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0016 STEVENS STREET
/� �S��v��s sr .., ��� �� i ', i i .� ��� ��'�- � v� �,�� �� ; � � chusetts Official Use Only Permit No. ices Occupancy and Fee Checked GU LATIONS [Rev. 11/99] leave blank O PERFORM ELECTRICAL WORK e Massachusetts Electrical Code(MEC),527 CMR 12.00 ON Date: To the Inspector of Wires: r intention to perform the electrical work described below. Telephone No. Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Und.grd❑ No. of Meters Overhead❑ Undgrd ❑ No. of Meters Completion of the ollowin table may be waived by the Inspector of Wires. No.of Total P•(Paddle)Fans Transformers KVA Generators ICVA l Above ❑ In- ❑ No. or Emergency Lighting rnd. rnd. Battery Units FTRF. AT.AR //!� �vi� �u �� � �� �' 8�26 /6 S�Fdfti�° sr �f,� ���s � - �, � � . � � � � ��15�� No. of Switches No. of Gas Burn No. of Ranges No. of Air Cond. No. of Waste Disposers Heat Pump Nu Totals: No. of Dishwashers Space/Area Heat Z W z No. of Dryers Heating Applian oho [n U Vf No. of Water KW o. o o a Heaters Signs ,,,N Z r No. Hydromassage Bathtubs No. of Motors Z o Z OTHER: LU ul INSURANCE COVERAGE: Unless waived by the owner CY o LL W the licensee provides proof of liability insurance including" 0- o r undersigned certifies that such coverage is in force, and has W Q a CHECK ONE: INSURANCE ❑ BOND ❑ OTHER aom L LU 0 o le Estimated Value of Electrical Work: WNo � N LL W W Work to Start: ' ' Inspections to be requeste -cc 0d P I certify, under the pains and penalties of perjury,that the i FIRM NAME: Licensee: Signati (If applicable, enter "exempt"in the license number line) Address: OWNER'S INSURANCE WAIVER: I am aware that the I required by law. By my signature below,I hereby waive this Owner/Agent Signature Telephoi Town of BarnstableBuil. ding FPost.Th�sCar:,dSo Thant is V�s�bleF.com7the Str etA'roved Plans Must beRetaionJob andthis CardMust be:Ker61t HAPIMABLE' a�' _':1 , p ro: ,v .; .. 6 YPostedUnt I'.Final Inspection Has Been Made k= � ° Wfiere�a Certificate:of Occu anc: is'Re uired;such;Buldm sfiall.Notibe Occu ied until a Final Ins ect�op hasbeen;,made , ;;,; Permit . Permit NO. B-18-1372 Applicant Name: EXCEL BUILDING SYSTEMS COMPANY INC. Approvals r Date Issued: 05/08/2018 Current Use:-, Structure . Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/08/2018 Foundation: Location: 16 STEVENS STREET, HYANNIS Map/Lot 309-182 Zoning District: RB Sheathing: Owner on Record: WALSH-CUNNANE TRAN W& LE TU QUYEN Contractor Name,,,EXCEL BUILDING SYSTEMS Framing: 1 Address: 16 STEVENS STREET COMPANY INC. b 2 • - Contractor-License 1�82094 HYANNIS, MA 02601 k Chimney: Description: re-roof stripping old shingles-yarmouth transfer Est Protect Cost: $6 900.00 . Permit Fee: $35.19 Insulation: Project Review Req: Fee Paid: $35.19 Final: Dater 5/8/2018 . Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: id _ Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized bf this permit is commenced within six,months after issuance. q Final Gas: All work authorized by this permit shall conform to the approved applicationand theiapproved construction documents.for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall 6'e incompliance with the local zonm�g b law an'd codes. �t rM This permit shall be displayed in a location clearly visible from access street or road and shall be,maintained open R rApubIi nspection for the entire duration of the Electrical work until the completion of the same. Service: The Certificate of Occupancy will not be issued until all applicable sign�tu�es by the�Build�nggand Fire�O�fficia, are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:' •. ,. - Rough: 1.Foundation or Footing Final: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. - Fire Department . "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT a �l Town of Barnstable - *Permit# Building Department fee 'restimonthsfrom issue date s�exsrne>vE Brian Florence,CBO �S 1 `""M 1 639. Building Coin si e � �d s 200 Main Street,Hy www.town.bamstable.ma us Office: 508-8624038 MAY 04 2016 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION TC� iY Not Valid without Red X-Press Imprint Map/parcel Number t r,, Property Address t� STF�aN S� . Sr. tLAWI n`V�S Residential Value of Work$ 0! ` Q0 On Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address T-L 11 W. t dr l ci 1 Contractor's Name to S��� Telephone Number C)wk3 Home Improvement Contractor License#(if applicable) pa��� Email: i� Construction Supervisor's License#(if applicable) ?313k c1 D.Workman's Compensation Insurance . Check one: ❑ I 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 Re nest(check box) ' 1 Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Pp QM�JVRN\ 1 �L ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ;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 J10111 e Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Qs C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\9NNOKXYW\RESIDENTILONLYEXPRESS.doc 09/26/17 The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations 600 Washington.street Boston,MA 02111 iPv►r•.mass gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Etectiicians/Plumbers Applicant Information Please Print Le6bly Name(Business organaatiowhdividual): Address: 6C7� 3t0 City/Stat&Zip:VUVJ69U�& 91D-% Phone#: Are you an employer!Check the appropriate box: Type of project(required): 1.X I am a employer with�� 4• ❑ I am a general contractor and I employees(full andlor part-time)-* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. - 7. KRemodeling- ship and havee no employees These sub-contractors have. 8. 