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HomeMy WebLinkAbout0192 PITCHER'S WAY Pr Town of Barnstable Permit# Regulatory Service._s , E�F teeres 6 monthsJrom issue date ' MAM Richard V.Scali,Director 1639• Building Division AVG 0 040) Paul Roma,Building Com�'�i"111�Mtier.., 9 200 Main Street,Hyannis,MA 0260 � www.town.barnstable.ma.us 14e Du 1VSIA Office: 508-862-4038 ��Eax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address ❑Residential Value of Work Minimum fee of$35.00 for work under$6000. Owner's Name&Address Z-,na jS 7-a)'h burr i AJe) 19,E lei h_A e Contractor's Name Z fl 0-1< i1 A/[.L/I t Telephone Number S'Uf a;t/ 8'S'j-f/ Home Improvement Contractor License#(if applicable) �lo �„��/ Email: A V1-L 1 iv�GL7 F fiVG G�1�4/ .eOry� Construction Supervisor's License#(if applicable) /d yQ 76 MWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ Ijam the Homeowner have Worker's Compensation Insurance Insurance Company Name y f? (C K Workman's Comp.Policy# Q 13-- Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) �e-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: � �, Q:\WPFILES\FORNIMbuilding permit forms\EXPRESS.doc 01/25/17 27w Commarnvealtlt of Ya&usetts DepmahtxErxf af&d,=&-ud Acciderds Office of1m &dgado= 600 Washington.&reef Boston,AIA 02111 mmma-mgravIdia Workers' CGmpensmUon Insurance Affidawt Bufl-dex-dCunfractarsMectn 'ten. fibers Applicant Iuf imam Please Print:E.e� tlY Na=(SasinessKOFxa-Er ionfladividnaY Addre�: °7 G�11:/s[t=_ �1,�le ,At �✓�4 y � fate1 u�4 Pho A,r�ey"an employer?Check.the appropriate ba= ' T of project r L R I am a em 1 uah 4. ❑I am a geaard confMator and I E e ] t ctiom = employees( andfor part-timed* Have Izired the sub-coal 6. ❑Rem delinrnciio4 2.0 I am a sole proprietor orpartaes fisted on- the afita6ed sheet.. y- ❑Remodeling g ship and have ao employees Uwe m b-caaftadors have 9-,❑Demolition. tvaidng fat me in any Capacity. employees andhave wod6ers' 9. ❑B,uildi ag addifim jlrTn 1v-a�ers' imp.ina==e comp_ia,¢�rt.arr�,# - - r q ked] 5_ ❑ �We are a�corpozafi(m and its 1 ❑RI�•�-tG; t repairs or addstiaus 3_❑ I am a bonieoun-er doing al}work officers have exexcrsed their 1 L❑Plumbiagrepaus or additions. my � self o warkers' sight:of emwnpfion per MGL c.I52, 1 aadwehaarena L-❑Roafrepairs incncancereT iimd-]i ( employees [To woA=e . 13-0 Otfier comp.i mmance.required-] • ayapp&c fastcbeds'bas#lmastaisafllo the sec�oabeTaw�atidagz eanrorkexs'compenm&npaHgjriaf3M=5 L ;AS..erswb.submft his at#it#a[u indiraring d ey Rm dm'&U we&sad the bire=tQde C0nt nre=amd so5mit a aeW a'ffida8t indite 5nrli TCagtracints�S[d�erYihfs bet must attached as additional sineet shonzog tbenuae of the sab-c�sr�rs ffid sfsdevrbcther ar not tbase enliti�sha� employees.iftbemb-cantactmShaceemplayea%they I p madetheu wadmw camp.pal un=bez I arrt all emproyer that fsprariaq warkets'campmsafian invirmwefor erry employees Below is 91arpolicy andiab sLfa hiforrnaNgm Bs;a aace Company i"Fame: V 1 L 'Po-1icy�4fl or SelfinS..UC.4�1 �3 7 Job gfe Address /9t� P f ri Cr H G R•V, WAY C yfStdelzsp: C N t'�R✓y /�— Attach a copy of the workers'conrpensation.policy-deciaration page(showing the pofiry,number and expiration date). Failnre to secure coverage as required under Section 25A of MGL c.157—can lead to the imipasition of criminal penalties of a terse up to$UOD Oa andfar one-year in4ximmaeeat,as ur811 as civil peualties.zn the form of a STUP WORK ORDER and a fine of up to$250-00 a day agaiust the violator. Be adcdsed that a copy of this statement.mag be fxwarded to the Office of Isveskigatiow oftiie DIA for