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HomeMy WebLinkAbout0074 SEA STREET Sr a o ,� Pao V4-LAq Application number.,..,. Q aaawsrasL& " Date tssued................................................................. JUG! 2 u 2018 Building Inspectors Initials.......... ........................... a pJ Pa rce I..A.11.............................. .TO OF BARNSTA LE 1q.5 EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET VILLAGE Owner's Name: Phone Number -O k- 1 5-7 -�Y Email Address: Cell Phone Number Project costs 7 `7 S 3 — Check one Residential ✓ Commercial OWNER'S 1WER'S AUTHORIZATION JIO As owner of the above property I hereby authorize to make application for r a building permit in accordance with 780 CMR Owner Signature: fee n,4r4 Date: TYPE OF WOPx ❑ Siding ❑ Windows (no header change)# Cl Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's review `Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S FORMATION Contractor's name A0,/ee Home Improvement Contractors Registration(if applicable)# 1/2-7 8 S (attach copy) Construction Supervisor's License# �q�6 U 5� (attach copy) Email of Contractor AS wee-� qlSte@ t�KQ. ev, Phone number 4o/- 7IV-6 32 9 ALL PROPERTIES TuAT HAVE STRUCTURES O R 75 YEARS OLD OR IF THE SUBJECT PROPERTY A.S IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X _ X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent.must be attached. Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOL)/COAL/PELLET STOVES X Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S LICENSE EXENTTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date ( .2 b- / All permit applicatiolffare subject to a building official's approval prior to issuance. r Home Improvement Agreement: Page 1 Home Depot License Number(s): Visit www.homedepot.com/c/SV_HS_Contractor_License_Numbers for latest license into MA: 107774, 112785 Salesperson Name: Robert Delisle Registration No. (if applicable): Home Depot U.S.A., Inc. ("Home Depot") or service provider named below ("Service Provider") will furnish, install or service the equipment listed below at the price, terms and conditions as outlined on this form. COUGHLAN JIM JEAN New England South I1-662PHY5X Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 74 sea st Hyannis MA 02601 Customer Address City State Zip (508) 957-2498 capetocape05@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT HOME DEPOT USA INC., 2455 PACES FERRY ROAD, BLDG. B-3, ATLANTA, GEORGIA 30339 or EMAIL he Home Depot I @ customercancellationnortheast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENTS WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT T NCEL. Acknowledged by: 06/04/2018 Cu er's Signature 0Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: 17753.97 e Includes all applicable taxes. Excludes finance charges.* Sales Tax: 10.00 (if applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33916), NJ, Wl(99%) Dep. 33 % Deposit Amount 12558.82 Remaining Contract Balance 5195.18 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 Customer Agreement(C,E,I)(31 Jan.18) v 50.1.2 Board of SuildifIg - : Lice: - - .. I WAS H9,UFZN AVE SH n 9F L 1 sm a r '-'f,fy ir:•::.a�s.•,r:./.:2.4Jrf, �,{-"t'p sraa7rM a,a+��> - CgGteciCOMWmerAftlm 3uVne--z'Rvg ra �IC1Pi9 IMPROVeNtENr CONTRACMR RtgWbwUm vaAd fw in&v�:d ow TYPE.Stmamwa owd beloye the aoiratjDn ctato U€aursa€a e VI-n tm g y at w Ottic*of CansurneerA2 M and SWncm Rogulomon y {r r�,�w p.-a as 4 1 r� Orf��e�,�1shbafto -3ult�e 19on f 3E.4 SsMEEt 1 t-- a�r,G `rO t1�ti��crn�ar� vafld u signature The Commonwealth of Massachusetts Department of Industrial Accidents y d 1 Congress Street, Suite 100 a Boston,MA 02114-2017 Www.muss gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly, Name (Business/Organization/Individual): JON D WALSH Address: 1 WASHBURN AVENUE City/State/Zip: KINGSTON, MA 02364 Phone#: 508-962-6942 Are you an employer?Check the appropriate box: Type of project(required): 1.®I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in ❑ 8. ❑Remodeling any capacity.,[No workers'comp.insurance required.] 3.111 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I.am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑RODE repairs These sub-contractors have employees and have workers'comp,insurance.