0 Demolition w for me in an capacity. employees and have workers'- working Y aP tY• I 9. ❑Building addition [No workers'comp.insurance comp.insurance. required-] ired 5. ❑ We.are a corporation and its. ME]-Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all.work 11.❑Plumbing repairs or additions myself. o workers' right.of exemption per MGL mY• � comp. T2.❑Roof repairs insurance required-]t c. 152,§1(4),and we.have no employees-[No workers' 13.❑Other comp.insurance:required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information- 1 Homeowners who submit this affida-it indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such " ?Contractors that ctieck 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-cantraaars have employees,they must provide their workers'comp.policy number. I am art employer that is prmiding workers'compensation insurance for Rey employees. Below is the policy and job site ' information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 rue er he res and penalties of petjnry Heat the information provided attb'ov�e is true and correct Si true: Date: s•"�•\'b Phone#: w-6 cka V%(-G Official use only. Do not write in this area,to be completed by city or town of ciat City or Town:_ PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityfI oum Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 dF� aAPNSTnsLE. Town of Barnstable �fD MAC A Building Department Brian Florence,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 rah. �*& �- L.k��t�( .c_ ,as Owner of the subject property vr'hereby authorize fl&) S\V,dWc to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date' Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\dewllik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\9NNOKXYW\RESIDENTILONLYEXPRESS.doc 09/26/17 Commonwealth of Massachusetts 01)" Division of Professional Licensure Board of Building Regulations and Standards Constrmctfori'§upervisor - - CS-098849 ^j �`f Expires:06/20/2019 RENATO F DA SILVA + P.O.BOX 436 i . FORESTDALE MA 02644 615N Ilk- i` f Commissioner sue. 4✓xe ty'om 7h onlvealel'6fC'rrllC[39��PlIrIJ�/J. Office of Consumer Affairs 8 Business Regulation 3j!' - HOME IMPROVEMENT CONTRACTOR n 3a TYPE:Corporation Registration valid for individual use only Registration Expiration before the expiration date.If found return to: -_182094 05/25/2019 - Office of Consumer Affa and Business Regulation r. 10 Park Plaza-Suite 70 F-2LBUILDING SYSTEMS COMPANY INC. Boston,MA 0211 RENATO DA SILVA 8 JAN SEBASTIAN DR�STE SANDWICH,MA 02563TM` Undersecretary R, Not without signature Client#:38860 2EXCELBU ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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: Dowling&O'Neil Insurance Agy PHONE 508 775-1620 FAX 5087781218 A/C No Ext: A/C,No 973 lyannough Road E-MAIL P.O.BOX 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A•NGM Insurance Company 14788 INSURED INSURER B:AssoelaW Employers Insurance Company 11 104 Excel Building Systems Company,Inc INSURER C PO BOX 436 Forestdale,MA 02644 INSURER o: INSURER E INSURER F i COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MWDD/YYY MM/DD A GENERAL LIABILITY MP02774T 2/22/2018 02122/2019 EACH OCCURRENCE $1 00O 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500 000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1 00O 000 + GENERAL AGGREGATE $2 00O 000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 PRO-POLICY JET X LOC $ A AUTOMOBILE LIABILITY M102774T 2/09/2017 12/09/201 COMBINED SINGLE LIMIT Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC5005009182017A 3/05/2018 03/05/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITYCRYJE ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 OOO OFFICERIMEMBEREXCLUDED? a N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMrT $50O 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C. ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD A,Q9n9l AAAA9n9AAA TOWN OF BARNSTABLE' Building .. tNE " 200804407Permit• BARNSTABLE, Issue Date: 08/19/08 9 MASS 1639. Applicant: GALVIN,PADRAIG J Permit Number: B 20081757 Proposed Use: SINGLE FAMILY HOME Expiration Date: 02/16/09 Location 16 STEVENS STREET Zoning District RB .Permit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 309182 Permit Fee$ 61.20 Contractor PROPERTY OWNER , Village HYANNIS App Fee$ 50.00 License Num OWNER Est Construction Cost$ 12,000 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND FIX KITCHEN AND BATHS(2)AFTER FLOOD DAMAGE THIS CARD MUST BE KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: GALVIN,PADRAIG J BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 16 STEVENS ST _¢ INSPECTION HAS BEEN MADE. HYANNIS,MA 02601 Application Entered by: PR Building Permit Issued By: � � THIS PERM T CONVEYS TIO RIGHT TO OCCUPY ANY STREET ALLEY OR SIDEWALK OR ANY PART,THEREOF EITFIER TEMPORARE Y OR PERMANENTLY ENCRO?CIIMB ON PUBLIC PROPERTY N0 h .. SPECIFICALLY PERMITTED UNDER THE BUILD G CODE MUST BE APPROVED BY THE JTIRISDICTION` STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS:THE ISSUANCE OF TFIh n . a S PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDMSION -, RESTRICTIONS;N z v a t 3 MINIMUM OF FIVE CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.SHEATHING INSPECTION 3.ALL FIREPLACES MUST BE INSPECTED AT THE.THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 4.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 5.PRIOR TO COVERING STRUCTURAL MEMBERS(FRAME INSPECTION). 6.INSULATION., 7.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). BUILDING INSPECTION APPROVALS . PLUMBING INSPECTION APPROVALS ELECTRICAL.INSPECTION APPROVALS CK; 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION. Map- Parcel ,.-Applicatidn # Health Divisio h Date Issued e> Conservation Division = A plication Fee p " Planning,�Dept: Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH Preservation Hyannis LP-rojig(:,�t--Stree�t-Address� Village AA 14 L07w—n e—r-- C"V6LV/k/ Address C-Te I j p—hi 5—ne_—_ CP__.er_mit_Request�- F it Y,-AA_e,, T 60' 1L15 4ptel n ao Square feet: 1 st floor: existing Proposed 2nd floor: existing proposed -----Total new Z6, 01ing District: Flood Plain Groundwater Overlay Project Valuation Z 000'-OoConstruction Type Lot Size 49 XI Z 5 Grandfathered: 0 Yes J,No If yes, attach supporting documentation.. Dwelling Type: Single Family (ir' Two Family Ll Multi-Family(# units) Age of Existing Structure L I-e-4-1s Historic House: J Yes UINo On Old King's Highway: Ll Yes U_<0 U Basement Type: WIPull Ll Crawl Ll Walkout 0 Other Basement Finished Area(sqft). Basement Unfinished Area (sq.ft) 6 7-0 E_ Number of Baths: Full: existing new Half: existing —new----- Number of Bedrooms: existing---new Total Room Count (not;inc.luding baths): existing new ---' First Floor Room Count Heat Type and Fuel: YGas Ll Oil Ll Electric Ll Other Central Air: L3 Yes dN o Fireplaces: Existing New Existing wood/cc all stovV- Ll Yes 5YIN' o Detached garage: Urexisting L3 new size—Pool: Ll existing 0 new size Barn: Ll existing Lhmew size Attached garage: Ll existing Ll new size Shed: Y"existing Ll new size Other: > Zoning Board of Appeals Authorizatidn Ll Appeal # Recorded U Commercial LJ Yes 0"N' o If"yes, site plan review# Current-Use Proposed Use APPLICANT INFORMATION (BUILDER OR ff-0—MEOW-NER) -:� N,ne 6;--)LVI u Telephone Number Address �5_ h�yky,5 167 License S 9' ':E2-9, C C . ;k - Y10 A/Ml 1 5 Oc2_6 01 Home Improvement Contractor# Worker's Compensation # .ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN To Or- C! 166 L_ SIGNATURE DATE _z 'L FOR OFFICIAL USE ONLY i f '$APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER y Y ' DATE OF INSPECTION: -1 FOUNDATION FRAME E INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL iR PLUMBING: ROUGH FINAL -GAS: ROUGH FINAL 11 FINAL BUILDING r DATE CLOSED OUT ASSOCIATION PLAN NO. t. i The Commonwealth of Massachusetts Department of industrial Accidents Office of Irivestigation.s 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affaclavit: Builders/Contractors[EIectriciansRlumbers bly A licant Information Please Print Leif amen(Btu-ms/Organi7atidnllndividual): P/ V' f'�`/I G L�L Al CY I City/Stat'elZip: i�} Q2te (�(�t Phone.#:� S� j G - Arc you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑Kew constraction employees(fun and/or,part-time).* have hired the Sub contractors 2.❑ I am a'sole proprietor or partner- listed on the [A�attached shmt 7. modeling ship and haveuo employees These suh-contractors l�avo $• ❑ Demolition employees and have work' working for mn m, any capacity. 9. ❑Building addition. [No workers' CAIIIp. incitranCC comp-iusurance.t ed_] 5. ❑ We arc a cozporation and its 10.❑Electrical repairs or additions > officers have exercised their I1.0 Plumbing repairs or additions I am a homeowner doing all work myself [NE)workers' comp right of exemption per MGL 12.❑Roof mpairs in - rance required.]t P. 152, §1(4), and we havt no 13.❑ Othcr employees. [No workers' camp.insurance required.] *Any appliCant that cbxla box#1 court also ED out tbr,section below showing thcu workeca'mrop=Mti on policy infaru atim-L t Homeowners who submit this affidavit indicating they arc doing aM work and then I iTr outside contractors must submit a new affidavit indicating such. Xcontractors that cbcck this box must attached an additional 6=t showing the name of the sub-cantratinrs and state wbctha ar not thMd cntiticx have en-iployem. If the sub-contractor;have ernploycra,tbey Trust prrrviLit:their workers'comp.policy Dm-nber. I am an employer that is providing workers'compensa6onz insurance for my emproyees. Below is the porky and job site information Insuzancc Company Name: Policy#or Sclf--ins. Lic.