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HomeMy WebLinkAbout0006 SAINT JOSEPH STREET <<� ,,+ T Qqmfir r2rOf't? Tr�t� 0, L;I S I VU 55 i� �npT�vck �Si✓�fSS name 0�1 firuck �s �. U . S . S . Ho_ t7 - ) -- - -� -1 -IS- - �� - - e oFY r T'O`6 n of Barnstable *Permit# ,t Expires 6 months from issue date yP °� Regulatory Services Fees:, A "' PERMITThomas F. Geiler;Director ibg9 ♦0 ATED�y y MAY. 1 1 2010 Building Division Tom Perry; CBO, Building Commissioner TOWN OF BARNSTABLE 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid 3vithout Red X-PressImprint Map/parcel Number Property Address t' �. (©D f Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owners Name&Address 'C'i�L,� P � 6�67 Contractor's Name Ai-6 o-i'V L � 'Z��-- Telephone Number SCJ g`.7 7,f E1 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner VI have Worker's C-ommppen❑sation Insurance Insurance Company Name ✓ 'C � -5r Workman's Comp.Policy# 0 J- u � 6 3 D Copy of Insurance Compliance Certificate,must accompany each permit. k X�- Permit Request(chec box) Re-roof(stripping old shingles)..All construction debris will be taken to � X ❑Re-roof(not,stripping.. Going over existing layers of roof) ET Re-side #of doors ❑ Replacement Windows%doors/sliders.U-Value (maximum_44)# of windows *Where required: Issuance or this permit does.not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: property,Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Super-visors License is' re red: . SIGNATrURE. The Commonwealth of AVfassachusetts Department of Industrial Accidents Office of Investigations J 600 Washington Street Boston, MA 02111 w3vw.mass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 4s- dktd� W�q City/State/Zip: ` C `r J 6 hone#: 5-6 -7 7 8 l� Are u an employer? Check the appropriate box: Type of project(required): I. I am a employer with 4. I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, .E] Demolition workingfor me in an capacity. employees and have workers' y9. ❑ Building addition i [No workers' comp. insurance comp.insurance.$ required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions right of exemption per MGL -... myself,.[No.worke>s..cozy?P>... .•_......._.. ......: ... ...c. 152 .._.1 4 , and we have no ..,...12. _ _ oof.,repairs........... . ...__. ........._:.�g_ P insurance required.] t ' § O I.Y 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self ins. Lic.#: l�u is `03 8r5q coo� Expiration Date: 7 1 A-0 Job Site Address: S r tj `3 City/State/Zip: i� l5 A, 6 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 cert unndd err}th�e paiins and penalties off try that the information provided abov is 11 ue and correct. Si nature: v rr "�"�' `'U" Date: �! Phone#: 5 6 o AW Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other f . Information and Instructions ter 152 requires all employers to provide workers' compensation Massachusetts General Laws chip ers for.their employees. p q p y Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair.work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,IvIGL 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-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 regiirred to carry workers compensation msurance. If an LLC of LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia 0,*VE r Town of Barnstable Regulatory Services BARNSTASLE, ' Thomas F. Geiler,Director 9 MAS3 D 19. 4 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 wwov.