ibsurramce-coverage smrifrcation. Ida kereby c-grtifj��Hader tJts prurss and psrsa r e. Fffjury tfi&tTie irrfarsra#ioTs prmzrTed abc�m�s is true rand arrrec t Bate- M 0f 7dd use oat£}. Da Hat write in tI&area,tfr be.cMnP&teJ by city or tairif m-�rcunt . I City or Town,: Persmtf &ease# ha ing Anthor€fy(drde One): L Board of Health 1.Budding Depmtnent 3.Cit flown Clem 4.Electrical Inspector S.Plumbing Emspector 6.Other Contact P'ersow Phone#: - - 6 Taformation aria T1s-r efioUs Mecca a" Gegeml Laws chapter 152 rem all=3P10y=to ire W011M&pe on for their employees. . f PMMUM3ttD this fie,am=-qrIoyew is defined as.¢ p saavice of MDffi M tinder M1y con ttad cfliae, express or jmpHe,(,Dial Dr wtdi= An�zrplvyer is defined as.-an individual,parfneasb�,assDCiSHEM,Crpgrrafton or otii¢legal eaaiiy,Or any two or more of fhe foregoing in a3o� ,and inclndmg the Iegal rej==da&=of a deceased emploper,or hie ret ei4er or trastee Df an ink PMb2E ip,association or other Iega1 entity,employing�plflY�- However the owner of a dweIImghhg not More than tbree aPMiMents andv o residesfhcrein,Drthe occ¢pant ofthe- dwelling hDUse of aanseavm nofher who employs pesems to do mai1M2-m cc,rr,•r,afmcd=or repair uponic on such dweII ng house or on.the gro=09 or bm1ft aPPmtmmAthmeb- shallnotbecause of sach employmedbe deemed to be an employer" MGL chapter 152,§25C(6)also states that-every state or local sew agency shall Wifhhold fhe issaance or renew-21 of a license or permit to operate m b�ess or to construct buildings is tEieonun coreweaith for nap $PPlicanf Who has aotprad-aced acceptable evidence,of campL-mae,with the insurance coverage regair•ed-" hall Ad�fionalb,MGL chaptra I52,§25C(7)sfa�s'N fherfhee c�wealthnor�Y ofitspolitical snbctivisions s.- FM into any contract for the perEmmanco ofpmblio wmk mmT acceptable e4idmc:e of=pliancevibh&e insor3.r,6.. r enfs ofthis ehaptPabaveliecapreseniedin the coniraciing.aniho3:liy:' AppH-zn- s r Please ffll oizt fine WO)j=,compensation affidavit completely,by c.h egg ffie boxes$at apply to yDar siinaflon and,ff n �Y,�PP1Y svb�onlracfnr(s)name(s), address(es)and phonenmmber(s)along wift their certiFacat s)of m=ance. L=itedLiabLKy Comp nies(LLC)or United Liabili y-Parbw s7�s(l.LP)'wzthno��other fhanthe members or partners,are not mquired,to cony wort s& compensation msaranm If an LLC or LLP does have empIoyees,a.policyiSr . Beadvisedfiaattlus.affida-yitmaybesnbmiib=dtatheDT&-tEa=toflndusfrial A=cieat for conrnmaEm of i mum=C°�� �o be sure to sign and date the a�davi The aft, Tit should beretnmed to ibe cry or town that the application for the permit or license is being repast A not the Department of CQ �+ Monldyou have any gnesdons reg�mg the law or ifyou are required to ob•Eda a wD3i=' compensafionpphcnpimsocaatlu;Deparfineotatthennmberliytrdbelow• Self-enscaedcozapanies shouldMiter their s elf_i soran=license number on fhe apprapziate line. City or Town Of cials . r Please be sate that the affidavit is complete mdprjafed legibly. The Depa:c menthas provided a.space at the bottom of the affidavit for you to fM out in tho event the Office ofjuvcsffgati=has to condactYam regarding the applicant Please:be sure in Ell in tine pemnit/Iicense mnnber which will.be used as a refrrence member. In addition,an aPplicant ,that must sabmit muYtiple perozitlrcemse appI>'catiDns in aay even.year,need only sobmit one affidavit mdirafin-g cozmt p olicv infomation�if necessary)and nndea"Tob 5"ne Q�s"tie applicant should vie-ail 1Dcaticns is (�Y or town)_'A copy of t-he-affidavitthathas been officially star ped ormadcedbytiie city ar townmay beprovided