$ 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u er the pains and nalties of perjury that the information provided above is true and correct Signature: 2kDate:.. 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of-Ylassachusetts Department of Industrial.4ccidents Ma Office of Investigations r=) I Conn ess Street,Suite 100 Boston,M4 0211'4-2017 t � l www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Flee tricians/Plumbers Applicant Information Please Print Le 'blv 1IIlz (ILsiness/Organization/In3i�ri/dual) O Ej Address: City/State/Zip: dl.S'y,T- Phone rt: ! ! 41_ �2 7,' - -2-I S�5_ Are you an employer?Check the 4propriate box: + Type of project(required): 1- I am a employer with 4• L I am a general contractor and I j employees(full and/or p -time). * have hired the sub contractors ti• ❑New construction 2 !� I am a sole proprietor or partner- listed on the attached sheet. 7. �]Remodeling shipand have no e to ees These sub-contractors have (— mP S. �Demolition working for me in any c�paci employees and have workers' � ty I 9. Btt lding addition [No workers' comp.insurance comp.ircttran�e.< i required-] 5..0 We are a corporation and its 10.❑Electrical repairs or additions ` 3.! 1 am a homeowner doing all work ofacers have exercised their i 1 l.❑P tmmbing repairs or addi ors myself. [Ito workers` comp. fight of exemption per MGL i � 1_ Roof repairs icsurance required.]t c. 152,§1(4),and we have no i employees.[No workers' j 13.El Other comp. insurance required] f 'Any applicant that checl-s 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 like outside contractors must submit a now 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. L-lsurance Company?lame: �y 1'J{.t� Q bttic�/ UM!o�/ ICI C, , A/5J Policy#or Self--ins.Lic.#: y�9 J 5 Expiration Date: Job Site Address: l q SeQ 5 t 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 s'50.00 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' ,urance coverage verification. I do hereby certify under i ainsandpepaltiesotf erjury that the information provided above is true and correct Si azure: // Date: Phone#: 5 — tv Official use only.. Do not write in this area,to be completed by city or town ofj4ciaL i 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 5.Other Contact Person: Phone tt: i_ L /. Cf � '�'? dJ '' J Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card. Registration: 112785 HOME DEPOT USA INC Expiration: 04/22-12019 2455 PACES FERRY RD C-11 HSC ATLAN i A.GA 30339 Update Address and return card. Mark reason for change. O Address ❑ Renewal ❑ Employment.❑ Lost Card Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoalenent Card before the expiration date. If found return to: Registration Expiration , Office of Consumer Affairs and Business Regulation 127E5 04;22;'2019 10 Park Plaza-Suite 5170 4 6ME DEPOT USA INC Boston_MA 02116 ANDREW SWEET �6 C 2455 PACES FERRY RD C-11 HSC U iili6ul signature ATLANTA,GA 30339 Undersecretary 5 AC CERTIFICATE OF LIABILITY INSURANCE DATE /YYYY) 14 CE F_ oz2uzola THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS }I 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION 1S 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 CONTACT MARSH USA,INC. NAME TWO ALLIANCE CENTER PHONE FAX 3560 LENOX ROAD,SUITE 2400 AfC No): E-MAIL ATLANTA.GA 30326 ADDRESS: CN 101642069-HaneD-GAW-18-19 INSURER(S)AFFORDING COVERAGE NAIC C INSURED INSURER A:Old Republic Insurance Co 24147 THE HOME DEPOT,INC. INSURER a:New Ham shire Ins Co 23ga 1 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk C live Insurance Company 2455 PACES FERRY ROAD BUILDING C-20 INSURER D: ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-16 REVISION NUMBER: 3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS.SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD[7OFSIR:SIMPEROCC LTR TYPE OF INSURANCE POLICY NUMBER MM/DDY EFF M M`D EXP LIMITS A X COMMERCIALGENERALLIABILTY WZY312717 03/012018 03/01/2019 EACH OCCURRENCE S 9,000,000 CLAIMS-MADE X ,OCCUR DAMAGETORENTED MITS OF POLICY XS PREMISES Ea occurrence S 1.000,000 MED EXP(Any one person) I S EXCLUDED PERSONAL 8 ADV INJURY c 9,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: X PRO- LOC GENERAL AGGREGATE S 9,000,GW POLICY❑ OTHER: PRODUCTS-COMP/OP.AGG S 9.000,000 S A AUTOMOBILE LIABILITY MWTB312718 03/01/2018 03/01/2019 COMBINED SINGLE LIMB X ANY auro - Ea a..' S 1000.000 BODILY INJURY(Per person) I S OWNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS ONLY AUTOS BODILY INJURY(Per accidem) S HIRED NON-OWNED AUTOS ONLY AUTOSONLY PROPERTY DAMAGE S Per accident UMBRELlJ1 LIAR OCCUR S EXCESS LIAB CLAIMS-WADE EACHOCCURRENCE S LIED RETENTION 5 - AGGREGATE S B WORKERS COMPENSATION WC 014122577(AK.WNJ,VT) 03/0112o18 03/012019 X PER oTH- S AND EMPLOYERS'LIABILITY B ANYPROPRIETORIPARTNERIEXECUTIVE YIN WC 014122578(WI) 03/0112018 03/01/2019 STATUTE ER OFFICER/MEMBEREXCLUDED? NIA E.L.EACH ACCIDENT S 5.000,G00 (Mandatory in NH) a If yes,describe under E.L.DISEASE-EA EMPLOYEE S 5.000,000 DESCRIPTION OF OPERATIONS below Continued on Additional Page S,C00,000 E.L.DISEASE-POLICY LIMIT S C Excess Auto 297-1-10011-00-2018 03/01/2018 03/012019 Limit: 4000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if More space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC 2455 PACES FERRY ROAD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING C-20 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. li I Manashi Mukherieea�,,�,,; ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo arc registered marks of ACORD I AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta . ik O ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY MARSH USA,INC. NAMED INSURED THE HOME DEPOT,INC POLICY NUMBER HOME DEPOT U.S.A.,INC. 2455 PACES FERRY ROAD BUILDING G20 CARRIER ATLANTA,GA 30339 NAIC CODE - EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance i Workers Compensation Continued: , Carrier:Indemnity Insurance Company of North America Policy Number.WLR C64783191(AL,AR,FL,ID,IA,KS.KY,LA,MS.MO.NE,NM,ND,OK,SC,SD,Tfd,WV!NY) Effective Date:03/012018 Expiration Date:031012019 (EL)Limit:S1,000,000 Carver New Hampshire Insurance Company 1 Policy Number.WC 014122576(DC,DE,HI,IN,MD,MN.MT,NY,RI) Effective Dale:031012018 Expiration Dale:03/01/2019 (EL)Limit:S1,0000D0 Carrier:ACE American Insurance Company Policy Number.WCU C64783221(QSI)(AZ.CA;IL,NC.OR,VA,WA) Effective Date:D3101/2018 Expiration Date:03/012019 (EL)Limit:S1,000,000 SIR S1000,000 SIR for the slates of AZ.CA,IL,NC.OR,VA,WA J Carrier.National Union Fire Insurance Company Policy Number.XWC 4595580(QSI)(CO.CT,GA,ME,MI,NV,OH,PA,UT) Effective Date:03101/2018 Expiration Dale:0310112019 (EL)Link S1,00,000 S1,000,000 SIR for the states of CO,ME•NV,MI,OH,PA,UT S750,000 SIR for the state of GA S350,000 SIR for the slate of CT Carrier.National Union Fire Insurance Company Policy Number.XWC 4595581(QSI)(,MA) Effective Date:031012018 Expiration Date:031012019 (EL)Limit:S1,000,00o SIR:S500,000 TX Employers XS Indemnity: Caniertilinios Union Insurance Company Policy Number.TNS C4916693A(TX) Effective Dale:03/012018 Ecpiration Dale:03/012019 (EL)Limil:510.000.OD0 SIR:S1,000,WD ACORD 101 (2008/01) ©2008 ACORD CORPORATION: All rights reserved. The ACORD name and logo are registered marks of ACORD r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # (DI G u -7 7y" Health Division Date Issued ((ENS tc). Conservation Division Application Fee Planning Dept. Permit Fee 0_ Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Addre 'a —De Village �/�1A/�l/iS /1 Owner iR1lteS e ovqh lr4n1 Address ;�3yo /Uwe 33 � .�e -(QI& Telephone Permit Request d i /1/l„/i iv.. �i ' `/ F�'�� MII (/^/ 0t l- `/ ! Ow+ , C,- k/>jdt✓ f r" -I t' ,4f Ul wi�►,�o�i/r�4S�, isiri� � R /luv�©��� �v. �k//1`i9Roii-/�� af,���-'19f1��4 ?e � /�, Square feet: 1 st floor: existing 9A q proposed 2nd floor: existing proposed v Total new n Zoning District Flood Plain Groundwater Overlay Project Valuation �dy Construction Type o Lot Size 10,o a o 3,�, Grandfathered: ❑Yes ❑ No If yes, attach sup,,porting docunWtation. Dwelling Type: Single Family '2' Two Family ❑ Multi-Family(# units) Age of Existing Structure 5e 2 '- Historic House: ❑Yes C��No On Old King's ghway:«®Yet Flo - m Basement Type: Gull ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Vole. Basement Unfinished Area (sq.ft) kx,4 S 9__ Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: &OX existing _new Total Room Count (not including baths): existing 5' new First Floor Room Count Heat Type and Fuel: ❑ Gas UrOil ❑ Electric ❑ Other Central Air: ❑Yes C"No Fireplaces: Existing / New Existing wood/coal stove: ❑Yes Wr o 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 s / L - 1 Proposed Use < 6 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 6'A'9 Telephone Number _7.76� f9 i, 2 Address !