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HomeMy WebLinkAbout0041 PONTIAC STREET �7 120?1�/�Ci S� Town of Barnstable r wilding Department Services Brian Floren"c6,` O�a � ` Building Co mm inner 163 16 200 Main Street, www.town.barnstable.ma:us Office: 508-862-4038 0" Fax: 508-790-6230 COMPLAINT/INC L-Y �EPORT cll� Dater - Rec'd by:- Y Complaint Name: M'i CK-0-1 i C< < C7 Map/Parcel Location ` 7 Address Originator Name:22,�` Streets-4b woe c��i.,r r G\J—Q_ Village ` 1 State: Telephone: 1-1 to 0 C) Q Complaint Description: FOR OFFICE USE ONLY Inspector's Action/Comments Date: Inspector: Additional Into.Attached Q:forms:complaint Revised:08/16/11 I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Mar Parcel Application 70(-((4 k Health Division Date Issued 6 Conservation Division Application_ Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Pr�Street Addrtesss / 0/V 7 v 5�b�7 Village Amlyl. /LM N0 Owne 5 ~�� Address 3'IA IVI//V 3/ �Telephone� 5-06 7 -oR Al c_-P_er_mit=Request=:�. t eC% S ,� �i ��° /C'/" Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay i-,Projeet Valuation=�O,0 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 Central Air: ❑Yes ❑ No <. Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No --Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ Q% ing ❑ raw Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: . Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ° -v Commercial ❑Yes ❑ No If yes, site plan review# ,. Current Use Proposed Use , , APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Nam' me=/�ltC(�IIG� dU► 1�� Telephone Numberx Address=__344;5-- RAW S j License# Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING OM THIS PROJECT WILL BE TAKEN TO SIGNATU�` �V �� DATED ' FOR OFFICIAL USE ONLY . APPLICATION# DATE ISSUED MAP/PARCELNO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME ` INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ^y ` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT A 1' `= ASSOCIATION PLAN NO. i i � 1 i 1 i Qj i 000 , 1 i , 1 ' t , • I t i 1 1 • I , I j 1 7 , i ' I i 1 f f N _ J 4 1~ • F ^� e i� t •i f t � ,S �_ __... - .. _ .. .. _. s. - .�i�� �: +t hb { d - --- —�_� f '-? F ��`; �'{4 1.,.:ip .X` e n The commonwealth of.1 ,assachusetts Department of f7tdustrial Accidents _ Off rce of..Investigations' 600 Washington Street Boston, MA 02111 wwlt�.mass.gov/dia Workers' Compensation_fnsurance Affidavit: Builders/Contractors/Ele&tricians/Plumberg Please print Leffibly AppLicant Wormation j CName:(BBus-mess/Organization/Individual): Address: City%State/Zi ��5 �� � 776 V4f phone.#: Are you an employer? Check the appropriate box: Type of proitct(required): 4. [� 1 am a general contractor and 1 6 El New construction 1.El I am a employer with have hired the slab-contractors employees (frill and/or part.timc).* listed on the'attached sheet. 7.• E]Reinodeling 2.[� I am a 3oleproprietor or'partt]er-' These sub-contractors have S. 'Q Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑$wilding addition comp. insurance. [No workers'•comp. insurance 10.Ej Electrical repairs or additic required.] 5, ❑ We are a corporation and its �3' ham a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additic myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs c, 152, §1(4), and we have no insurance required.] t Other _ employees. [No workers' comp,insurance required].- "Any applicant,that checks box#1 must also fill out the section below show rs ing their worke 'eotrrpcnsation 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, tContractors that ebeck this box must attached an additional sheet showing the name of the sub contractors and state whether of not those entities have employees. If the subcontractors have employees,they must prvvidt their workers'comp,policy number. X am an employer drat is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: . • Policy#or Self-ins.Lic.#: ' Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers.' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criiniji4l penalties of a fine up to$1,SOO,DO and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fu of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the'Office of Investi atioas ofthe DIA for insurance coverage verification. I do hereby certi u er the ains•a enalde of perjury fh forrnatian pro,vtded above is true and correct �._� — �Si Phone #: Official use only. Do not write in this area, to be compleled by city ar town offtciaL City or Town: PerrrWLicense # Issuing Authority (circle one): n _a �xro�irl 2 Rr,;IriinaDeoartment 3. City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector Information and Instructi®ns Massachusetts General Laws chapter 152 requires all employers to.Pro�eidecworkers' of anoth P undero any contracri'for their. t o Drees. Pursuant to this