to the . applicant as proofthat a valid affidavit is on file for t�nre'pennits or licenses_ A new affidavitmust be tSIled out earli year."Where a home owns or citizen is obtaining a license or permit not related io any baseness or comet ercial wee Cie.a.dog license or pew to bum leaves etc.)said person.is NOT rmju .to complete tbn affidavit The Office of Invesbgqfi=would131am-to,thank you ia advance for your cooperation and should you have any gncsfiom, please do nothes�to give m a call The Department's address,telephone and:faxn�ber: - Thl-CGIM20n Ith of MLIM&URCM Departnmt cLflndmftiAAccUdnts B zM&oil11 -Ta 4 617-727-49W m t 4.06 cr 1­977-MASSAFE Fax#617 727 7m -�evised4-24-07 gqVVC� Town of Barnstable Regulatory Services 4oF Richard V.Scali,Director Building Division RAIUMABM Paul Roma,Building Commissioner KAM ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-ocMied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner.acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building yermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor,is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fomss\EXPRESS.doc 06/20/16 Town of Barnstable Regulatory Services INAW` Richard V.ScaX Director,. Building Division Paul Roma,Building Commissioner ,a° 200 Main Street,Hyannis,MA.02601 t www.town.barnstable-maxs Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I , as Owner of the subject property hereby authorize to act on my beb4 in all matters relative to work authorized by this building permit application for. (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature:of Applicant Print Name Print Name Date Q:FORMS:OWN MFERMISSIONP00 S MEN w : . ... „+� :q ..q . t a - _ ,.::.> , ,N`-..,.. .: r.,. i n _,!..fl.i, , .::'�. � > #� � .irEi Ott 7: �q .,..L, -it .i�`• -+;,• - ur:�+ .. = . ., Oar r.; bx,. ..,�� � '�. � •--� }.�:,: : ...J-. :, �',. :p Ov �., ..,.. ,... rt.. .. L:. ,..:r.4 �. ... �..::. ' .<,s' U�" .. " .,F. is j+:l::h,'i" I:T. :.y= 1. :,4 m f „ ...t e , t&.x���.-; ..., t.., ? .;C:rG 'rJ,�: +i 8 Me `4 I,n z+s.�„..!"" yr :'.,.. 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"' -. ._,- '�* r -,j eau- i _ :4; .:_fit -� �-'�: srz 3-_ :: 4 =_.; r ..x _ a E= -. ^.a �-a,,i -. sw- _; -" a ''sap H `�'r4r'' '; %" -& r� ry *'?u v. tK s i s � �. k p,. �. t '� C l�J`TRk: f..TIO 1 Ci0! (TRACT � g� _.1 . _ ,. 7I1 ,- S F This Construe#ion Contract (the ontracv. is madeTand entered into as of 6 6`-17'e(Qate)2 b'y:N h& between Laws°Tambur`rino (Name; herd after caned fihe�'�Cus#orr r" and Mark M: ':tUlU11i -'QB- - f Descn Mof"Worlk» ontrae#orshaCldo alI the�nrork �n accordance with ttetermsof this � = Mi(inRoeng'and5id'in Irtchav nests r nci'P al offceat onnemara111/a' W'Yawn `u ham .:,.T. ,� g p p y, o f f .-� ,, = � = MA 02673 (hereafter called theContractor ) � � A_ Propert . ` __` - . M _ °;" � f `° -., G - '?t ' �� -r �^' fit `'' i �' ";_` N k:f�I, z°' rrs' M - a. ,-, -fi e y.. saF .'pa✓' 3 �_� .�s'' a�. 3 T,'x S�',. `f. ,�''# 3 �` , �' �a'' '. 1n consideration of the_mutual pram ses hereafter set>"forth and intendrng4ta be bound hereby, the f k t; .= part es+.hereto agree.as follows .