HomeMy WebLinkAbout0034 POTTER AVENUE 3y Poi�ec Avic
I
Cape Save Inc. TOWN OF BARNSTAB E
7-D Huntington Avenue
South Yarmouth, MA 02664 2 2 DEC 18
Tel: 508-398-0398 Fag: 508-398-0.399
12/10/12
Town of Barnstable
Thomas Perry CBO
Building Commissioner
200 Main St. Hyannis,MA 02601
T
RE: Building Permits
Dear Mr. Perry,
This affidavit is to certify that all work completed for 34 Potter Avenue,Hyannis has been
inspected by a certified Building Performance Institute(BPI)Inspector.
Ceiling: R-38 cellulose in one storey section R30 cellulose in enclosed slopes and upper attic
Walls: R-13 dense pack cellulose
Floor: R-19 Fiberglass blanket
All work performed meets or exceeds Federal and State Requirements.
Sincerely,
William McCluskey
[ J
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
,i
Map Parcel S b Application # o?®��O 7F
Health Division Date Issued I l�-
Conservation Division Application Fee \ �
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/Hyannis
Project Street Address ' Q o+-P.( b-Ye
Village H`I 0.nn is nt
Owner V1G+or �r-uai+;s Address a90 1�411� St-*601i ``� m�atmi �ftGj FL
Telephone 30 5— 9 3 :-- 2•��-I
Permit Request pp� R" 33 c_e�I Llge_ lz4I, "i^coLe
XW1 vGn-FlIeAllon -fie code, u,1 tog Vco.s. NA - 19 -u0:ZPJ,%ss
b gemr,n4 co'I it n g. )We e 4L&k LAr PL W 1$+h ►Z-13 ce( A
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No .
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ^; -i
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.V:7' -J
ca
Number of Baths: Full: existing new Half: existing new t '
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count w
Heat Type and Fuel: ❑ Gas ® Oil ❑ Electric ❑ Other : '
Central Air: ❑Yes ® No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No�
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes 9 No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name W;11'1 M-A
nc. Telephone Number 65(a. -3 4$ - 0318
Address �-�I� f f tu+` 0�on NYp_ License # C
SbIkA 1 PLr(nffjj , �T� �c��l� Home Improvement Contractor#
Worker's Compensation # TWC 3319 0 0 4-
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE t l <
4
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
f
ADDRESS VILLAGE
1h
OWNER -
i .
� k
DATE OF INSPECTION:
FOUNDATION
;4 FRAME
i
INSULATION
a FIREPLACE
.b
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL .
GAS: ROUGH FINAL
5 FINAL BUILDING
{: DATE CLOSED OUT
ASSOCIATION PLAN NO. �'' • -
E
r iA
( j y z
/• H.< t_ k l .r fir, t {�i l.ti C ITtI `iLt�?
t. +c n •; s ; \ 11J}t ti.l t�M)Hi 3698
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t{ ( }} —Sr Al zat
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ATI
' W"011% t h ii v'l r mi Rio' n
F r,&%e
Your tenant has requested and is`eligible for'weatherization o our'
rental home through government funding. Thls,;w®/t be pro at"rro
cost to you. Program regulations permit us to spend around.$4, Q0- Fat
��,uvu in t-i aterials and iatsoi per �l e,lifig: u.s"u�. -
,.
Program regulationszrequire us to weather-strip a'nd caulk doors and
windows; insulate attics, sidewalls and floors. AII'work is professionally,
done by established private contractors'.'. We,wili conduct a final
inspection3to make.sure that all Work is completed to',sPe6fications.
If you request,-you will,be informed,of the estimated measures before ,
they are done and provided with a-list.of.the actual measures and
costs following the completion of the work.
We also-need roof that p` you own the property. copy of"'CURRENT
y ,
n T' BILL'OR DEED listing you as the/ ,owner,will satisfy this
n .
requirement
Please fill-in all blank areas of the enclos
_ ed agreement and return frith the proof of ownership as soon as possible.
