra tMoflhirees; Massa erson in the serve pursuant to this statute, an enapMyee is defined as "...every p express or implied, oral or written An amployer is defined as "an individual,patacrsbip, association, corpora lion or otbr lcgai entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deeeascod enl$owcvcrhtho artnershi association or other legal entity, employing y receiver or trustee of an individual, P P, • owner of a dwelling 4ouSe having not more than three apatmcats and wbo resides thcrcin, or the occupant d e house dwelling house of another who employs persons to do znaintV a ce of s h emplooyznent be decmrd to bedan e ploycr." or on the grounds or bu-Mug appurlc nano thereto shall not b MGL, cba to 152, §25C(6) also states that "every state or local licensin dguneyn hh coznzaonrt althsfor JLOY r P rearwa. of a license or permit to operate a business or to construct g applicant who lxas not produced acceptable evidence of e ononw th nor any of its political subdrvisions'shall MGL ohaptcr 152, §25C(7) states "Ncithcr th Adds into any contract for•rho performance of public work until acccptablc cvidmcc of complizncc a2th AdditionaIly, the insurance contracting authority. requircrncnts of this chapter bave been prescntcd to the Applicants the boxes thattc;apply to your situation and, i Pleasc fill out the workers' comp atio( ddr ss(cs) and phon ncumbcr(s) along with their ccrti&fi te(s) of trLh tM hPO necessary, supply sub-contractors names , insurance. Uc itcd Liability'Con1panics(LLC) or Limi.tod Lability Paztn san ps an)LLC or°L1 doee bavtccz than tho mombrrs or partners, arc notrcquzrcd to carry workers compcnsatzon ms cmployecs, a policy is required. lac advised that this affidavi uma t° slsub nd data thclaffidat.ntThe ffidaviclshould Accidents for coafirmation of insurance coverage. Also be s bo returned to the city ar town that the application for.the permit oc war° o aro required to obtain aewornkcr ' of Industrial Accidents. Should youhave any questions regarding th y please call the pepartmcnt at the nurr}bcr listed below. Srlf-insured cozrP=cs co cnsafionPo�icy, should enter their self-insuran,o license number on tho a2PrOpriato line. City or To-ffP Oftldnls Plcaso be sure that the affidaYit is complete and printed legibly. The Department has pro adze arding thcappu ant of tho affidavit for you to fill out in the event the Occ of Investigations has to contact y g tion, an applicant Please be raze to fill in the permit/liccnsc number which will bYen ccax p cd only s bmi rrfcrcncc tonp�dcr. ja ayit indicating current that must submit zwltiplo permit/liccnsc applications in any y policy information(if pecessary) and undcr"7ob Site Address" rho ap k debt should h°e dy mor own locations b proY�dcd to or A copy of tho efFdavit that has been officially stamped or s mar s. A new affidavit must be Edlcd out each appjii-ant as proof that a yalid affidavit is on fi1c for future Pe °t not related to any business or commercial vcntuzo year.Whcro a home owner or citizen as obtaining a liccns c or p, c.) said persoA is NOT required to complete this affidavit (i_e, a dog license or,permit to bum lcaYCS et ' our coo eration and should you be Yc any qucstioas, Tbo Officc of lnvcstiga-dons would bloc to thank you in advance for y p please do not hcsitato to give us a call Tac Department's address, tcicphonc•and fax number: TIn@ COm monwtraj.th Of Mmsarhu ,,,ts D xa�At Of ladusfxia.l Accidents OfRce o estigat .aus 600 Washin�ton Strtat $osfon, MA 02111 617-727-490.0 cxt 406 ar 1-877-MASSAFE Fax# 617-727-7749 RCYiscd 11-22-06 wv�N.maSs..gov/die 5/19/2010 6:01:19 AM PST (GMT-8) FROM: insurancevisions.com-TO: 15087906230- Page: 2 of 2 -®AC�/2t7 CERTIFICATE OF LIABILITY INSURANCE DATE(MfN/DDIYYYY) �-� 5/19/2010 PRODUCER DOWLING & O'NEIL INS AGENCY INC THIS CERTIFICATE IS ISSUED AS A MATTER'OF INFORMATION 973 IYANNOUGH RD ONLY AND CONFERS'NC RIGH'TS'UP.(5N THE CERTIFICATE HYANNIS, MA 02601 HOLDER. THIS CEF�T`IF1eATE DOES N13TyASVIEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 508)775;1620 508 778-1218 INSURERS AFFORDING-COVERAGE NAIC# INSURED PAUL CROSSEN - INSURER A: LIBERTY-MUTUAL GROUP - DBA PAUL CROSSEN BUILDER iNSURERB: ' 317 MAIN STREET wsuReRc: HARWICH MA 02645 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. INSR DD' _ - POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER - YYYLIMITS GENERAL LIABILITY - EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES Ea occurrence $ CLAIMS MADE OCCUR MED EXP(Any one person). $ PERSONAL&ADV INJURY $ . GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGG $ POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT. $ ANY AUTO (Ea accident). ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Peraccidenl) $ r PROPERTY DAMAGE (Per accident) $ GE LIABILITY - AUTO.ONLY-.EAACCIDENT $ ANY AUTO EAACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY - - EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $: $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION WC2 315-328028-020 3/1.9/201.0 3/19/2011 WC STATU-I TH O - AND EMPLOYERS'LIABILITY-- Y/N - - 3 `� O S R ANY PROPRIETOR/PARTNER/EXECUTNE . - - E.L.EACH ACCIDENT $ 500000 OFFICERIMEMBER EXCLUDED? Y - (Mandatory in NH) If yes,describe under E.L.DISEASE-FA EMPLOYE $ 500000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 OTHER - - DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS. - - Workers Compensation Insurance: Part One of the policy applies only to the Workers'Compensation Laws of,the State of MA! THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR PAUL CROSSEN , CERTIFICATE HOLDER CANCELLATION ~~= - SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLEDOEFORETHE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 O`-�-DAYS WRITTEN TOWN OF BARNSTABLE � i i ATTN: BUILDING DEPARTMENT - - NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BiT�FAtL�TODOSO SHALL " I 200 MAIN STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THe INSURED'I frS AGENTS OR L� s's HYANNIS MA 0260.1 REPRESENTATIVES. .. AUTHORIZED REPRESENTATIVE (j/ Jeff Eldridge 4 7 �s � _ �, I rIf ACORD 25(2009/01) ©1988-2009 ACOR,JD CORPORATION. All rights reserved. CERT NO.: 7424685il Anne Chandler 5/19/2010 5:5B:22 AM Page 1 of L r - oFrHsr� Town of Barnstable' R.egul2torY Services xixxsrAntE, Thomas F. Geiler, ]director . 16:5q. Building Division prFo µa " g Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www,to)vn.ba rnsta ble.ma.us Fax: 508-790-623 Office: 508-862-4038 - property 0Wne.r Must CoMpiete and Sign This Section Zf 'Us itig A Builder as Owner of the subject property p � c� S to act on my:beh.alf, hereby authorize -- "`�- in all matters relative to work authorized by this building petrni.t application for: . co- rIDr� (Address of Job) Signature of Otdner Date Print Name If property Ovmer is applying for permit please complete the Homeo'Wnets "License r Exemption Form on th•e reverse side. Town of Ba astable °FrHery° Regulatox'Y Services y Thomas F. Geiler, Director . t aARNSPAI3LE, MASS. TI sa Building Div-ision V. ,� Flo MAMA Tout Ferry,$uilding Corrzrnissioner 200 Main Street, Hyannis., MA 02601 yt�yy�Y.toK'ri:barustable.ma.us Fax; 508-790-6230' Office; 508-862-4038 _ _ ------- _ RmEOWN>R LICENSE EXEMPTION Please Print DATE: )O$'LOCATION: street villago number "1-10MBOWNER home phone N work phone$ narnc CURRENT MAILING ADDRESS: zip code c i ty/town state ts or less The current exemption for"homeowners was extended o include o possess a license,e�Yrovided that the zowner act na hire who does not possess a , to allow homeowners to engag e an individual for htr supervisor. DEFINITION OFHOMEOWNER Persons who owns a parcel of land on'which he/she resides or intends to reside,such use anch da.ere is,.orj'�intended d/or or farm sti•uctures. to O accesso to s c res be, a one or two-family dwelling, attach ed or detached stru hi rY t be considered a person who constructs moruch e than one home ff cial on.aaforrntacd shall no ceptable to the Bu/ding O;ftic alo hat has he shall be "homeowner"shall submit to the Building 0 res oitsible for all such work pGrformcd under the building ermif (Section 109.111) "�The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. uilTh'e undersigned "homeowner"certifies that he/she understands the Town of Barnstable procedurg's and Mini inspection procedures and requirements and that he/she i�nll comply y requirements. Signature of Homcovmcr Approval of Building Official Note; Three-family dwellings containing 35,000 cubic feet or larger will be rcquired.to comply with the State Building Code Section 127.0 Construction Control. IIOIyMOWNLR'S EXEMPTJON The Code states that: "Any homeowner erfor pming work for which a building pc rmit is rcquired shall be exempt from the provisions of this section(Section 109,1.1 Licensing