�(J'2 Ca e �R 4 C License # C� P A 0 2 J? Z- Home Improvement Contractor# /Z 0 � Worker's Compensation 4-SO L/3 O S?3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 4_4 IAPZZ SIGNATURE DATE Oc—/ Z 0 r FOR OFFICIAL USE ONLY x ' :APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS r VILLAGE OWNER l DATE OF INSPECTION: f FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL =? ry ; PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING z DATE CLOSED OUT ASSOCIATION PLAN NO. y TAe Commonwealth of Afassachusetts Depar finent of Xndustrial Accidents z Office of Investigations, '> 600 fflashington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApplicantInformation // Please Print Legibly Narrie (Business/Organizationllndividual): Z '3/� rn �"�° Address: Cit /State/ ip: C ,�-Z41, �} /`'! ®�� L Phone.#: 7--7 le-7�2 1 �'�-- Ioyer? Check the appropriate box: Type of project(required): asfi a eIF mployer with ' 4• ❑ 1 am a general contractor and 1 6. 0 New construction have hired the sub-contractors employees (full and/or;art,titn.e).* 7.. Reutodelin listed on the attached sheet. ❑, g 2. 1 am a soleproprietor or'parfl]er These sub-contractors have g.'D Demolition ship and have no employees ' working for me in any capacity. employees and have'workers' 9 ❑Building addition insurance.[No tvorkers'•comp.•insurance co 'lo.[]-Electrical repairs or additions r 5• ❑ We are a corporation and its . . ,. required.] , 3.❑ am a homeowner doing all work officers have exercised their 1.1.0 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 ' employees. [No workers' 13'El Omer 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 submits new affidavit indicating such, tContractors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not those entities have emplo.yecs, if the sub-contractors have employees,they must provide their workers'comp.policy number, lam an employer that isproviding workers' compensation insurance for my employees. Below is the Po[icy and job site information. hsurance Company Name:/ /L/ 1-3Policy#or Self-ins. Lic:#: S 57 �g� 7fa"rgBxpuation Date: b j✓ ® �'" AQ City/State/Zip: - Le)2, O Job Site Address:• --�, _ . 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 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. I do hereby cent under t e pa' •and pettaldes ofperjury that the information pro,vlded above is true and correct. Si attire: Date: — Phone#: Official use.only. Do not write in this area, tb be completed by city or town official. .City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health '2.B wilding Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector for ad"on a d lnstructious compMassachusetts General Laws chapter 152 requires all employers to provide worrkefsanoth r under any cont employees.act fhire, ce Pursuant to this statute, an employee is defined as ...every person Ln,the serve c-kpress or implied, oral or written." or any two or An employer is defined as"an individual,partnership, association, al rp°1eb nt tiven or sher of legal cieceased,employ or the ore of the foregoing engaged in a joint.enterprise, and including the legal P employees. However the receiver or trristee of an individual,partnership, association or other legal entity, employing owner of a dwelling house having not morn than three apartrarnts and who resides therein, or the occupant of the dwelling house of another who employs persons to do mainten ° Hof such employment be deemoed to be tion or repair work ell p�verse or on the grounds or building appurtenant thereto shall not becauseP 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 buildin;s in the commonwealth for any applicant who has not prodnced•acceptable evidence of compliance with the insurance coverage required." Additionally,MGL ohapter 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 Frith 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),address(es)and.phone numbers) along with their certificate(s)of insurance. Limited Liability Companies (LLC) or Lirr ted Liability Partnerships(L )with or 'cmployeLLP does havteher than the members or partners,axe not required to carry workers''compensation insurance. If an 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 regaxding the law or if you are required to obtain a workers' copensation 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 