statute, an employee is defined as ...every person express or implied, oral or written." or any o or An emplayer is defined as "an individual,partnership, association, al rP°Letient tivcon or shofer a deceas degal �employer, or core of the foregoing engaged in a joint enterprise,and including the legal P ees. However the receiver or trustee of an individual,partnership, association or other legal entity, employing employ re than three apartments and who resides therein, or the occupant of the owner of a dwelling house having not mo dwelling house of another who employs persons to do maL°tecausce Hof such rraolo}znent be deemn or repair work oed to be anemployer$e of on the grounds or building appurtenant thereto shall not b P 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 corrtmonrtyealte for any applicant who has not produced•aeceptable evidence of compliance ronwealth nor any of its political gubdivt required." shall . AdditionaIly,MGL chapter 152, §25C(7) states `Neither the enter into any contract for.the perforrzaancc of public work until acceptable evidence of compliance)6th the insurance ontracting authority. requirements of this chapter have been presented to the c Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)namc(s),-address(es)and.phone numbers) along with their certificates)of mited Liability Partnerships(LLP)with no'employees other than.the insurance. Limited Liability Companies (T LC) or Li members or partners, axe not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required Bq 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 d,not the lication for the permit or license is being requ be returned to the city or town that the app to obtain ewoarkers+t of rm Industrial Accidents, Should you have any questions regarding the law or if You are required lease call the Department at the number listed below. Self insured companies should enter their compensation policy,p self-insurance license numb on the appropriate line. City or Town Officials Please be sure that the affidavit is completc'aad printed legibly. The Depertm.ent 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(licensc number which will be used as a reference number. In addition, an applicant that must submit multiple perrnioiceasc applications in any given year, need only submit one affidavit indicating culr in (City eor policy information(if necessary)and under"Job Site Address the applicant should write"all loca be srovided to the town);".A copy of the affidavit.that has been officially stamped or marked by the city or town may p 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 horge owner or pitizen is obtaining a license or permit not related fo any business commercial venture (i.e. a dog license or permit to btim leaves etc.)said person is NOT required to complete this affidavit.' avit 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, telephonc•and fax number: Tba Commonwealth of MaSSachusettS Depazfme:nt Of ladustr Al Accidents Office of Zz���Siigafozxs 600 WasHagton Stxcet Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Town of Ba7rnstable �z r � o Regulatory Services= Thomas F. Geiler,Director 4 sr�ar..e >3nrtN q� KAS& Building Division 019.°Teo Mat a Tom Perry,Buifding Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Fax:_ 508-790-6230 Office: 508-862-4038 HOMEOWNER LICENSE EXEMPTION Please Print D TE:Z—, �[:w f10_B L:OCAT10:=- / S� street village number 7 7/ 2 "HOMEOWNER', �' ""' home phone# work phone M �I name `/ CURRENT MAILING-ADD-RESS; © t�b 1` AJ JS 0� state zip code city/town - of six un or less and The current exemption for"homeowners"was extended to include owner-occupied dwellinded that the towner acts as to allow homeowners to engage an individual for hire who does not possess a license, rov supervisor. DEFINITION OF HOMEOWNER Persons)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 pe rmed under the building permit, (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Codo and other applicable codes,byla`vsi rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department. minimum inspection rocedures. requirements and that he/she will comply with said procedures and Signatur of omeow er•� eppcoval of Building Official Note: Three-fanuly 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 pervisors);provided that if the homeowner engages a persons)for hire to do such of this section(Section 109.1.1-Licensing of construction Su work,that such Homeowner shall act as supervisor." aware that they are assuming the responsibilities of a supervisor(see Appendix Q, Many homeowners who use this exemption are un Rules&Regulations for Licensing Construction Supervisors,Section 2.15) "Phis lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor, The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor, On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a forrn/ccrtification for use in your community. YHA, Town of Barnstable Regulatory Services k 1ARNErrABLL, Thomas F. Geller, Director HAM Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis, NfA 02601 www.town.barnstable.ma.us Office: S08-862-4038 Fax: 508-79( Property Owner Must Complete and Sign This Section If Using A Builder X , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of job) Signature of Owner Date Print Name zf Property Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division Date Issued Conservation Division Application Fol Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Addresses Village Owner J,-JV,4&" a Address .