otconstrue work, that such Homcowncrsha)l act as supervtion Supervisors);provided that if the homeowner crtgagcs a persons)for hire to do such isor, articular/ c unaware that they arc assuming the responsibilities or supervisor(sec Appendix Q,y Many homeowners who use this czcmption ar s, a rtic I sod Rucs &'Regulations for s,unliccgscd pc onsonIn this cast, Board can)o plrocc do against Lhc uno itccnscd personcasoit Would ti p when the homcowncrh r Supervisor. The homeowner acting as Supervisor is ultimately responsible, To ensure that the homeowncTderslafu)ads the rcosp tnsi�bihliccT �of abSutpery or.y0n the laslLpagc of Ibis aispue iss atform currently used by lha.t the homeowner certify that ho/she n munity. r" /r.c sification for use to your com • � C s 0�. YY. Ile tl LOT 1 Y 4",/`3. ' o p u s p t 4-31 fir,a, i :,2011011v sgra,'7c.ws CERTIFIED PLOT PLAN [10 ;T ; ic }` u LA1 -i:LtF J! jK\ SCALE, V DATES �l sla,c l° CEE?il'!f�'� THAT THE �,�•'n.yr-aA ' . 961, 9NT' SHOWN ON THIS PLAN 19 �.��.�T�'R�D RI~OIs1r�F8ED L4QATIC Cd1�lL ILl�1M® Ill: 1 � ON THE GROUND A9 INDICATED A1 . ,. .: GONFORMS TO THE ZONING LAWS ENGINEER RVEVOR Dr RNS1'ASLE, MASS Y 12' M A I N STREET C��y` fi i���s` /..�. � ' J� HYANRIS MASS. ATE ' -_` Town.Of Barnstable P °tYxetg� ermit# P ti Ecpires 6 months from issue dot: Regulatory Services ]tee C2, S, aaaxsr.+BLF ' MASS. a . y� i639. Thomas F. Geiler;Director _ . Building Division ®PRESS PERMIT Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601+ MAY 2 4 2010 www.toiwn.barnstable.ma.us Office: 508-862-4038TOWN OF B N87 , 6230 EXPRESS PERMIT APPLICATION RESIDENTIAL'ONLY 7Yot valid without Red X-Press_bhprin Map/parcel Number o)yk_ Property Address ['�Residentiai Value of Work 4� 6 0-�•� Minimum fee of$25.00 for work under S4000.00 Owner's Name&Address ��j Contractor's Nam �� S 5 it/ Telephone Number��--Cj2� Home Improvement Contractor License,#(if applicable) 2—<(? Construction Supervisor's License# (if applicable) d 1 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor n ❑ I am the Homeowner have Worker's Compensation I surance Insurance Compan y Name Workman's Comp.Policy# W J S 3�,S d Copy of Insurance Compliance Certificate must accompany each permit: Permit Request(check box) II All construction debris will be taken to VC � Re-roof(stripping old shingles ❑ Re-roof(not stripping. Going over' existing layers of roof) ❑' Re-side p' #of doors ❑ Replacement Windows/doors/sliders:U-Value (maximum .44)# of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. * Note: Property Owner must sign Property Owner Letter of Permission. A y of the Home Improvement Contractors License & Construction Supervisors License is e q u red. SIGNATURE: _ _— i Bo�ot` i g.l(�Iafiosis anid`S'tandar°�s� f License or registration valid for tndividul use only HOME IMPROVEMENT CONTRACTOR before the`Ixpiration date. If found return to: Board of Building Regulations and Standards Registration: 12852$ One Ashburton Place Rm 1301 Expiration 4/.15/2011 Tr# 284326 I U19 Boston,Ma.:02108_ Type Individual PAUL N.CROSSEN PAUL CROSSEN a i '. a1a 317 MAIN ST HARWICH,MA 02645-•�i_:i�-" Administrator Not vah "without signature • _ Massachusetts- Dgmrtrncnt of Public Safct� -r� ens Board of Building Rculatiiins and Stand.0 ds _ Construction Supervisor !License License: CS, 741714 Restricted to: 00 ; PAUL N CROSSEN y " 317 MAIN ST t HARWICH, MA 02645 . -�- 'y Expiration .12/14/2010 F r - f I 5/19/2010 6:01:19, AM PST (GMT-8) FROM: insurancevisions.com-TO: 15087906230' Page: 2 of 2 AC'"R"® D CERTIFICATE OF LIABILITY INSURANCE ATE"(MM/DDIYYYY) 5/19/2010 PRODUCER DOWLING & O'NEIL INS AGENCY INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 973 IYANNOUGH RD _ ONLY AND CONFERS 'NO12�S*IRIGH`f5 ZFION 7THE CERTIFICATE HYANNIS, MA 02601 HOLDER. THIS CERTIFICATE DOES Nt]TFAh71END, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. • 508 775-1620 � , _0; 508 778-1218 -. INSURERS AFFORDING COVER4G NAIC# INSURED PAUL CROSSEN INSURER A: LIBERTY MUTUAL GROUP DBA PAUL CROSSEN BUILDER INSURERB: 317 MAIN STREET HARWICH MA 02645 wsuReRa --' INSURER D: " INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING —ANY-RE-4UIREMENT—T-E-RM-OR-CONDIT-ION-OF-AN-Y-CON-T-RAC-T-OR-OTHER-90C-.UME-NT-WI-TI -RESP-E-CT-TO-WHICH-THIS-CE-R-T-IFICATE-MA-Y-BE-ISSUE-D-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: INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION - LTR NSRQ TYPE OF INSURANCE POLICY NUMBER LIMITS GENERAL LIABILITY - - EACH OCCURRENCE $ COMMERCIAL GENERALDAMAGE TO RENTED LIABILITY - - PREMISES Ea occurrence $ CLAIMS MADE El OCCUR MED EXP(Any one person) $ PERSONAL B ADV INJURY $ ' GENERAL AGGREGATE 1 $ GEN'L AGGREGATE LIMIT APPLIES PER: - - PRODUCTS-COMP/OP AGG $. POLICY " PRO"- LOC AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT $ ANY AUTO (Eaaccidenq ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - EA ACC $. .. OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION WC2 315-328028-020, 3/19/2010 3/19/2�11 WC STATU OTH- AND EMPLOYERS'LIABILITY ,'Y N - '�". TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE 1 E.L.EACH ACCIDENT $ 500000 OFF ICERIMEMBER EXCLUDED? ❑Y. - - - - (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS'ADDED BY ENDORSEMENT/SPECIAL PROVISIONS - -" Workers Compensation Insurance: Part One of the policy applies.only.t6 the Workers'Compensation Laws of the State of THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR PAUL CROSSEN CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLEQBEFOREiTHE EXPIRATION TOWN OF BARNSTABLE 'DATE THEREOF;THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAY©+,,� S WRITTEN BUILDING DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,bi'U FAILU�'�O DO SO SHALL` 200 MAIN STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON T'LE'INSU Tf'ITS AGENTS OR HYANNIS MA 02601 REPRESENTATIVES. ��' • AUTHORIZED REPRESENTATIVE - ^' Jeff Eldridge (I t1 ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION.'Alf-rights'reserved. CERT NO.: 7424685 -Ahne.Chandler.5/19/2010 5:58:22 [ant Page 1 of 1 The Comrnonwe.alth of Massachusetts Department of Industrial Accidents Office of Investigations ! 600 YYashington Street Boston, NIA 02111 rv;•vfv.mass:gov%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual); - - s Address: nn aj l f Y aA, A City/State/Zip: Lt Phone #: Are you an employer? Check the appro� rial box: Type of project(required): 1.©am a employer with 4. I am'a'general contractor and I 6 [JNew construction a rt-time),* have hired the sub-contractors employees (full and/or p ❑ listed on the attached sheet. 7. ❑Remodeling 2. I am a sole proprietor or partner- ship and have no employees , These sub-contractors have g, E] Demolition working for mein any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp.insurance.$ S. [] We are a corporation and its 10:❑ Electrical repairss-or additions -.. required.] - ,. 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions right of exemption per MGL �. . .. __.myself,..[No yvorke�s._coznP,. _. _ .. .... ....... 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 in Formation. ' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit in such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance_Company Name: �- Policy#or Self-ins..Lic.#: (_ 2 3 �j_� 0 2 p 6 ration Date: Job Site Address: tit'-efs�Cr��,� cw City/State/Zip: ( 1 ) 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 MOIL c. 152 can lead to the imposition of criminal penalties of a fine.up to$1,500.00 and/orone-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 und, ains and penalties ofperjury that the information provided above is true and correct. Signature' ( Dater- i 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): I. Board of I7ealth 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 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 s persons to do maintenance, constniction or repair.work on such dwelling house dwelling house of another who employ 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 ofcompliance with the insurance coverage required." Additionally,NIGL 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 msurarice: 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 usedas a reference number. In addition, an applicant that must submit multiple permitflicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and Linder"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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 - tn"»v m:1CC an-VM 7 �FIKE Tp� Town of Barnstable ^ regulatory Services uxrisrasiE Thomas F. Geiler,Director 9 MAss 1659. Building Division QED hlP�� Tom Perry,Building Commissioner ..200 Main Street,Hyannis,MA 02601 -vvww.t6wn.barnstnble.ma.us .Fax: 508-790-6230 Office: 508-862-4038 Property Owner Must T complete and Sign This