- _ , . :, ., � - Contt-gctor ',Obl,�atr_ ons ACo tractor shall complete the foliowrn Prole t herein des'cnbed;in-' an shall providesuperirision�necessarj+_fa cornmenc�e andf�fnish th 'Pro ectxdit©is1:` n a _ wo'rkmanl ke ma-nner, in accordance with the"all�applicable cotles, laws ordin noes rule �"� ` - I-x regulations and aide+$. G.onZract, as-described w g Y ` .' d Y - 3'i r'- z2 J i Install new vynil soffit Doer all soffits Wrap glum, mover the�rake boards Install new ji Cert-n - -d Main Street vyr>rl'siding overthe existing_siding:on #lie frontvof the=house Remavp� ,- the roofing onjthe shed idTep ac�vut Land+ rk roofin shin les b Certainteed lust l'I _ 3 g g y , copper ridge over the ridgevto�preuermold=a�ndalgae growth."Repair damage to th.e-fascia boar"d and:soffit before ms#aping alumint �n over the ral,, s i r k :, _ t ,f � w - � x � ' _ y � 2 Contract Sum Ir conside atran�af the perfprmanCe by Coritract�ir off�ts duties-and oblagaJons - i r � s}, Y .r,c �. .. F hereunder; ustamer shah ply Zo contractor the sum of $6,805 Pay ent:schedule C)wner sha t pay fhe&contras or a010 of tie c ontrac.-sum_u an=signin.t-►e _ t { .: coritracf, 0°/a upon startin' th'!Wdesc b�ecl work a rd tJ ;e remaining-50% upon completion of the contract:work. x : J, ,. @ - Y F tractp 's esoonsEb�l�ty `GonZrao#or'is an independent contractor for all Work to be 06rfoe dd.hereunder,I e gAailed manner and method ofaing tb W rk,s all'be-;0nder lhe control of the Contractor All"employees-of the CohAradt e brqhg Work bn r-t is:Contr t shall be and remain the Cbh-rbctde­ It pJpyes _ -i a The Cori factor shall supervise Arid direct the Work, :using its best skills. = ,. Confractar;shall:be res onside for, nitiatm , mamtainin and su ervisin all safe E p 9 g p- g ty _ " precautions in conne - with the.Work. - - . ". is .:.: : ^, ... ... - .: ;. . - - - - .: 11 e . .' I rvu..r nca r-cva:ar-ru rvvnrlva. a r ry c yr rWOVIyr aIl-L ran =%4v c al to Nay r,ur arr=�;;rcra r rr€a ar ru-,. . _ governirmental fees, licenses`a - inspections.necessary for;the proper execution.and completion of thie _bolo u h parmitsgand ii erases st�ali be the' ro erty{of the Customer and 4 shall be delivered to Qje Customer::upop request The Cgntractor:shall give all natives and 1 µg comply with all applicable codes, 1aws,..ordJnan'ces, ales, regulatp�s*and orders of arry pblic s authority in connection with the performance pf tiie UV.o. and the Gontractor``s obligations 4 hereunder g: t e � s i,a t Insurance: Ca tractor ackQ_W_edg's���ad agr, es hak£CNstomer rxpwrter shall not be s a :z t obligated„to fcarrry any nsur nce��rr connect�onrw�th�tk f),@ C f�or,�a benefit a�the, t�actpr T a , .w Contre4r'Ttnsurance Contractor_shall,at III tires mamtain andkee yin full force end effect, i tits expense, any and all Insurance couerage�rwh - jspru en ;h ' ' - "ary¢`OfAesirable for--the protection'of the:interests of'Gontrac#or : ontrac#flr shall fur -, h to Customef certificates pf 3 ! 'for the following #ypeS of Insurance - Insurance ,-s. �. yam. 'ta Lam..-erg^'.-� �' .-- ^*' - - '` a Commercial General Liability Insurance; 1 x . . A a b Workers' r�ompensation Insurance to cover full liability under the Workers' F f Cotripnsatiot Laws, �.! � :q �. �� t g ,.:r a _ { All waste assodated wth this protect wilt.be dispose of properiyfi -- , r ,3 _ s.n. u . r_-_ : _ - &s` 1�� s S w 'g"fi # '�g !N UVITNESS ICUHEFtEOF, the p Trues hereto have executed this Contract as of the''" and<year:first ,;�­*,__ -_r r., sue£ x -' .-? +. —�,:} _ + ' ` ,t -s. ,y above written 24 F� }X 3 F�#4 fi }¢ t x•#4>� �- �.h,'€ia':._ ' t .-,�._ - .it ,�s,� fit:` �.,:.i te&� _,I "�. �;w+��a,er �d �'�'y"��r:'��„ j �r^- � t. i *,s # } z'' ',at 'r` ..^ i �' fit. '� x-p£ '$RIV E 5 Customer Con_ tractor Corripany t8�q Y _.. - L }r"z"Q.._ Tx A .. d g By P `1� By - s � �;..';-" .,ex':`��` `P' nu"� ,�„ p,, 3 2'e._ fr`-4 �, .�t� Gr.� ;. �� .-`- T �'# � 'i -#�i+ "•m - ` 1: �4--L�--­,j,�­rz�-,A__Zk,_____Q,A,_--�-i-I,-_�, Print Louis Tamburnno Mark Mullin MulIlnRoofing &Siding;Inc } _ g =. ;- -�� r � �Sf (7� C(�onnernara;lNay,.