If-we do iof receive the enclosed form within a weeks, we Will-^ d � � di �f t e, no �et��r T_ �► work
can be recommended or done. �4 ' }.e
. a
if you have any questions please"call Gathy Finn at 508-771=54001
LANDL ORIJ x` r f ,
t •. r • r✓ a ty .
-� TENANT/PROP RTY 01NNER/AGENCY WEATHERIZATION,AGREEMENT,
1. The Parties to this Agreement are the following;
' (hereafter known as Tenant),
(print Your tenants name)
� '(hereafter known as Property Owner)
(print your name)
t and Housing Assistance Corporatiod(hereafter known as Agency).
In consideration of the mutual,promises hereafter:stated,the Parties agree as follows:
2. The date of Agency's signature will be the effective date of this Agreement
3. �Prowrty Owner and Tenant consent and agree that the Agency may do the following with
resrect to the property located'at(street,town)
and currently "
_> leased or rented to the Tenant _ r
ia) Enter the premises for the purpose of performing a Weatherization inspection..
b) Enter the premises to perform Weatherization work which the Agency'determines
in its discretion is necessary and appropriate as a result of the Agency's
inspection of the property and in accordance with the approp riate priority list for
the type of dwelling. The'Agency and the Agency's contractors may also enter the '
- appropriate common areas of the building for the purpose of accomplishing the
-Weatherization work. The Agency,and representatives of the Commonwealth of L
Massachusetts, Department,of Housing &Community Development{DHCD} may
further enter the property to inspect any and all work hereunder. The Agency wilt
provide reasonable notice of the timing of.the Weatherization work and ,
inspections. The Weatherization work will be performed in accordance with the
' Property Owner's consent as further specified below.
A
r, � , :t � ����iFl•eEE�-soli=�o��
• N
1 consent to performance by the Agency and its contractors of any'
r .Weatherization work determined necessary and appropriate by the Agency as a
result of its inspection of the property. I understand that the Agency will provide
:. a.detailed statement of the actual k performed-and Vie-associated wattre ate
the completion of work_
$ I will provide a separate consent to performance by the Agency and its
u contractors of Weatherization work following my receipt of the Agency s
inspection report and a statement of,the estimated work and associated value._,
"this additional consent will be sent under separate cover as Attachment A.
understand that the Agency will provide a detailed stater�pt_pLit►e_actuaiwnrk
;.perernned and the associated vathe at the completion of ttje wo€k. ,.
4. Ttie Property Owrier.understarids and agrees that anyand all work,`including related
repairs for which the'Property may also be`eligible, will be performed at the Agency's ,
'discretion'-The Agency estimated completion-of the Weatherization work by the end of
b. 201,:1/201
5 'if the Property Owner is'required to make repairs to the property prior to the -; ..4 : ' commencement of Weatherization work by the Agency;ttie Property Owner will be notified
by the Agency and will be required to make the repairs as soon as possible. Except where
the�Property Owner receives'a written extension from the.Agency, time is of the essence in
the performance of repairs by the Property Owner.,
• .s
- .. _ � sx, . �F '},max•a4 W s �`*. �°'�,"., •' a .. .. '•,
' 11. For breach of this b Agreement
g y the Prop"Owner, the Property Owner shaft reimburse
the Agency in an amount equal to the cost, as certified by the Agency, of the
Weatherization materials installed and labor performed on the premises, as well as
attorney's fee and court costs. The Property Owner may also be liable for damages to the
Tenant-in accordance,with applicable law;in such.instance,the Property-Owner shall
reimburse the Tenant for attorneys fees and court costs. Without limiting the foregoing,the
Agency may at its option terminate this Agreement, by providing written notice to the
Property Owner and Tenant, in the event of breach by the Property Owner or Tenant
12. Performance of the Weatherization worts hereunder by the Agency is contingent upon the
availability of funds to the Agency from the commonwealth of Massachusetts and the
federal government, as well as the eligibility of the Tenant under WAP program
requirements. The Agency may terminate this Agreement, by providing written notice to
the Property Owner and Tenant, if the Agency determines that the unavailability of funds or
ineligibility of the Tenant warrants termination.