#: Expiration Date: Job Sitc 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 und.cr 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 tlzc form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violater. Bc advised that a copy-of this statement may bo forwarded to the Office of Iavesti ations of the DIA for ing ranee covers e verification. I do hereby certrfy under sins and penalties o perjury that the information provided above rs tPrue rind carrect Vt -cam Date: / Phone#: Official use only. Do not write in this area, Lb be completed by city or town offr.ciaL 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#: 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 iwclling house of another who employs persons to do maintenance,construction or repair work on such dwelling house Dr on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." vIGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or -enewal of a license or permit to operate a business or to construct buildings in the commonwealth for any Lpplicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Wditionally,MGL chapter 152, §25C(7) states`Neither the commonwealth nor any of its political subdivisions shall nt er into any contract for the performance of public work until acceptable evidence of comipLiznce with the ins-maite cquircmcnts of this chapter have been prescntcd to the contracting authority. Lpplicants Lease fill out the workers' compensation affidavit completely, by checking the boxes that apply to.your situation and,if ecessary,supply sub--eontractor�s)name(s), addrcss(cs) and phone numbers) along with their ccrtificate(s)of nuance. Limiti-.d Liability Companies(LLC) or Limited Liability Part ac ahips (LLP)with no.employees other than the wcrnbers or parbncis, are not required to carry workers' compensation inm ance. If an LLC or LL.P does have mployecs, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial midcnfs for conformation of insurance coverage. Also be cure to sign and date the affidavit The affidavit should returned to the city or town that the application for the pcnmit or license is being requested,not the Department of idustrW Accidents. Should you have any questions regarding the law or if you arc rcq Tired to obtain a workers' )mcpensation policy,please call the Department at the number listed below. Self-insured companies should enter their 1f-insurance license number on the appropriate line. ity or Towm Officials ease be sure that the affidavit is complete and printed legibly. Tho Department has provided a space at the bottom flic affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant ease be sure to fill in the permit/liccnse number which will be used as a reference number. In addition, an applicant rt must submit multiple permitllieense applications in any given year,need only submit onp affidavit indicating cuaent licy information(if necessary) and under"Job Site Address" the applicant should write"all locations in (city or va)."A copy of the aif�davit that has been officially stamped or marked by the city or town may be provided to the plicant as proof that it valid affidavit is on yule for fuJnrc permits or licenses. A new affidavit.must be EMed out each ir.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture ;. a dog license or permit to bum leaves etc.) said person is NOT regtvrcd to complete this affidavit affidavit Office of lnvestigations would hlm to thank you in advance for your cooperation and should you have any questions, asc do not hcsitatc to give us a call Department's address, telcphone-and fax number. Thu C6mmmwWth of Massachusetts 1]epartmmt of Industxie Accidents Office of InvestigadUns 6Qo Washington Street Boston, MA 02111 Tel. # 617-727-490.0 ext 4.06 or 1-V7-MAS-SAFB Fax# 617-727-7749� I 1-22-06 www.mass.gov/dia . . ,, Town of ]Barnstable of Yr+E rosy°. Regulatory Services • z -PNSTAsr. , Thomas F. Geiler,Director MASS. Building Division p�pTEO µg- A,�� Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 0260E www.town.barnst2bl'e.ma.us fice: 508-862-4038 Fax: 508-790-6230 ' �--.