(:��I�V Ya�mflutt:MA ' �=_� k� F { ,a` £ "�- €.,'`.a f S � '"_",$J- '�' VlJ� {Y1 Ya7=1 flr s £ } 4f t t; } as ��w 4: � e X i ;.Address 192 Pitchers way Hyannis, MA - ._ ..., ._, - r .. .r d: ' £ Date $ 8 17 Date i, 8 17 �' x :� } g Phone4number � ° tLr ns�e Na C=S�#104076�H1C#167281 � � ��,4 x it # a. q'ram r-".` .'v #' �#�,=_' r -4°"- #.. .. -"s.� l'r'a _ -, 'r ivy' 3 E n. -'� ? Y x `� Email address IouisAma a�ao! comma P Email address, mullinroafir all co - . _ - x k i '# a'g'1 tg2": �y "'.,^xw'T''1.,""'' er �' ..F fi} r-r z..-s `J"=3 �-' s - -�4 k �? - F r* a i 7, P_t. `L`e z y,,,. f+t "� '.,.,,v R,,;. g,n '�` -W, a._` bL�_ ,`x�oi x l.� 'f,�.s " a ,., r bbss �.. x 'l „ @k`> }x x §� '£ z�'.,3� -'' .�i z?{, - y'Y-'Y �a ri E- ri,'.: � . =' P --^ 3. wt v-4- F �..,.: _' .. £' -q.0: r '- 1. Vy;,,.'{s ;,_ :. __ ... " M. A .. _ y,8-`„.,m.t—�.a 3 :,`,: rf t. i # j:F i f 1 �x� r.._ k ::r 1 ..`.'i '- _.{;''�.s,�'4r 3-'�, -, —�' a s"##t.'# _ ;�1 I x" a"} �z t yr y 1 j. a C, IF , Ns,. & .. , w wg '4 p.p- ':v ':. -"� .,.? h i ..- -I - sz-. _ _ _ t s "" rm 3 r,, 'I 9 -: , ,t � I - .-. -. - _ _- _ ...E _ . ,.: ! _ - -. .. .. } ' - '. _ - - _... . .... .. _ :: _ r . - M' { .r . a- a£' . 'j _. '..: .. .. .-' I. .'. s3 - '5 ..-. 1. 1. - -F NOTICE OF ASSIGNMENT EMPLOYER: COMBO I.D. STATUS OF EMPLOYER MULLIN ROOFING AND SIDING INC 000422586 Corporation 7 CONNEMARA WAY WEST YARMOUTH, MA 0.2673 COVERAGE GROUP 0422607 Coverage under this assignment The Waiver of Our Right to applies to Massachusetts Recover from Others Endorsement operations only. For coverage is available on Pool policies.• outside of Massachusetts, contact Contact your agent for details. the appropriate Pool or Plan for that state. INSURANCE COMPANY: AGENT MARGARET J GRASSI INS AGENCY AMERICAN ZURICH INSURANCE COMPANY OR DEBRA MARTIN Jonathan Scharnberg PRODUCER: 1188 MAIN ST P 0 BOX 3556 W WAREHAM, MA 02576 ORLANDO, FL 32802-3556 (800) 453-9843 AGENCY FEIN:. 461155686 CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED CODE TOTAL ANNUAL PREMIUM REMUNERATION -------------------------------------------- ----- -------------- ---------- ---------- CARPENTRY-DWELLINGS - THREE STORIES OR LESS 5651 $22,387 8.11 $1,816 ROOFING NOC &-YARD EMP, DRIVERS 5545 $1,130 37.05 $419 CARPENTRY NOC 5403 $0 11.00 $0 CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $0 8.11 $0 EMPLOYERS LIABILITY 100/100/500, 9845 MOD FACTOR 9898 .89 $-246 .STANDARD PREMIUM $1,989 ALL RISK ADJUSTMENT PROGRAM 0277 1.00 EXPENSE CONSTANT 0900 $338 TERRORISM CHARGE 9740 $7 TOTAL POLICY MINIMUM PREMIUM $500 TOTAL ESTIMATED PREMIUM $2,334 DIA ASSESS. 5.6% $111 TOTAL EST. PREMIUM PLUS ASSESSMENT $2,445 INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $2,445 THIS IS NOT A BILL COMMENTS Coverage effective 12:01 AM on 02/25/17. Subject to 11/18. Anniversary Rate Date. Add endorsement WC 00 03 08 to this policy. An approved Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors - was submitted with this application. DATE OF NOTICE: 02/28/17 PREPARED BY: Joanne Shea The Workers'Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street- Boston, MA 02110 (617)439-9030 • FAX(617)439-6055 •www.wcribma.org NOTICE OF ASSIGNMENT EXT 530 * * VOLUNTARY DIRECT ASSIGNMENT LETTER ID: 4765075 n The Workers'Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street• Boston, MA 02110 (617)439-9030 • FAX(617)439-6055 -www.wcribma.org q � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map— d� Parcel cJ� Application # - S pp Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Feed z Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address /, 0? I�j�TI` b-.:r Village _2&ZAZ.A4 : Owner a&uz 4�4g_ fi AZy Address Telephone S-;0 f;'/4 YLz Permit Request J,A1 �—; 4,/1 /.3 11Y 3leo< 1,34.5'C/fv,� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation d ®,� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes )d No On Old King's Highway: ❑Yes XNo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: BUILDING G u E _' . Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ DEC 02 2016 Commercial ❑Yes ❑ No If yes, site plan review# TOWN OF �3fi�;t�o :': y:•• Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �/�.�� ,�,�i�,�` �� Telephone Number s3�a7 5' / Address < Ca Ai License# /e D 2 Home Improvement Contractor# Email !< ��el c 7"<<3�.�/��� -�� . 6worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO .0 SIGNATURE DATE Z ��//w FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' FOUNDATION FRAME INSULATION FIREPLACE i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL f GAS: ROUGH FINAL c FINAL BUILDING `r DATE CLOSED OUT f ASSOCIATION PLAN NO. 4 Town:of Barnstable e 'Regulatory Services sun kAsid V.SeAbh*etor iB3P A.�O Tom Perry,U*IoiftC:on mn&sioaer 200 Mara Street,Hyannis,MA 02601 wwwIe ialarnsaabie ma us Office: 508-862-4038 Fax: 508-790.-6230 prop e $ �k�+'owner�US CJDmpXete ra I.d'Siga This Section Y.� L�t1 ;S 7'A r► ��('('1 n 0 ,�as bccm�cif.clue sn�iJecrp��rty hembp au�hcrize n S tJ ci T"J acc on in be a f, in au masters relative to wo authaized bythu building pe�iii applica�inn.for {Ad�res`stof�o�}; "Pool fences and i6i= -the esponskilftyof-ffie.apphc=t. Pools . :ire o> to:be.filleck�r ii�ilired�ieforefibz e is-iugtall�d'aLnd a final- inspe-ct ozis are Ver£aimed-and.amcptel 4 `1 S i tlu�of Owner . S%=Urebf Applicant Pxxat dame. Print Narm /l (( P(o Date Q�OR1�4StO1Vl'�.,RPE:t1.S15S101eF.QOT.S � The Commonw ealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www,mass,gov/dia l-Vurkers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers, Applicant Information TO BE FILED WITH THE PERMITTING AUTHORITY, , Please Print Le ibl Name (Business/Organization/Individual): 1/11 Address: , 2 city/state/zip: 5 � 2� � Phone #: Are you an employer? C eck the appropriate box: 1 Type of project(required): I.Z-t am a employer with ,/•.✓ employees(full and/or part-time).' 2.7 1 am a sole proprietor or partnership and have no employees working for me in F . ❑ New construction any capacity,(No workers'comp. insurance required.) , [] Remodeling 3.[]1 am a homeowner doing all work myself. [No workers'comp. insurance required.)t 9. ❑ Demolition 4.[]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole Proprietors with no employees, I I ❑ Electrical repairs or additions 5.Q 1 am a general contractor and l have hired the sub-contractors listed on the attached sheet, 12.[]Plumbing repairs or additions These sub-contractors have employees and have workers'comp, insurance) 13,QRoof repairs 6.®We are a corporation and its officers have exercised their right of exemption per MGL Q. 14, Other 152,§1(4),and we have no employees. (No workers'comp, insurance required.) 