13. The Parties acknowledge that this Agreement is under seal. "It is intended by the Parties
that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and
shall have a right of enforcement
Phone: c7CJ 9.3 7:,;)—o y
Address: P l
Tenant Signature-ftArij Date
Agency Approved Weatherization Company 4L v
AI! pe Energy Caliber Building & Remodeling Cape Cod Insulation
Cape Save , Creswell Construction Frontiei•.Energy.Solutions
Lohr&Sons° "* Peter Smith ° =Resolution'Energy
Building Performance.Contracting LLC Nial Hopkins Builders Inc.-.'
Michael T McMahone&Son Inc.
This agreement becomes effective as'of the date of the Agency's signature:The Agency
-MR sip, And-return_ropies�4 the agreerr ent-tp atl.parties, upon completion of the ,
proposed weatherization work. The Agreement shall remain in effect for one full year from
the effective date.
Agency Signature Date
The Conzrnompealth of Massachusetts
Department of Industrial.Accidents, '
Office ofInvestiaations
600.R'ashington Street
Boston,M10-7111 _
www.mass.a ov/dirz r
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information —�+ Please Print Legibly
Name(Business/Organization/Individual): n C.
Address: - D HMM►-tini+on Nvgko fi .
City/State/Zip:,.J�o,t_41 Yac-MOVA, MR OA64 Phone# 50$-- 3 9 $ ' 0 3 9 g
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with t— 4. ❑_I am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors 6.. New construction
"
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling.
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in.any capacity. employees and have workers' 9 ❑ Building addition '
[No workers'comp.insurance comp.insurance
required.] 5. ❑ We are a corporation and its - 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work' officers have exercised their I i.❑Plumbing repairs or additions
myself.[No workers'comp. - right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,§1(4),and we have no ,
employees.[No workers' 13.0 Other. 7 106-
comp.insurance required.]
;Any applicant that checks box Rl must also fill out the section below showing their workers'compensation policy information. k
*Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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 tltat is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: T GG�n o l otj G n
Tw
Policy or Self-ins.Lic.r: C 3 3 t $ 0 �' Expiration Date: (4 ' I I .[ 3
Job Site Address: 3 N Q e' P r City/State/Zip: CT ann'S _
Attach a copy of the workers'compensation policy declaration page(showing the policy numb r 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIA for insurance coverage verification.
1 do hereby certify under the pains andpenalties ofperjury that the information provided above is trnie and correct
S i Qnature: l th
Date: _
r
Phone- �� 03Q�
Official use only. Do not write in.this area,to be completed by city or tP►t7t official
' r �. -
'City or Towrr Permit/Iicense -
F Issuing Authority(circle one):
1. Board of Health ?Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector '
-6. Other ,
a . Contact Person -�
Phone r:.
,
f
ACC> CERTIFICATE. OF LIABILITY INSURANCE DATE
0 22 20 2'
THISRTIFICATE 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
R S AUTHORIZED
F INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN-THE ISSUING INSURE O,
BELOW. THIS CERTIFICATE O .
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy()es)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 c°Nr.CT Shannon Sperrazza
Risk Strategies Company �°IAIC (781)986-4400 Fax u:(781)963-4420
15 Pacella Park Drive E-ovE ,ssperrazza@risk-strategies.com
Suite 240 INSURER(S)AFFORDING COVERAGE NAIC#
Randolph MA 02368 WSURERA:Selective Insurance
INSURED - INSURERB:Safety Insurance Company 3618
Cape Save, Inc INSURER c Technolo Insurance Company
7 D Huntington Ave INSURER D:
r.
INSURER E•
South Yarmouth MA 62644 MSURERF:
COVERAGES CERTIFICATE NUMBER:CL12102253933 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.