provide re vide ga spacearding�atethe bo pp antra ' of the affidavit for you to fill out in the event the Office of Investigations has to contact 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 permiWicense applications in any given year, need only submit one affidavit indicating (city oor policy information(if necessary) and under`lob Site Address" the applicant should write"all locationsbe 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 tilled out each year.Where a borne owner or eitizen is obtaining a license or permit not related fo 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: Tho Commonwealth ofMassaGhusetts Llep$ztrnont Of Iu lustri,al Accidents Office oflavestlgadQas. 600 Washington St-eat Boston, MA 02111 Tel. # 617-727-490.0 eat 4.06 or 1-$77-MASSAFE Fax#'617-727-7744 R_;,,A 11 9_n66 n,aco ffnV/dil THE Town. of Barnstable ti Regulatory Services )A"ffrADLE, - Thomas'F, Geiler,Director s.4 MA 0.39. h �Buildin Division Tom Perry,Building Commissioner "200 Main Street,Hyannis, MA 02601 www,town.b arnstable.ma,us Office: 508-862-4038 Fax: 508-790-6 Property Owner Must Complete and Sign-This Section '. If Using A Builder T, 1/>1� S C�°®u•���fgn/' , as Owner of the subject property hereby authorize- to act on my behalf in all matters relative to work authorized bythis building pemut application for ; (Address o job) - eiCn'=—f Owner Date Print Name If Property Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. b Town of Balrnstable �z rti y o� Regulatory Services ' Thomas F. Geiler,Director SARN6TAHLE, ' H"�9. Building Division prfo a Toni Perry,Buifding Commissioner 200 Main Street, Hyannis,MA 02601 ww-w.town.barnstable.ma.us 4v; K \` Fax: 508-790-6230 Office: 508-862'`4038. - - HOMEOWNER LICENSE EXEMPTION J`•� Please Print DATE: JOB LOCATION: 6�`T /4 I number street village ,.HOMEOWNER"; name home phone# .averlephone# �>°!! CURRENT MAILING ADDRESS: 3 city/town state zip code The current exemption for"homeowners"was e tend(, to include owner-occupied dwellings of six units or less and ual for l r who does not possess a license,provided that the owner acts as to allow homeowners to engage an individ supervisor. DEFIN TO OF HOMEOWNER Persons)who owns a parcel of land on which Z11 he reNddes or intends to reside, on which there is, or is intended to be, a one or two-family dwelling,attached or ched stru, tares accessory to,such use and/or farm structures. A c more than home ' a two-year pe 'od shall not be considered a homeowner. Such constructs son who be person he/she shall "homeowner"shall submit to the Building fficial on a form a ceptable to the Building Official, that h responsible for all such work erformed nder the buildingerm't. (Section 109.L 1) The undersigned"homeowner"as/_Uresponsibility for complian with the State Building Code and otheapplicable codes,bylativs,rules anlations. << �' understands the Town f Barnstable Building Departmen t � at he/s he The undersigned homeowner//certifies that he will com with said procedures and minimum inspection procedures and requirements and that he/she requirements. Sig cure of Homeowner ` Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be re iced to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The�ode states that: "Any homeowner performing work for which a building permit is required shall exempt from the provisions of this section jSoction 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a \on(s)for hire to do such work,that such Homeowner shall act.as supervisor,". 4any 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/certifcation for use in your community. f e , r ✓fie V�anvrrearuuea,CC�i o���aaac�iuQelt6 Board of Building Regulatiohs and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registratio 110321 Board of Building Regulations and Standards ns ` One Ashburton Place Rm 1301. Expiration 10/20/2010 Tr# 275345 a- Boston,Ma.02108 i Type DB& . _,. ; CAPRA HOME IMPROVEMENTS:} r FRANK CAPRA 40 COPPER CENTERVILLE,MA 02632` f Administrator Not valid without signature (Massachusetts- Department of Public SafetN AM Board of Building; Reggulations and Standards Construction Supervisor License License: CS 12430 . Restricted-to: 00 r 4 FRANK G CAPRA t_ 40 COPPER:LN CENTERVILLE, MA 02632 Expiration: 6/16/2010 Commissioner Tr#: 26090 i i i E l I I i AiCL *tip ' u u j f-x?Gs i , ;