-- � Ol11EO WNER'LICENsE EXEMPTION DATE: �G. [� �`�`�� • JOB LOCATION: Village number street g 8 �f�Ol �l G 6A�-V r n� s 9 ',L,5 "HOMEOWNER": work phone# name home phone# CURRENT MAILING ADDRESS: U tf �� city/town _ state rip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units of 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 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 dwellin , attached or detached structure's accessory to such use and/or farm structures. A t . y g person who constructs more than one home in a iwo-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 buildingpermit. (Section 109,1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. I7ie undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department nu=um inspection procedures and requirements and that he/she will comply with"said procedures and •equ. menu. � �t V 1 :ignaturc of H co .ppmval of Building Official Note: •Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the tate Building Code Section 127.0 Construction Control. $OMEOWNER'S EXEMPTION The Code states that "Any homeowncr performing work for which a building permit is required shall be exempt from the provisions homeowner engages provided that'if the homeowner a person(s)for biro to do such this section(Section 109.1..1 -Licensing of Boost u.ction Supe )rk,that such Homeowner shall act as supervisor," Many homeowners who use this exemption aic unaware that they arc assumingonsi the respbilities of a supervisor(see Apprndix Q, i)es&Regulations for Licensing Construction supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly un the homeowner hire unlicensed persons. In this ease,our Board cannot proceed against the unlicensed person as it would With a licensed pervisor. The homeowner acting as supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her rrsponsibilitirs,many communities require,as part of the permit application, .t the homeowner certify that hc/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by reral towns. You may care t amrnd and adopt such a forrn/ccrtification for use in your community. Erg ToWn of Barnstable � o - Regulatory Services + )AHNSrABLF, v auSM $ Thomas F. Geiler, Director. Eoi 9. X - Building Division ' Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnsta ble_ma.us Office:. 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Compl . to and Sign. This Section f Using .A.. Builder I , as wner of the subject property ' hereby authorize. to act on toy behalf, in all matters relative to work authorized by thi uilding p t application for: (Addres of Job) Sigmture.of owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 04/18/2008 08:26 5087786448 HYANNIS FIRE PAGE 01 ❑ Delete NFIRS - 1 01922 MA L 4/17/2008 001 - A280296 �0 B change . State 1 Incident Dale Station IncldsmNumber l Exposure No Actively BaStC p P`❑ Crrech lhis box to Indicate That the address for this incident Is provided on the Widend Fire 7� Ceneu6 TraU 40 [7 Location * Module in Section 9'Alternetive Location Spedfim lon'.use only for wildland fires. ® Street Address I 16 _J L�J S'1 EVENS ST1 ET ST J I � ❑ Intersection NumberlMilepost Prefix street or Highway re¢l ype Sultix ❑ R front of J MA J 02601 ❑ Rear of ;._ J Hyannis ❑ Adjacent to Avf./SultarRoom CtY rate zipcoae ❑ Directions Ilarea of Winter st ❑ Cross street or direction a,as app cable c Incident Typ® * E1 Dates&Times Midnight is0000 E2 Shifts&Alarms 522 Water. or steam leak Local Option Check boxes if Month Day Year Hour Min Incident Type _ dates are the U Still 3 J same as Alarm ALARM etwey8 required P Aid Given—Received * Date, Alarm * 04 l l� 2-008 ) 1:12 plat(atoo NpOfAlarm®Islrct 1 ❑ M.uival aid received ARRIVAL required,unless canveleo or did nvt arrive 2-❑ Automatic aid recv. � U Arrival * 04 L 17J 2008 1 1:a 8 E3 Special Studies Their FDID 'their LoralOpf- �, ❑ Mutual aid given $late CONTROLLED options',except for vniaanofrea '4` Automatic aid Given ❑ ❑ Controlled Li 5 ❑ Other al given xt+l.: NOoe Last Unit LAST UNIT CLEARED,reavired exoeptwltdls.d are sped Special �:. r nc, em Number ® Cleared L4J LJ 2008 12-:08 study Oil studyvalu6 pictions Taken �1 Resources G2 Estimated Dollar Losses&Values - Check this box and skip this section If an ❑ Appgretue or Personnel form is used. LOSSES: Required for eh fifes If known..Optional for non fires. L6 I Investigate r� -- ` I c-- Non 8 Primary Action Taken(�) Apparatus Personnel Property q ❑ suppression 4 El Contents -� 45 Lemove hazard I �z` .: - ` ;.AdmuonalActonTaken(2) EMS 0 0 PRE-INCIDENT VALUE: optigdal L84J Lefer to rimer authiority Other Q J I 0 J Property ❑ Additional Acilon.Taken(3) Check cox if❑ resource counia include aid Q received resources. Contents f ! t~oPnpletE!Modules Hi C3 None Hs Hazardous Materials Release Mixed Case Pr"operty _ Deaths injuries - 1 ire Fire I N 09 None NN® Not mixed �'2"' ' SeMce 0 1 ❑ Natural gas;slow leak.no evacuation or MazMat actions 10 ❑ Assembly Use ❑i'St'r,it,Fturc-3 � 2 ❑ Propane gas; <211b,tank(asinhome8EQgrliq 20 [� EdUCatIOnUS® [}CIvili:an Firc Gas.�4 33 ❑ Medical use JFiro;:Serv. Gasualt I 3 [] Gasoline:van;elerueltankorportableoontelner 40 ❑ Residential use Y^Civilian 0 II 0 4 Kerosene;fuel burning equipment or portable storage �..J 1,�_. 