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HomeMy WebLinkAbout0038 STERLING ROAD u - -- 1 - - - --- - - - - - _ _ �89 - i�/ L_ ell -Application.number..... .......................................... . .......... .. Fee ................... .............. MAM t Building Inspectors .....ILI....t .............. 163 terr„p �A Date Issued....... .�:......1A....... q Map/Parcel........c7 r .r;� .................... TOWN OF�BARNSTABLE _EXPEDITED PERMIT APPLICATION: , ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY.INFORMAT;ION''' .& + ':�: - .•�.;_ � �.• . to.i... -1a • r - �-: _ ...Y i.LAD Addressof Project: cC n16� Y NiTNIs R , - STREET; .� i • r.. ;,VILLAGE i - Owner's Name: 1°��- Phone Number Email Address: 6�TP�-� ��� CDWtA$1 �YC l Cell Phone Number Project cost$ �� } Check one Residential } Commercial OWNER'S AUTHORIZATION __ .: �__ _. �_ •� As owner of the above property I hereby authorize to make application for fo01 r ermit in accor e with 780 CMR Owner Signature: Qv Date:'-, ' ch TYPE OF WORK <. i � ❑ Siding f W}ndows (no header change) # D rpInsulation/Weatherizat3on F , 1;0 ❑ Doors (no header change)# Commercial Doors require an inspector's+review Roof(not applying more than 1 layel of shingles) Construction Debris will he going to -4- - t- - �-- —CONTRACTOR'S INFORMATION`---- Contractor's name Home Improvement Contractors Registration(if applicable) # (attach copy) • ,''� r.,". a:•,1t'- "c►� " jt ,•, �+i s � ' s.1r'� 1i ,.i' ,�rR .y: E' ....r'.`".s�4c•, Construction Supervisor's License# V"l"l t (attach copy)x . Email of Contractor hone numbetSDF) 509 ALL PROPERTIES THAT HAVE STRUCTURES OVER 7S YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE 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. Purpose of Event. Check one: this event is a: for profit non-profit event Check one: Food served Yes No i 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. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side i- HOMEOWNER'S LICENSE EXEMPTION - - 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 - -- Signat Date t k- 5 , 1 l All permit applications are subject to a buil 'ng official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 �e e' www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 2 Please Print Le gib Name (Business/Organi non/Individual):,k"�. Address: L r City/State/Zip: ,V_S Az + h- �> Phone#: Are you an employer?Check the appropriate box: Type Of project(required): I.E!fl am a employer with _employees(full and/or part-time).* 7. ❑New construction 2.n 1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q 1 am a homeowner doing all work myself.(No workers'comp.insurance required.] 10 Q Building addition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub=contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.[:]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.) aAny 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. I am an employer that is prov d1n9 workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:((`. V2� _ U i kplration Dat : IS - 10- Zo c Job Site Address:-DO S'(tN_A_ & City/State/Zip: t 02-6q Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under IvMGL 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.hereb •ti order the pains and pe es perjury that the information provided above is true and Corr ct. Si natuCeL /_�; - �_r) Date: 4l .......... Phone#: C 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): t 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: w CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 07/02/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONE 508 775-1620 FAX N, E-MAIL ADDRESS: lsuilivan@doins.com 9731YANNOUGH RD INSURERS AFFORDING COVERAGE NAICS HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURERC: INSURER D: 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 420827 REVISION NUMBER: THIS 1S 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 TYPEDF{NSURANCE ADDL SUB POLICY EFF POLICY EXP LTR POLICY NUMBER IMMA LIMITS COMMERCIAL GENERAL LIABILnY EACH OCCURRENCE $ CLAIMS41ADE DOCCUR PREMISES SEESS i N Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ M'OTHER: L AGGREGATE LIMIT APPLIES PER: PRO- GENERALAGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS WA BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $. HIRED AUTOS AUTOS Per accident $. UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ e DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YINX STATUTE ER _ ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? I WA WA WA 6S62UB8H08580919 05/10/2019 05/10/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts.employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance).. The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/iwd/workers-compensationrinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Barnstable Insurance Company ACCORDANCE WITH THE POLICY PROVISIONS. 108 Route 6A AUTHORIZED REPRESENTATIVE Yarmouthport MA 02675 Daniel M.Cro4v)ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvemenf'Contractor Registration Type: Individual OLIVER KELLY Registration: 128957 8 RHINE RD Expiration: 06/13/2021 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 0 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TY?E:.Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 128957_e°_? 06/13/2021 1000 Washington Street -Suite 710 OLIVER KELLY. ., Boston,MA 02118 OLIVER M.KELLY-::; 8 RHINE RD. YARMOUTHPORT,MA 02675 Undersecretary Not valid without signature Commonwealth of Massachusetts } Division of Professional Licensure Board of Building Regulations and Standards Construction'StJoerdisor Specialty CSSL-099167 Expires:09/2812021 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 - bb Commissioner JLAAA.,L)