I SR TYPE OF INSURANCE D S POLICY NUMBER UBRPOUC EFFYll
PO�UCOY EXP LIMITSLTR
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
DAMAGE TO RENT'
X COMMERCIAL GENERAL LIABILITY PREMISES Meoccurrence) S 100,000
A CLAIMSMADE rx]OCCUR S199448001 0/16/2012 0/16/2013 MED EXP(Any one person) S 10,000
• PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG S 2,000,000
X POLICY PIFCT RO LOC S
AUTOMOBILE LIABILITY- COMBINED SINGLE LIMB
accidentl 1,000,000
ANY AUTO BODILY INJURY(Per person) S
B ALL OWNED F_y_1 SCHEDULED 6208200- 1/6/2011 1/6/2012 BODILY INJURY(Per accident) $
AUTOS AUTOS PROPERTY DAMAGE $
X HIRED AUTOS X NON-OWNED AUTOS Peraeciden
Underinsured motorist BI split S 100,000
X UMBRELLA LIAB OCCUR + EACH OCCURRENCE S 1,000,000
A EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 1,000,000
0 16 2012 0 16 2013
/ / /
DED RETE ON S
19944800Y S
C WORKERS COMPENSATION Officeri excluded - X I WC STATU- OTH- 1
AND EMPLOYERS'LIABILITY YIN ' _ I
ANY PROPRIETORIPARTNER/EXEcunVE❑ NIA /9/2013
from coverage _ E.L.EACH ACCIDENT S 500,000
OFFICERIMEMBER EXCLUDED? C3318007 ,, /9/2012
(Mandatory In NH) . E.L.DISEASE-EA EMPLOYEE S 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S 500,000
DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space Is required)
Issued as. evidence of insurance. Issued as evidence of insurance.
Thielsch Engineering, Inc. is listed as additional insured as respects General Liability as required by
written contract. ,
s Y
CERTIFICATE HOLDER CANCELLATION
m ong@capelightcompact.Org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Cape Light Compact
Attn: Margaret Song
PO BOX 427/SCH AUTHORIZED REPRESENTATIVE I :
3195 Main Street
Barnstable, MA 02630 �
Michael Christian/SMS
4
ACORD 25(2010105) 01988-2010 ACORD CORPORATION: All rights reserved..
INS025 onira t ni The Arnion namo onei Irvir+are ranictamri mav*a of ARnPn
�iasachusett - Dcparttnent Of Public SafefN
B(aard (rr Building, Reaulatiuns and Standar(is
j Construction S'apervisor Specialty License
License: CS SL 102776.,
Restricted to: IC r ;
,WIL-LIAM MC CLUSKY
` 37 NAUSET ROAD r
.. WEST YARMOUTH, MA 02673 t t
cam=_d i Expiration: W812013 µ
(r,nuni..i.,,,�,• !r: 102776
`moo; 91te eowm'�N'` f Office of Consumer Affairs and usiness Regulation
l�, }
cu 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
w -Home,Improvement Contractor Registration
- - Registration:. 171380 ;
Type: Corporation
Expiration: 3/14/2014 Tr# 222184
CAPE SAVE INC
WILLIAM McCLUSKEY = -
7-D HUNTINGTON AVENUE
SOUTH YARMOUTH, MA,02664 -
k -7 Update Address and return card.Mark reason for change. .
Address Renewal' j Employment Fi Lost Card
• .PS-CA1 it 50M•04/04•G101216
/ze �a�rLfn�.zc�ealC/a Ilan acl:uaelt License or re strati lid f idi on valid nv idl only
use on
Ofrice of Consumer Affairs&B siness Regulation y
HOME IMPROVEMENT CONTRACTOR • before the expiration date. If found return to: ; ..