51 ❑ Row of stores `:kiazMat-7 — 5 [1 Diesel fuel/fuel oil' vehicle tuel tank or portable storao 533 ❑ Enclosed mall Detector 6 ❑ Household solvents:Horne/office spill,cleanup only 58 ❑ Business&residential ( Wild'La.nd Fire-8 H2 Requlredflorconfirmednres. `59 ❑ Office use Apparatus-9 7 ❑ Motoroll:rromertgineorportablecontslner 60 [3 Industrial use Personnel-1 0 1 ❑ Detector alened occupants 8 PAlht'from paint cans lotalin®<SS gallons 63 ❑ Military use 2[3:Detector did not alert them. 0 ❑ Other:special 14 =Mat actions required or spill-55 gal., 55 ❑ Farrn use U❑l Unknown please complete Ine HazMal form 00 ❑ Other mixed use Property Use Structures 341 ❑ Clinic,Clinic Type infirmary 539 ❑ Household goods,sales,repairs 131 Church,place of worship 342 ❑ Doctor/dentist office 579 ❑ Motor vehicletboat sales/repairs 131 ❑ Restaurant or cafeteria 361 D Prison or Jail,not juvenile 571 ❑ Gas or service station 161 ❑ Restauem or nightclub 419 ❑ 1•or 2-family dwelling 599 ❑ Business office 162 ❑ Elementary school or bndergart. 429 ❑ Multi-family dwelling 615 ❑ Electric generating plant 213 •Elgh school or junior high 439 ❑ Rooming/boarding house 629 ❑ Laboratory/science lab 449 ❑ Commercial hotel or motel 700 ❑ Manufacturing plant 241 ❑ College,adult eel, 469 ❑ Residential,board and care 019 ❑ Livestock/poultry storage(barn) i • i 11.:,: -Care facility for_the aged 464 C3 Dormitory/barracks. 882 ❑ Non-residential parking garage 331 •..: Hospital ❑ 619 ❑ Food and beverage sales 891 ❑ Warehouse putside g36 ❑ Vacant lot 951 ❑ Construction site Playground or park • "' 656',. Crops or orchard � [3Graded/cared for plot of land 984 ❑ Industrial plant yard 951 ❑ Lake,river,stream Forest(timberland) a:`. ❑ 951 ❑ Railroad right of way i•1 '''807 : ❑ putdooratoragaarea 960 ❑ Otheirstrvet L>=k�pende�w. PropenyUa 918 Dump or sanitary landfill 961 ❑ Highway/divided hi highway Property Use code only If L_41 .T' 931; ' Open land or field g y yo u have Use ohedcetl e 962 ❑ Residential street/driveway Property use box: I 1 or 2 family dwelling) ' 4 - pia$.,Rrv4bna]'11� „00296 - EXP 0, 4/17/2008 PAGE 1 OF 2 uvnnIA174Z FrOP /1FPARTMF1VT- MFIRS REPORT 04/18/2008 08:26 5087786448 HYANNIS FIRE . PAGE 02 K1 Person/Entity Involved 859-523-7652 ^^ Local Option I guslness name(11 appfrable) Phone Number Chackthlsboz! I�alll u Galvin Suffix same address as Mn,'Ms.,Mre Pkst Name MI heal Name inhen t.kip the n.three L—�I I -t• Then skip the IhrBe I 0,plicaleaddreec L 3900 �J Crosby Drive firm. Street Type Suffix Number/MllapOst Prefix Street or Highway Lexington _ L_.�_. — - .Apt.,S�I1QJRo 1623of city i Poel Orrice Box i K 40515 Y L ! y v Stale Zip code . ]ryltsjrepeople Involved? Check this box and attach Supplemental Forms(NFIRS-1S)as necessary. Own9r ameaspereonirno 859-523�7652 K� Then check this box and skip Paul y Phone Number Local Option lRe rest or this scclion. �neap name( epp IGa ef' t (s�enience)ca Idhdtar eb9o8 9 if 8 JI Galvin � I SuttlXPaul Mr.,Ms.,Mrs. First Noma MI Last Name ihten s location Then snip the three dupli'Ste addrese 3900 I I Crosby Drive _ -- Ivws, h� Street Type Suffix NumbetlMl Prefix Street or Highway - J 1623 .J I Lexington ...:� Post orrice®ox ADI.ISviterRoom City � I l-......4051 SJ state Zip Code Remarks: — - --- Local opton .w !.ITEMS WITH A '* MUST.ALWAYS BE COMPLE7ED1 ® More remarks?Check this box and attach Supplemental Forms - (NFIRS-18)as necessary. MAuthorization - 1197404 J lJoseph p Cabral, J — I I.Captain/EMT LSuppression 04 17 L2008.1 Ofricar in charge ID $ignauue Position or rank Assignment Month Day Year GSsck box 11 same as •omcot In . C9 197404 J IJoseph P Cabral, J Ca rain BMT I Suppression L04J 1 1711 2008 1. Member makingreponID SionahKa Postionorrank ppsl®hma u Month Day Year 3-8 296 - Exp 0� 411712008 16 STLVFNS S'1lt�El page 2 of 2 HYANNIS FIRE DEPARTMENT - MFIRS REPORT r 04/18/2008 08:26 5087786448 HYANNIS FIRE PAGE 03 ❑ 0elete �NIP711RS - 1S0,1922 ( MAI4/17/2008Exposum 001 LA280296 0 ❑ Change ISemental L� g�je Inudent Date $teLlon k CdenL Number 16 STEVENS STREF-T 1'\3 Remarks smoke alarms Feceedwalk in report from former cal firefighter-.et 4lZesponseichael E. lengine 823onoghue eo y with porting myself and home on Stevens Street near eshall. LaMothe (driver), Corbett analCoggisture around several l find the home to be unoccupied and the correct address is 16 Stevens Street..We dad a walk the exterior and hear thu sounded to be water running.The lairms sounding. We e smoke aalso neighbor at 13 Stevens Stre t had the windows and we could hear what so n owner ax� M85915Z3(7652 Galvin Homes ). 3900 Crosby Drive Apt. name and a telephone number of the home o 1623 Lexington, Kentucky 40515. 'Telephone & F Fire alarm operator Doherty was abl e to contact the owner and we were advised that there was a key under the .rxlat at the back door on Side 13. We made entry aatd find water leaking down into the kitchen r �. above the second floor. There also was water over flowing from the kitchen, sink. We went down to the r was also wn into nt mostlY base:E�nent and -shut the water off at the directly kit h n- The power on to thehh nee We shut the on . ,• side '1B the laundry area which is y vvaier off at the meter. W� shut the power off at the panel. We shut the gas off at the meter on Side d A,fte't further investigation on the second floor we find the bathtub, and bathroom sink over flowing. The "throom sink which has an over flow drain built into the sink was covered wit) � duct tape_ The toilet was �• plugged solid with toilet