� Telephone SD ' 7,02— Permit Request /d '' ,1�9T�� ,2,?_S`a1�K5 L' G�-�f��,��r� 1� �, � 1 Z�2Ge 7"e4W �-J�.-0 -104 X-4&X �����i��� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation A az7i yConstruction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family El" Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes Ell'IVo On Old King's Highway: ❑Yes im-1-No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq#' Number of Baths: Full: existing new Half: existing =1: new --, Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count_=� - t 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: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # ---Current Use - Proposed Use = r APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �/_ Telephone Number Address f,�i— K4,&,0 4 a;�t W J License # D d �ff ,L�4 4/4.— Home Improvement Contractor# , 45:�l 7 Worker's Compensation #Aladp.,-,a ��f ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I ' FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. rs ADDRESS VILLAGE , 4 OWNER j DATE OF INSPECTION: FOUNDATION FRAME i INSULATION FIREPLACE i ELECTRICAL: ROUGH FINAL .� PLUMBING: ROUGH FINAL It GAS: ROUGH FINAL 7 j FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ; r 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration :. ., Registration: 153567 r _ Type: Private Corporation - Expiration: 1 211 5/20 1 2 Tr# 206433 CAPE COD INSULATION, INC HENRY CASSIDY 455 YARMOUTH RD. HYANNIS, MA 02601 +_ ';` - — i w tJ date Address and return card.Mark reason for change. r `L] Address Renewal Employment Lost Card DPS-CA1 Co 50M-04/04-G101216 Oft-ice o mer Affairs Bus nc lie�u�htion License or registration alid for individu! use en-!;; HOM &W�"IJ`�'� TRAc9Z "'uQel�a before the expiration date. If found return to: Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 OD INSULATION` Nc HENRY CASSIDY,ti__ ' t it 455 YARMOUTH RID HYANNIS,MA 02601c i J Undersecretary t alid ith t si tune ' MAxktchusetts-department of Public Safet% Board of Building Regulations and Standard:s�- ®; Qonstruction Supervisor License License: CS' 100988 �A. p HENRY CASSIDY 4? 8 SHED ROW Y" WET' ARMOUTH MA 02673 `.« Expiration: 11/11/2013 ('umm i.. i„ner Tr#: 7620 , r r The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations ° 600 Washington Street FW Boston, MA 02111 7c� g����0�a www.mass.gov/dia Worker's compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ca io e C el C Address: City/State/Zip: 6wo (e- 1141A aa 6o/ Phone#: i0 Z/Z6 Are you an employer?Check the appropriate box: . Type of project(required): 1. L8l I am a employer with 4•❑ 1 am a general contractor and I have 6. ❑ New construction employees(full and/or part-time).' hired the sub-contractors listed on 7. ❑ Remodeling the attached sheet.$ 2. 8. 0 Demolition I am a sole proprietor or partnership These sub contractors have P P P P and have no employees working for employees and have workers'comp. 9. ❑ Building addition me in any capacity. [No workers' insurance.$ 10. ❑ Electrical repairs or additions comp insurance required.] 5.❑ We are a corporation and its officers have exercised their tight of 11. ❑ Plumbing repairs or additions o g 3• ❑ I am a homeowner doing all work exemption per MGL c. 152§(4),and 12. Roof repairs myself. [No workers' comp, we have no employees. [No workers' 13. Other insurance required.] t comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box musi attach 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: A t I a6 v M�4C f C-0, Policy#or Self-ins.Lic.#: �iC . Expiration Date: Zn b'17n Job Site Address: • City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.Be advised that a copy of this statement ma e forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here c under the nains and penalties of perjury that the information provided above7/7- true and correct. Signature: Dater 2 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 S.Plumbing Inspector 6.Other ' Contact Person: Phone#: Date: 4/19/2012 Time: 10:13 AM To: Cape Cod Insulation, Inc @ 1508-778-5735 Rogers & Gray Ins. Page: 002 Client#:4597 CCINSUL` ACORD,M CERTIFICATE OF LIABILITY INSURANCE D4E(MMiD 2YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER .L UNTCT Margaret Young - Rogers 8 Gray Ins.