� ` Re istration• . .171380 Type: Office of Consumer Affairs and Business Regulation ;
g( Wt 9
Expiration 3/14/2014 Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
CAS SAVE INC:
WILLIAM McCLUSKEY
a 7-D HUNTINGTON AVENUE
SOUTH YARMOUTH.MA 02664 Undersecretary Not valid wit signs
4 �
1
oFV , To Wn of Barnstable *Permit#
Ey rn ue date
Regulatory Services F
9cb ,ASS ���- `^Thomas F. Geiler,Director
alr } r Building Division
Tom Perry,CBO, Building Commissioner
`ZOO Main Street, Hyannis, MA 02601 _
www.towm.barnstable.m.a.us
Office: 508-862-403 8 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid wit/rout Red X-Press Imprint
Map/parcel Number _3051isu
Property Address /d'7`tC r ✓2 �ftf�
residential Value of Work ]Minimum fee of S35.00 for work under$6000.00
Owner's Name&Address Ac,'. /4rJG n`i �5-
90 1-14 �, sk Ai (00i )\lcrkt �'Pt4►.�� get �1 s(60-3�N�
Contractor's Name •
Sb��t /'4e�ct: 'TelephoneNumber 5;0* s6y- aVS&
Home Improvement Contractor License#(if applicable) � 0
Construction Supervisor's License#(if.applicable) , c s- 5*Aq5
❑Workman's Compensation Insurance
7 k one:
am a sole proprietor
❑ I am the Homeowner, <
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp. Policy#:
Copy of Insurance Compliance Certificate must accompany each permit_.
Permit Request(check box) , T
❑ Re-roof(stripping old.shingles). Alf Construction debris will be taken to
a
❑ Re-roof(not stripping. Going over, existing-layers of roof)
❑, Re-side
#of doors
2"Replacement Wind ows/doors/s I id ers. U-Value • 3 '. (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 copy of-the Home Improvement Contractors License & Construction Supervisors License is
required.
SIGNATURE: S'h4►�c__ �(aGtts
Q:\WPFILES\FARMS\building permit forrns\EXPRESS.doc ` ' -
Revised 070110. .
The.Commonwealth of Massachusetts
Department of Industrial Accidents
), Office of Investigations
i ,
1 ,I,,U / 600..Washington Street
Boston", MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:'Builder`s/Contractors/Electricians/Plumbers
Applicant Information P Please Print Legibly
Name (Business/Organizatio0ndividual) ��Gr�p, p�tGhflty
Address: 1-4CtyeS c� '
City/State/Zip: Cei-kcrvi ilc M&L C41 t0 3 A Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a em to er with 4. ❑.I am a general contractor and I
P Y, 6_ ❑ ew construction
mployees(full and/or part-time).* have hired the sub-contractors
2.L0 I am a sole proprietor or partner-. ' listed on'the attached sheet. Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp.insurance. 9. E] Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ]0:❑ Electrical.repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.],t employees. [No workers'-, 13. Other -
comp. insurance required.]
*Any applicant that checks box#I must also rill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their.workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my'employees. Below is the policy and job site
+ information. j
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 criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in•the,form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement.may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains`and penalties of perjury that the information provided above is true.and correct.
Signature S�4ru. .. �4�h�w Date:
Phone#: SUB 30q- ayS�
Official use only. Do not write in this area;to be completed by 60 or towd.official
City or.Town: Permit/License
Issuing Authority(circle;one):
1. Board of Health 2. Building Departrtent 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
4
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 em to er is defined as"an individual partnership,association corporation or other legal entity,or an two or more
p Y_ �P R � rP g tY� Y
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152 25C 6 also states that"ever state or local licensing agency shall withhold the issuance or
P , § ( ) Y g g Y
renewal of a license or permit to operate a business or.to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. if an LLC or LLP does have
employees,a policy is-required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to 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
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
� T � Town-of Baru-stable
o .
• f 'Re& atoty Services
• p ��>�. p
v was. g Thomas F.Geiler,Director.
t6S�
�Eo Building;Division
Tom Perry;'Building Commissioner
200'Main Street,Hyannis,MA 02601•
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-623 0
Prope -ty 0wrier Must
.Complete and Sign This Section
If Using A'Builder
I, C,•�vr �✓�nl�i S as Owner of the subject.property
. J- .
hereby authorize C4Ket, to act onmy behalf,
in all matters relative to work authon'Wa by this building permit application for.
3�i �oder fJvf- Rvq"r, c'
(Address of job)
4 ( S o1(Q f 11
Signature of Owner Date
Print Name t
If Property Owner is.applying.for..pem-.t pleas e complete. the
'Homeowners License Exemption Form on`:the reverse'side.