1��� —�— Any applicant that checks,box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submiMis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'contpensatt'on insurance for►rry employees, Below is tftepolicy anrljob site Information, Insurance Company Name: fZ. 1 Policy #or Self-ins, Lic. #: Expiration Date: Job Site Address: C �•� - . Attach a copy of the workers' compensation policy eclara ion page(Showingtthe policy cy n ber and expiration Failure to secure coverage as required under MGL c. 152 25A i P on date), and/or one-year imprisonment, as well as civil penalties in the form of STOP 1WO1RK ORDER and punishable yaafine of up Coto 1$250.00 day against the violator. A copy of,this statement may be forwarded to the Office of Investigations of the DIA for insurance a coverage verification. I rlo hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: i ' Phone#: 677 Official use only, Da'hot 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 Lco'lltactperson:_ ther Phone#; CAPECOD-27 DEATON TE(MMIDDYYY) CERTIFICATE OF LIABILITY INSURANCE . 712920/2016 /216 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. s IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Ileu of such endorsement(s). PRODUCER CONTACT Rogers&Gray Insurance Agency,Inc. PHONE Fax 43 Rte 134 c o E t• vc No),(877)816-2166 South Dennis,MA 02660 n DRless:mall@rogersgray.com INSURERS AFFORDING COVERAGE NAIC q INSURER A:Peerless Insurance Company INSURED INSURER B:SafetyInsurance Company 39454 Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 4171:8 18 Reardon Circle INSURER D:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBRI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY) (MM/DDIYYYYJ LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 RENTED CLAIMS-MADE OCCUR CBP8263063 0410112016 0410112017 PREMISDAMA3EES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY R0 F71LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B ANY AUTO 6232707 COM 01 04/01/2016 04/0112017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 C EXCESS LIAB CLAIMS-MADE EXCI0006635001 04/01/2016 04/01/2017 AGGREGATE $ DED I X I RETENTION$ 10,000 Aggregate $ 2,000,000 WORKERS COMPENSATION --7_PE_R_--7 I OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER D ANY PROPRIETOR/PARTNER/EXECUTIVE WCE00431902 06/30/2016 06/30/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED' El N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CLEAResult,Eversource and National Grid are listed as Additional Insureds on this policy on a primary,non-contributory basis. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED-RE—PRIESSEENTATIVE ©1988-2014 ACORD CORPORATION. All rinhtc rpcarVAd. Massachusetts Oepartment of Public Safety Board of Building Regulations and Standards License: CS•100988 Construction Supervisor. HENRY E CASSIDY� 8 SHED ROW WEST YARMOUrH �S) ;4 5 5 )I'151 5' , C ^^� Expiration; oMmissloner 11I1112017 t/ � a Office of Consumer Affairs and Business Regulation a 10 Park Plaza = Suite 5170 Boston, Mausetts 02116 Home Improve ment-VKolltractor Registration Type: Corporation -- " ' Registration: 153567 Cape Cod Insulation, Inc n; � = Expiration: 12/14/2018 18 Reardon Circle So. Yarmouth, MA 02664 ° v Update Address and return card. Mark reason for change. 'CA 1 0 20M-05/11 ---------------- -------------------------_-._----- edrl�no 11 l��. .,�. n G,,,nln. an I .r` &e Ip.rnuaeaCC1 olb ffaaaaclaaeen 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: _t '` Office of Consumer Affairs and Business Regulation µ Reeglstration Expiration 12/14/2018 10 Park Plaza-Suite 5170 ?/ Boston,MA 02116 Cape Cod Insulation J1cl Henry Cassidy 18 Reardon -- So.Yarmouth,mA — Undersecretary Not valid without signature .r ' ' TOWN OF BARNSTABLE,BUILDING PERMIT APPLICATION Map Q� Parcel Permit# � 6 � C Health Division Date Issued -- Conservation Division °- • _ Fee" c�—� •"®® Tax Collector Treasurer 61 2 q Planning Dept. Date Definitive Plan Approved by Planning Board ; Historic-OKH s Preservation/Hyannis , Project Street Address ~ Village A1 f S Ownerv� '7�'�.,�, �.