paper and flushed. What I first thought to be a broken water pipe was, a purposely!; .done act to cause damage to the home. I requested Barnstable Police to the scene. Officer Brian Morrison badge 205) arrived on location. He requested Barnstable County Identification officer to the scene for photos. The Barnstable Police case number for this incident is 08-970- OF report by officer Morrison_ I requested N Star Electric to cut the power to this home. NStar arrived and cut the power at the top of pole nuxna r 193 / 2. t $poke to the owner by phone and he advised me he.h.ad a caretaker en route from, East Dennis, Connie Tvf•ooers of 12 Danvers Lane East Dennis cell phone 1-978-697-9092 and a home phone 508-385- 2193. Ms, Mpoe,rs rarrived op location and I turned the house key over to her_ Mr. Galvin is planning on coming into � y.an '.this weekend. As to who and or why this took place is a police matter: 1 turned the property over i,• {o;the owners caretaker Connie Nlooers..l will notify the wiring inspector when I get back to the station. pgl,ne,$23 cleared at 1208 Hrs. I cleared the scene in car 803 at 1313 Inns. 7 tait>'Jose h P. Cabral Jr. 4/17/2008. I t.. i L ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 1 ! Parcel , ��� . � �� Application 00&*K Health Division Date Issued ? 9 Conservation'Division ;`. Application Fee -� Planning Dept. Permit Fee ` : Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/Hyannis Project Street Address Village Y/f/V iv/,S Owner OtlJ '/pVI 4�9 Vi/b/ Address K'f. qoS 23-1 2- Telephone Permit Request V, h Tf/L 01) Af >- iio y� to j T D k Ir ldJ/N- Al Su op c r f I Square feet: 1 st floor: existing k�Sproposed G 2nd floor:°existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Ud Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 3/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: 6Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing / new Half: existing new Number of Bedrooms: - existing _new 0 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: 9 Gas ❑ Oil , ❑ Electric ❑Other .' Central Air: ❑Yes ❑ No Fireplaces: Existing J_New 67 Existing wood/coal stove. 0 Yes ❑ No Detached garage: dexisting ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ezi'ating 0 newt size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ r� ram, Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION_ (BUILDER OR HOMEOWNER) Name Wh/�L :CAl R f' C adrA 414a41 Sa Telephone Number r Address License# C7 7 q <�r A,Al f ���= <;, d,�� �' Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO P t SIGNATURE��� �� DATE Q tl .Z FOR OFFICIAL USE ONLY ` APPLICATION# DATE ISSUED , MAP/PARCEL N0. ADDRESS VILLAGE OWNER , z DATE OF INSPECTION: FOUNDATION FRAME ; INSULATION ' FIREPLACE ELECTRICAL: ROUGH 'FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 4 600 Washington Street Boston, MA 02111 r www.mass.gov/dig " Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/fndividual):AtA ILL i IV • ,E y TJ A "A/ ky l C_ Address: 2 M e tL.1 C/i r►. Phone.#: G _. City/State/Zip: �a ���� .�� ✓`�/� G� �� Are you an employer? Check the appropriate bog: Type of project(required): . I am a general contractor and I 1.[�I am a employee with� 4 _ 0 - 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.El 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 � • working for me in any capacity. employees and have workers' 9 Building addition [No worker' comp.-msurance comp.insurance.$ required] 5. We are a corporation and its 10.❑Electrical repairs or additions eq„ir ]. 3.El I am a homeowner doing all work officers have exercised their I l.0 Plumbing repairs or additions myself.[No workers' comp. rigbt of exemption per MGL 12:❑Roof repairs insurance required•]t c. 152, §1(4),and we have no employees. [No workers' 13.[' they comp.insurance required.] L, TV j1e l`L e "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. tr—M racton that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have mmployees. If the sub-contracton have employees,they must providt their workers'comp.policy number. lam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and jab site information Insurance Company Name: lL f L.L j) Policy#or Self-ins.Lic.#: 'S r2 12 Ll �_'> 5 Expiration Date:O!y_, Job Site Address: �[�.3 cs T�t/�.r�j*S' S' T City/state/zip: dV 11/I� 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 crimiuial penalties of a fine tip to$1,560.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip 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 WA 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 Date: Phone# Official use only. Do not write in this area, to be completed by city or town offuiaL 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#: 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." 