S
e
Town of Barnstable
Op THE Tp�y
Regulatory Services
MAN 11SUBM ; Thomas F. Geiler,Director
s639 ,� Building Division
Tom Pe , Building Commissioner
try, g
200 Main-Street,,Hyannis,MA 02601
www.fown-barnstable.ma.us
Office: 508-862-403 8 Fax. 508-790-6230
HOA�OV ER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name hone phone# work phone#
cuRR Nr MAILING ADDRESS:
city/town state zip code
Tie 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 BOMEOW'NER
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 contras more than one home in a two-year period shall not be considered a bomeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Cods and other
applicable codes, bylaws,rules and regulations.
The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department
minim=inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Butlding•Offrcial
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 homcowna performing work for which a building permit is required shall be cxmnpt from the provisions
of this sccti. .(Section I D9.1.1 -Licensing of construction Supervisors);provided that if the homeoryncr engages a pason(s)for biro to do such
work,that such Homcowna shall act as supevis or."
Many homeowners who use this exemption are unaware that they arc assurrling the rcsponstbrlitics of a supervisor(set Appendix Q,
Rules&Regulations for Liccnsing Construction Supervisors,Section 2.15) This lack of awareness often rtsulrs in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it wrould with a licensed
supavisor. The homeowner acting as Supervisor is ultimately responstble.
To ensure that the homeowner is fully aware of his/haresponnbilitia,many communities require,as part of the permit application,
issue a form current] used b
that the homeowner certify that hdshe understands the responsibilities of a Supervisor. On the last page of this is e u ,f y y
several towns. You may care t amend and adopt such a forrn/eertification for use in your corrununity.
it
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\ Office of Consumer Affairs&Business Regulation 1
HOME IMPROVEMENT CONTRACTOR
Registration .164440
Expirat on 10/6/2011' Tr# 289575` I
Type:-! Indroidual I _
I
SHANE PACHECO
SHANE PACHECO
143 HAYES RD.
CENTERVILLE;MA`02632=` Undersecretary
M
s- 'lassachuwtts - Department.of Public Safety
Board of Buifdim,Rc ulations auul Standards
Construction Supervisor License
License: CS .92958
Restricted to: 00
SHANE PACHECO
143 HAYES RD
CENTERVILLE, MA 02632
Expiration: 10/17/2011
Cmnlnissi"'n(r Tr#: 4144
,
ea
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 30� Parcel i5to Application #
32.
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address 3 q `o+�e-- Avg
Village 14 s
Owner yiciof Aryenb S Address 090 llq-f1, 54 4 (Vol
c,t 14fA;
Telephone do-71
Permit Request �e.vnocUk t' -Clk n wlk�- neW Cc0bi^4AS , 'V�Ioorr*c r„,l Cogn- crr •
I�tlr1 , 114v►� . ioo�iho �f� 3��l,�oa�, 4� �; =.'
Square feet: 1 st floor: existing proposed 2nd1oor: existing proposed: :Total r w
CZ)
Zoning District Flood Plain Groundwater Overlay , I 1
Project Valuation G,U00 Construction Type .W
Lot Size ° a Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family lB Two Family ❑ Multi-Family(# units)
Age of Existing Structure 1141 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: YFull ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) _ Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing I new 0 Half: existing new
Number of Bedrooms: 3 existing 0 new
Total Room Count (not including baths): existing 6 new ® First Floor Room Count
Heat Type and Fuel: ❑ Gas 2(Oil ❑ Electric ❑ Other
Central Air: ❑Yes R(No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: iexisting ❑ 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 iNo If yes, site plan review#
Current Use i eslctn4id k K4 Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name S�0w ?4c" Telephone Number 3(c
Address I q 3 1AC es 9d License # CS 9 d96'13
Cen�rryi iLz Mc, 6ac03A Home Improvement Contractor# i to
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
gins
SIGNATURE J�a�- �� DATE
4
'i
r =
FOR OFFICIAL USE ONLY
s APPLICATION#
DATE ISSUED
`> MAP/PARCEL NO.
4
!� f
ADDRESS VILLAGE
OWNER
r`
1
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
i
F FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
!t -
GAS: ROUGH FINAL
FINAL BUILDING
i
DATE CLOSED OUT
4
y
ASSOCIATION PLAN NO.