�R6�csr Address 1 Telephone ;2 �2 ,2 Permit Request ,_/ ►° -� �, 4 _ Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost ,!�20®> Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach'supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ ' Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:.existing new Number of Bedrooms: existing ' new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other i Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes` ❑ No P Detached garage:❑existing ❑new size Pool:Q.existing ❑new size Barn:❑existing ,c❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals-Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use r BUILDER INFORMATION Name </= V7 ° tv y - Telephone Number '7 7 Address �2 Sr ij License# 0 Lt k/A jN Ai fg ate) r+s< Home Improvement Contractor# /b 3 q a Worker's Compensation# {✓ / ® G ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURES v`.��-�.� DATE _l _ FOR OFFICIAL USE ONLY - `PERMIT NO. � '.r .. •_< • 'DATE ISSUED _ MAP/PARCEL NO. ADDRESS ~ TgVILLAGE r t OWNER DATE OF INSPECTIOI I fI . FOUNDATION ;4 a FRAME INSULATION t FIREPLACE 1 ELECTRICAL: ROUGH FINAL ` PLUMBING: ROUGH FINAL a E: GAS: — ROUGH' FINAL f FINAL BUILDING - - r DATE CLOSED OUT. ti ` ASSOCIATION•PLAN NO. R The Town of Barnstable B&RTMAMZ t Department of Health Safety and Environmental Services - �c rug' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: Estimated Cost Address of Work: Owner's Name: It. :7�` Date of Application: / 0 �a 5/9 9 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law OJob Under S 1,000 Building not owner-occupied E30wner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby appA for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Name q:fbr ms:Affidav The Commonwealth of Massachusetts -_ �. Department of Industrial Accidents - � � Office ollntrestigatio11s 600 Washington Street �? Boston Mass. 02111 Workers' Com ensation Insurance Affidavit name: ✓yt-off, /&,4A 1 location: °� P�?� A o�,e Lt//� l/ city e.4/y^c/_.c. phone# R -J ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one workin in anv capacity ❑ I am an employer providing workers* compensation for my employees working on this job. compnnv name a address: �i : ... city: /lam phone#- 2 7 /, insurance co. policv# f ✓d p — r' ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have , the follo«ing workers' compensation polices: compan.v name.• address: city: phone#: insurnnce co. olicv# company name, address: city- phone#, insurance co. olicv# _.. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to$1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of 3I00.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature Date _ Print name Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department + (:)Licensing Board ❑check if immediate response is required (:]Selectmen's Office ❑Health Department contact person: phone#; ❑Other X.•:•. :.. ..,. (revaen W 95 PJA) r Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any cc=--c, 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, c: 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 section 25 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 as not produced acceptable evidence of compliance with the insurance coverage required. Additionally, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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 cons=you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 lovesugatlons 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 C X"+...: �•[ $N 1