Section If Using A Builder I r as Owner of the subject property hereby authorize to act on my behalf, y in all matters relative to work authorized by this building permit application for: « Address of Job) . - 2Z rc� Signature of er . Date_ Print Name if Pro e Owner is applying for permit please complete the Homeowners License Exemption Form on the. reverse side. t: Town of Barnstable o • 0 Regulatory Services " Thomas F. Geiler,Director a BA-RNSrABLE, 1639. a��� Building ]division lFD MAC 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{I 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,orris 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) r , 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. 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 helshe 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\homeexempt.DOC TOWN OFSARNSTABLE Permit No. 28099 Building Inspector f IMSTAX Cash ----------- OCCUPANCY PERMIT Bond x Issued to Bayside Building Co. Address Lot 4A, 5 ,Peacodk Lane, West HvanmisDort Wiring Inspector Inspection date Plumbing Inspector Inspection date /// i'11L Gas Inspector MCI— Inspection date X)�-Engineering Department Inspection date Board)of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE I BUILDING CODE. ................................ .............. ......... ...... Building Inspector ��P,, �•., TOWN OF BARNSTABLE BUILDING DEPARTMENT 2 BARWIS TOWN OFFICE BUILDING rua t639• �� HYANNIS, MASS. 02601 �o rr��• MEMO TO: Town Clerk FROM: Building Department DATE: An Occupancy. Permit. ,has."been issued for the,building authorized by Building Permit .$�. .... .. ....... .. . . .. .......... ....._..........._..... is d t ...... .....�!... .. .. . .... i.. ............................. �. Please release the performance bond. Assessor's map and lot number ............................................. TH E TOE Sewage Permit number ................................................L,. 333AE39TAJB3 E, House number ........ NO3 AG& .............................................. 9. Ar, TOWN OF BARNSTABLE BUILDING INSPECTOR -APPLICATION FOR PERMIT TO ....... .................. 1(i 0 TiPE OF CONSTRUCTION ..... an�z.... 4.................................................................................... ....................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location'......4,- ............... ...... ......................... ................................................... Proposed-Use ...... . ....... ........................................................................................................................................ - > District ........Zoning District ........... ....................................................Fire -I Ji r --,I- ...........; .. " ......................................................... Name of Owner ....i& ....... .... v.Address ....... .64 Name of Builder .... ....... Address ............re_412......................................................... Name of Architect .................................................................. ... ....................Address ........... Number of Rooms ......... ......................................................Foundation ....... de........................ Exierior ...................Roofing ........e-6 ..................................................... X Floors .....(4r .ao.A......X.1.11.!.A.,`.:U......................................Interior ........................................ j Heating . .. H , ...... ....................................Plumbing ... .......... ........... . ... ... . .............. Fireplace ...... ...........:9;��..... ........................Approximate Cost ................... ................................. Definitive Plan Approved by Planning Board --------------------------------19--------- Area ....... (7,- Diagram of Lot and Building with Dimensions Fee ............. ........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH r tr INJ LA OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ........... ........................... Construction Supervisor's License BAYSIDE BUILDING CO. A-24 No .................099 permit for ,. One Story ................. Single f g amily Dwelling ............................................................rve...... e Location ,.Lot 4A, 5...Peacock. . . .. ............. e ......... .... . . ...... ....... West Hyannisport ........... ............ ............................. Owner .......Bayside Buildin Co. .......................................................... Type of Construction .....Frame ............................. ............................................................................... Plot ............................ Lot ................................ Permit Granted ...........June 26, 19 85 ................. Date of Inspection ....................................19 Date Completed 19 Assessor's map and lot number .. &...o?.6-1.......� ���,re�e day 11' o FINE v �. v � o�y Sewage Permit number ..........��...... .................. !, SEPTIC SYSTEM !MUST INSTALLED IN COS F •`F ?. rI $ARNSTADLE. House number. .... . ... . ............................ .........• 4/— _ s !`!�° TITLE � 9°0,�•o639•a�a� ENVIRONMENTAL C() YPY _ TOWN. OF BAR.NSTABLE,4 /. BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..t�Q?2 5..1.!� G ........I. A..... ..............KX�. .. . ................ TYPE OF CONSTRUCTION ..... em ..... ................................................................................... t 4 L......... ....................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: vuLocation .... .�./�...........J...i°CCL( UGC..... 2/. .............. .... ............................:..................... ProposedUse ...... .�t° °i12:L. ........................................................................................................................................ Zoning District .........X...:.G?....................................................Fire District ......../J� . .................................................. Name of Owner .....I.!4: ...... 1....�y........... LAddress .......... ............................................................ Name of Builder ....3. . t� .Lille.......................................Address ............I ........................... Name of Architect ...5.....n.......�c`9�`�..(f...................Address Number of,Rooms ............. ......................................Foundation ...... lf.'��1J2>° ..... Gf!1 vl.`�........................ t Exterior .1. ?.� ,.... ... `.l .;}: .............Roofing ........� �l�C T Uu .. ........ Floors CG?.>..0 :... .....�.I. ..... . :.�...............................Interior ........ -l........................................ fl l/ Heating Plumbin..... C� ...........;. ..%� / I O r,_, .............y..... Approximate Cost ...........1t.Fireplace .... (.C.K ....... .... llP!�!.C./ ................................. .. .. qq 2VDefinitive Plan Approved by Planning Board _________________�_____________19________. Area .......I..�............�.......... Diagram of Lot and Building with Dimensions Fee F .... ... ... SUBJECT TO APPROVAL OF BOARD OF HEALTH D OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..�r..:'�`.�............a... ....................... Construction Supervisor's License ....... ............... .. BPIYSIDE BUILDING CO. No 2.8.0.99 ... Permit for ...One...Story............. Single Family Dwelling.................. ........................................................... Location .......L.o.t...4.A.......5...Peacock...Lane ........ ...... . . ... . ...... .......................West Hy( ispq.T.t.................... .............. .... Owner Bayside B ..Co................. ......... Type of Construction ......F.r.ame......................... .................................................. ............................. Plot ............................ Lot ................................ Permit Granted ........June...26, 19 85 Date of Inspection .... . ..........71 ....19Y Date CoMpleted ........ .. .........................19 R � r f a t bra- it y MAa lk -!Fr`7 ��f v try _ k � E, � �` j .� Q, ¢t •t ;- IV t ' { z f>x 4r3.q 3gv `Y h 14 13 N a Q -v7 y `' Af CERTIFIED PLOT PLAN I ' f fit >i_ S 555 SKr � `i tie 'Plo: 10367 IN F. ���` ��/'fit r ,,' r z : .•3� ' •s .� ��e�'j�' -�= `ti3�� , � �� � � A acALEl DATE1 �f �/8S" Now 1' CERTIFY THAT THE t�I��IST.E1tR:D ; �498 SHOWN ON THIS PLAN 13 LOaAT4W 1 . �Q ON THE GROUND AS INDICATED AIIW + Lk` 4 LAND +. r + , } CONFORMS TO THE ZONII LAID � iT EHAINSE , SURVEYOR 4F RNSTAD�.E' M9A88 rl� A x E af�9T t 12' MAIN ::5TRE8T , " x Ci:; Y1 c ti r�h MYAN 1S, MASS x` `� ,,� BEET_. .OFa.... ATE E LAND. MUM' `3 t _ r y1 4 177 �W i a ►_ Now d t"T oor v r_ t a _ , , rrt A - I- ` I I _i I f ± � I ± r � I I 1 1