-So.Dennis PHONE 508-760-4602 F 434 Route 134 5Q8-258-2102 AIc No Ext: ac,No •MAIL r0 erS ra ADDRESS:DU YOUn 9ma @ 9 g Y•com. P.O.BOX 1601 PR ER , South Dennis,MA 02660-1601 CUSTOMER ID INSURER(S)AFFORDING COVERAGE NAIC#. INSURED INSURER A:Peerless Insurance 18333 455 YarmoutthhRoad Cape Cod Insulation odInc INSURER e:Ohio Casualty Insurance Company INSURER C.Atlantic Charter Insurance Hyannis,MA 02601 INSURER D:Commerce Insurance Company 34754 f INSURER.E: , INSURERF: 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. IN SR DDL UBR POLICY EFF POLICY EXP TYPE OF INSURANCEIN SR D POLICY NUMBER MMIDDIYYYY POLICY YYYY LIMITS - A GENERAL LIABILITY CBP8263063 . /01/2011 04101/2012 EACH OCCURRENCE $1 OQO QOO X COMMERCIAL GENERAL LIABILITY - r DAMAGE TO RENTED PREMISES Ea occurrence $100 000 CLAIMS-MADE r X]OCCUR r - MED EXP(Any one person) $5,000 _ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 - GEN'LAGGREGATELIMITAPPLIESPER: - 'PRODUCTS-COMPIOPAGG $2,000,000 POLICY PRO- LOC .-. $ p AUTOMOBILE LIABILITY 11MMBCKVMK 4/01I2011 04/01/201 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ALL OWNED AUTOS ANY AUTO - BODILY INJURY(Per person) $ X SCHEDULED AUTOS- BODILY INJURY(Per accident) $ ' - � � - _ PROPERTY DAMAGE X HIRED AUTOS • (Per accident) $ X NON-OWNED AUTOS ' - - $ $ B UMBRELLA LIAB X OCCUR 0001254514645 /01/2011 04/01/2012 EACH OCCURRENCE $1 OOO 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1000,000 ' DEDUCTIBLE '�' •- - • $ X RETENTION 10000 $ - C WORKERS COMPENSATION WCA00525902 6/301201.1 06130/2012 X WCSTATu- 0TH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVEa NIA E.L.EACH ACCIDENT $500 OOO OFFICERIMEMBER EXCLUDED? (Mandatary In 11 yes,describe a under - E.L.DISEASE-EA EMPLOYEE $500,000 under � - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks Schedule,it more space is required) - Workers Comp Information Included Officers or Proprietors 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 REPRESENTATIVE r G1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 . The ACORD name and logo are registered marks of ACORD #580552/M68179 MEE yr i R OWNER AUTHORIZATION FORM R (Owner's Name) s owner of the property located at `7 l i0G (Property Address) (Property Address) P hereby authorize C10 EV, U (Subcontr ctor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. i J- wneiKs Signature - Date—� F EC[E99 VIE DMAY . 1xOi2, ' M AY`. 31 2012 " TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION_ Map le I Parcel o =_ `Application 63 �5 Health`Division Date Issued Conservation Division .Application Fee Planning Dept: Permit Fee 0'S' Y Date Definitive:Plan Approved by Planning Board �--- Historic - OKH Preservation / Hyannis Project Street Address I PCN rogC, 5_rX96_r Village NYC+INN Is, Owner Address 4/r?1��� Telephone 50? 776 {c'�l L Permit Request 00 N Va7itj -6FDRCOA _T27 D h6DAwkf RE-PAMUN6 VAN !w, Square feet: 1st floor: existing ) proposed 2nd floor: existing proposed-56 � Total new Zoning District, Flood Plain Groundwater,Overlay #roject Valuatio Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family -A Two Family ❑ Multi-Family (# units) Age of Existing Structure I-I ® Historic House:. ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: YFull 'Crawl ❑Walkout ❑ Other P/7 FL7t L , 1 � cl?lwi, Basement Finished Area (sq.ft.) NON C Basement Unfinished Area (sq.ft) Number of Baths: Full: existing:- o9' new Half: existing new Number of Bedrooms: existing Z new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: WGas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes No Fireplaces: Existing l New Existing wood/coal stove: ❑Yes ❑ No `vetached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ rj�ttached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other ,V-• 1 C) y:a C) Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Ln - - - Current Use Proposed Use W k� e APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name SAPY7 ��—�7U / US� Telephone Number �`""' Address Yf -P®NTI�e, 5r License# �}7tiN/U (S , $4 M LPR60 f Home Improvement Contractor# Worker's Compensation # rn,, ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �� Il�ll'f SIGNATUR e DATE W y / FOR OFFICIAL USE ONLY r APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE 3 f OWNER } DATE OF INSPECTION: - -- FOUNDATION FRAME S INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. x s. -x t The Commonwealth ofAfassachusetts Department.of industrial Accidents Office of investigations' 600 Washington Street Boston, MA 02111 www.mass.gov%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/P11imberg Applicant Information f Please Print Legibly Name(Business/Organization/Individual): Address:__ City/State/Zip: I t��IVIV i5 M It Dry�0 I phone.