Thie Cotnrnonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
`600:Washington Street '
;1 r Boston,'MA`02111�
y a wwmmas4bv/dia rt
Workers' Compensation Insurance'Affidavit:_Builders/Contractors/Electricians/Plumbers
Applicant Information _Please Print Leaitily
NaMe (Business/Organiz-ation/Individual).
Address: � +VeS Qe.�Y411
City/State/Zip: C�n�tcrv►l�- �4` Q��3� Phone;'#: 0 8 3 6y- ,;I 4 S(0
Are you an employer? Check the appropriate box: L Type of project(required):
1.❑ I am a employer with ' 4 Ej I am a general contractor and I.
1. (full and/or part-time).
*' have-hired the sub-contractors-, 6. 0 New'construction
2. I am a sole proprietor or partner- fisted on the attached sheet. 7:. remodeling
ship and have`no e`m to ees wt .^ %These sub-contractors.have ', 8 Q Demolition
p P y em'to ees and;`have workers' `f
working for me in any capacity. s P y $ 9:r Building,addition
[No.workers' comp. insurance p
r , com insurance.
required.] 5:.0 We are a corporation and its 1.0'.0 Electrical repairs or additions
3.0 I am a:homeowner doing all work ,''. ` .n _officers.Piave exercised their,. 11.0 Plumbing repairs or additions
myself. No workers' com right of exemption perANIGL '';
. y [ P � 12.❑,Roof repairs ,
insurance required.].t c. 152,§,1(4);and we have no',
`employees:-[No worker's' ,;13..❑ether
comp.insurance-requiied J'
*Any applicant that checks'box#I.-must also.fill out the section belowishowing their workers'compensation policy information.
t Homeowners who submit this affidavit indicatin f tthey are doing-all work-and then'hire outside contractors must submit;a new affidavit indicating such.
#Contractors that check this boz must attached an additional-sheet showing'.the name of the sub-contractors and state whether or not those entities have
employees. [f the sub contractors have employees,they must provide their workers'comp.'bpolicy number
ra.
I am an`employer that is providing workers''coinpensation cnsurgnce for my employees:. Below is the policy and job site
information r. '
-Insurance Company Name:
Policy#or Self ins. Lic. #: Expiration Date:.:
Job Site Address:'. Ciry/State/Zip: y
Attach a cop' of the workers' compensatiefitpolicy~declaration page(showing the policy nun}ber`and expiration date).
Failure to secure coverage as required undei 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,a, 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 coveragttverification:
I do hereby certify under the pains fond penalties of perjury that-the information provided above is true and correct
Signature: 4 - G.GF� Date:
Phone#:
Official cse only. Do not"write in this area, to be completed by cit),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 Inspectirr .5. Plumbing Inspectbr.
6. Other
Contact Person: Phone#:
Information_and Instructions.
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise;and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
R
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out thew.orkers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation.of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the'permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in'the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if rlbeessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A.copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a_home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do'not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
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
www.mass.gov/dia
of Tx�t�
anaxsTU e F -
KAI%.
1639. �,�� Town of Barnstable.
rFD MA'S •.
Regulatory Services
Thomas F.Geiler,Director
Building Division.
Thomas Perry,CBO
Building Commissioner
200 Main Street,.Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign..This Section
If Using A Builder
I, G wl All ht <S ,as Owner of the subject ro er
p P ty
hereby authorize c n.Y G C•Lek to act on my behalf,
in all matters relative to work authorized-by this building permit,application for:
Ae /"/C-In1 S
(Address of Job)
A.4 41 IL9 el
Signature of Owner Date
Print Name
if Property OFvner is applying for permit,please complete the Homeowners License'Exemption Form on the
reverse side.
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary intemet Files\Content.Otlook\DDV87AAZ\EXPRESS.doc
Revised 072.110
ti
Town of Barnstable
OF 4HE
Regulatory Services
rtsTAere Thomas F. Geiler,Director
16) ,�� Building Division
'0r�µptA 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#
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,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 perm t. (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 witlr,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 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:forms:homeexempt
I
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U13
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