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This. Section If Using A Builder, AV(.e— as.Owner of the subject property hereby authorize AA i-e� to act. on my behalf, _ in all matters relative to work authorized by this building permit application for: (Address of Job) Q b Signature of Owner D to Print Name ; If ProperCY Owner is applying for permit please complete the Homeowners License Exemption Form on the.reverse side. Q:FOPJvIS:O WNERPERM ISSION Town of Barnstable o regulatory Services " Thomas F. Geiler,Director :ARNsrasrE, 7,,A MASS ,� . Building Division Teo► �A 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 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 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 a 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:\WPFILES\FORM S\homeex empt.DOC "L_UIIZU tN5 CUTUIT PAGE l CERTIFICATE OF LIABILITY INSURANCE CSR AB DATE(MM/DO/YYYY) WFu�iZE50 09 18 09 ,OMAN 6 ASSOCIATES INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ��NANCIAL SERVICES INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE /:33 FALMOUTH RD. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED 6Y THE POLICIES BELOW. j HYANAiIS MR 0260].I/ Phone:508-775 E010 Fax:508-790-0249 INSURERS AFFORDING = ... — - INSURED --.-. ...__._ - _ NAIC.# INSURER A: SCOTTSDALE INSURANCE Co INSURER B ST PAUL TRAVELERS - _... WENZEL FRAMING INC- INSURER C --- -- - .......- I�•" 45 WHIDAH WAY _--- — CENTERVILLE MA 02632 INSURER D: ----•-- COVERAGES INSURER E: -..—_.. .-•--.. ..__.... _ ... _. _—_. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED,4BOVC FOR THE POLICY PERIOD INDIC\TEO,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 DESCRI@EO HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CLAIMS. L R NSRa TYPE OF INSURANCE POLICY NUMBER PDATE L I M FF��l9V2 TH Mr DM' OAT®• A I I XG�2 N—fi RA LLIABILITT I MM/ODM/ HACHOCCUftRENCE LIMITS _ $ ]000OO O — I COMMERCIAL GENRALLIABILITY CLS140O422- I 07/10/09 II 07/i0/10 � ERCi � � CAIMS MADE I) OCCUR REMigB(E �coan)) 3100000 00 MED EXP(Any one p ADVINJURYes PERSONA 1_S5000 _—.�., 1000OpO _ - -- -- - I CENERALAGGREGATE 55 2 - -GE AGGREGATE LIMIT APPLIES PER 000000 PRODUCTS I --• - — EOWCY J GT LOC _COMP(OPAGG $-2000000 AUTOMOBILS LIABILITY — I I ANY ALrrO - - I • I I COMBINED SINOLE LIMIT I S ,• ----- AIJ OWNED AUTOS SCHEDULED AUTOS BODILY INJURY 5 I HIRED AUTOS NON•OWNEDAIJTOS I eODILY INJURY S I(Per eccldeni.) - PROPERTY DAMAGE I a " (Peraccidenl) (GARAGE LIABILITY 1 - I ANY AUTOAUTO ONLY.FA ACCIDENT I$ I I .-`----. --_. _ OTHERTHAN EAACCI$ AUTO ONLY: -- EXCESS/UMBRELLA LIABILITY AGG I$ EACH OCCURRENCE g I -1 OCCURI CLAIMS MADE I Y —— ---.... I I AGGREGATE -- y 1� - - EDUCTI9LE I •--- ..—._. .-_ .._ RETENTION S 8 --- — IWORK6R3COMPHNBATION-ANp I 3 `•---- B EMPLOYERS'LIABILITY. I - �TORY LIMITS I ER _ ANY PROPRIETOR/PARTNFWEXECUTIVE 47PJUB903X389508 07/10/0 . Q7�1O/lO E.L.EACNIACCIDFNT y OFFICERIM_MBER EXCLUDED? _ 100000 i __. . If yes,clomdbo under - - - - E.L.DISEASE-EA EMPLOYE S 1 O 0 0 Q Q SPECIAL PROVISIONS bobw -.. ••— OTHER E.L.DISEASE-POLICYLIMIT S 500000 I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDOgSEMENT/SPECIAL PROVISIONS t-Al �` C! 771 v 00 CERTIFICATE HOLDER CANCELLATION MYxOrzEK SHOULD ANY OF THE ABOVE pE9oRIBED POLICIES BE ANC ELL HD REI'ORL T XPoRATIO . DATE THEflfiOF,THE ISSUING INSURER WILL ENDFiAVO TO MAIL 3�., DAYj3 WRITTEN a NOTICE TO TN9 cERnFICATR MHO NANEO TO THE LEFT,BUT FAIRE TO DO 30 HHALL I MYRNA WILLIAMS '� IMPOSE NO OALIG Ow OR IJABILrtY OF ANY KIND UPON THE INSURER,ITS,AGENTS OR. 148 MILNE ROAD REPMMENTATIV 8, OSTERVILLE MA 026555 AUTHOR1 0REP QSE ATI E ACORD 25(2on�/DI3) ANN LOUIS E W ACORD CORPORATION 1988 1 q. TI 4 ' <• < 13ourd dBuiiding-lket ulationa and Staudurds . .. HOME IMPROVEMENT CONTRA OR i w Registration: 100285 Expiration: 6/15/2014 7r# 26832? ..: Type: Private Corporation VUFNZ'�:L Fib,'MING, NG. r iviark Wenzel 45 Whidsalt bW<ay' Vert _ < Centerville,MlA 02_G3 �duri�sistrutnr — . ma sachkis Its Depa.11111ent of public S° ft'f;a fit trtl tst'BijildiTig, I2C rll.trtt3at ;stiff Stantlards C on tr"tion Supervisor License License" CS 9055 R .t-ticted to: of MARK A WENZEL { 45 WNIDAH WAY CENTERVILLE, MA 02632 sr r t r ias-p 26876 �t"H jgp- iKl - r < License or registration valid for in dividul use only before the expiration date. If found return to: Board of Building Regulations and Standards .• ' One Ashburton Place Rm 1301 1� a.02108 :.�.,. Boston,M &17/2010 L/ s : x Not valid without tgnature l r .