#: S08 ?�� '2/411 ` Are you an employer? Check the appropriate box: Type of project(required): 4. 0 1 am a general contractor and I 1.❑ I am a employer with 6. ❑New construction employees (full and/or part.tim.e).* have hired the shb-contractors 2.0 I am a soleproprietor or'parttier=' listed on the'attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. '0 Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers'-comp.-insurance comp. insurance.t 5. 10.❑Electrical repairs or additions required.] 0 We are a corporation and it s 3 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions ` myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no 13.0 Other employees. [No workers' comp.insurance required] . *Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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. lam 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.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'.compensation policy declaration page (showing the policy number and expiration date). Failure io secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimiri4l penalties of a fine tip 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 maybe forwarded to the'Office of Investigations of the DIA for insurance coverage verification. 1d6 hereby certify unr�er t e pains are enalties of perjury that the information provided above is trueand correct. // J Date: 7/ �' Si ature: — Phone#:' 7 7C - 2-1 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 S.Plumbing Inspector 6. Other Cnnf'art Percnn- Phone#: Information and. Instr'uctIons 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 tivstee 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 stage 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." Addition ty,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'szth 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-contzactor(s)name(s), addresses)and.phone numbers) 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' insured companies should enter their compensation policy,please call the Department at the number listed below. Self self-insurance license number on the appropriate line. City or Town Officials .Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town).".A copy of the affidavit.that has been officially stamped or marked by the city or town 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 eitizen is obtaining a license or permit not related io any business or commercial venture (i.e. a dog license or permit to bum Ieaves 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: Tho Commonwealth of Massachusetts Depaztm.ent of Industrial Accidents Office of Tuvestigadans. 600 Washington Street Boston, MA 02111 Tel. #617--727-49-00 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia Town of Barnstable o�IKE rod o Regulatory Services • Thomas F. Geiler,Director, snxrts�rAar.s, 'x"9'9. Building Division ATfo �a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862=4038 Fax: 508-790-6230 3j HOMEOWNER LICENSE EXEMPTION Please Print -'DATE; JOB LOCATION: number / street village J "HOMEOWNER": name home phone# work phone# AILING.ADD DRESS: C3 `l3o�c CURRENT MAILING city/town state zip code i The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and 'iN 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 Y person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department <'; minimum inspection procedures and requirements and that he/she will comply with said procedures and re uire n tt ss Signah of Homo er 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 of this issue is a form currently used by several towns. You may care t amend and adopt such a fom-Jcertifrcation for use in your community. QAWPFILES\FORMS\homeexempt.DOC 0 BIKE rC�'L Town of Barnstable Regulatory Services M 1ARN8'rAUL6. Thomas F. Geiler,Director MA 89. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder L , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signature of Owner Date Print Name If Property Owner is applying .for permit please complete the . Homeowners License Exemption Form on the reverse side. 0:FORMS:O WNERPERMIS SION ----- -. - i _ Nr 4- QCX V _ � t . I F - 1001. l i � • r '�t i i I l v tle ` U CAPE COD N S U L AT 10 N 7ii1? SE. 12 ` I18BR OLA55 SEAMLESS -SPRAT FOAM MPENOEO BAT .GYTTEPS INSULATION CEILINGS 1-800-696-6611 DA = Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 . Date: t1Nl a- - Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector.All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address , Village �V1eG�el 1YIG/1 Cc�v�� Nuo)el) Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings Slopes Floors Co-atvLL 3ce,GP-, ( ) ( )" (ZO ) Walls ( ) ( ) ( ) ( ) ( ) ,41 v' f Sincerely He y E Ca sidy r, President Ca e Cod sulation, Inc.