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 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(LL.P)with no employees other than the members or partners, are not required to cant'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 aidavit 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would lice 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 CammonwWth of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston,MA 02111 TO. #617-727-490.0 ext 4-06 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia r �oFTHETo,,� Town of Barnstable Regulatory.Services �BMASS.AMSTABM Thomas F.Geiler,Director t6.39. a`` Building Division Tom Perry, Building Commissioner 200 Main.Street, Hyannis,MA 02601 www.town.barnstable.ma.us y Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �w I. J , as Owner of the subject property hereby authorize w�'�w�� n ���� to act.on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) i Signature f caner U Date E Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 1 q Town of Barnstable mop SHE rp�� Regulatory Services . • Thomas F. Geiler,Director • swtttvsTwat.t:, . Mwss. Building Division PIED FM't A Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 R'ww.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 c+ 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) } i 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 i 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 persons)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 tamend and adopt such a form/certification for use in your community. Datet 4/23/2008 Time: 1:56 PM To: Kathleen @ 9,1,5087609995 R&G Ins. Agay. Page: 001 Client#:32193 WHALRES ACORD,M'•'.CERTIFICATE OF LIABILITY INSURANCE: 4123808°'r"Y"' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 "' HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 1601 x South Dennis,MA 02660-1601 ` INSURERS AFFORDING COVERAGE NAIC# INSUFZ® NSURER A: Arbella Protection Co Whalen Restoration Services Inc NSURERB: Arbella Mutual Insurance Company 22 American Way NSURERC: South Dennis,MA 02660 NSURERD: NSURER E: - COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO T-IE 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 AF=ORDED�Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN NAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBEP. POLICY EFFECTIVE POLICY EXPIRATION -. - LTR NSR DATE MMIDD1YY DATE MMiDD/YY LIMITS A GENERAL LIABILITY 8500024585 04/01/08 04/01/09 EACH OCCURRENCE $1 00O 000 X COhIMERCIAL GENERAL LIABILTY - - DAMAGE TO RENTED - PR ISES cc, $100 000 CLAIMS MADE a CCCUR MED EXP(Ary one person) $5 000 PERSONAL&ADV INJURY $1 000 000 - GENERAL AGGREGATE $2 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 PCLIC�7 PECTRC- LOC - - J A AUTOMOBILE LIABILITY 74917400001 09125107 09125/08 COMBINED SINGLE LIMIT g1,000,000 ANY AUTO _ ." ( ) ALL OWNED AUTOS - - - BODILY MURY $ X SCHEDULED,AUTOS (Forpapan) X HIREDAUTOS , BODILY INJURY g X NON-DWNED AUTOS (For accident) PROPERTYDAMAGE $ (Fer accident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSAXMBRELLA LIABILITY 4600021586 - 04/01108 04/01/09 EACH OCCURRENCE $1 00O 000 X CCCUR CLAIMS MADE AGGREGATE $1 000 000 $ HX DErUCTIBLF $RETENTION tM:$10000 $ B WORKERS COMPENSATION AND 9091320406 04/01108 04/01/09 X WC STAPJ- CER EMPLOYERS'LIABILITY --' - ANYPROPRIETORIPARTNERiEXECUTIVE E.L.EACHACCIDENT $SOO,000 OFEICERIMEMBER EXCLUDED? - E.L.D SEASE-EA EMPLOYEE $500,000 - If yes,cescribe under - - SPECIAL PROVISIONS below �. E.L.D SEASE-POLICY LIMIT $500,000 OTHER - DESCRPTION OF OPERATIONS!LOCATIONS J VEHICLES 1 EXCLUSIONS ADDED BYENDORSEMENTI SPECIAL PROVISIONS Project location: 16 Stevens St.,Hyannis,MA 02601 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Padraig and Paul Galvin DATE THERE-OF,THE ISSUING INSURERWILLENDEAVORTOMAIL 10 DAYS WRITTEN 102 Goodrich Ave, NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Lexington,KY 4050349112 i IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 'REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 of 2 4S3553611111134002 ���_ CBR ©ACORD CORPORATION 1988 f �f'L� �C9Yl/J3'cf//ZCU,°LL�� �-•aLtrdSGil/iUCc:�� _ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR f3 �; Number CS 074928 p Birth&te 08/10/1961 ,. , Expires 08/10/2008 Tr.no: 1273.0 Restricted 00 WILLIAM WHALEN =< 122 POND STREETAl BREWSTER, MA 02631....:, Commissioner Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration 129244 Expiration 7/.30/2009 Tr# 132276 :Type .Private Corporation Whalen Restoration Services Inc. .,; William Whalen 22 American Way ,", South Dennis, MA 02660 Administrator / a t c f' Town of Barnstable *Permit# 0 Expires 6 months from issue date ®� Regulatory Services Fee ,9 5 RESS IT Thomas F.Geiler,Director n SEP 2 0 2007 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 without Red X Press Imprint Map/parcel Number 30 Property Address /G' //�/yS — /-�7fjd�/l�/.� /-74 0,26 O/ ❑Residential Value of WorlA;4,0 45,90e). Minimum fee of$25.00 for work under$6000.00 �wner's Name&Address Contractor's Name Telephone Number CIS '�1� ��6? Home Impro ment Contractor License#(if applicable) Construction Supe or's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I 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 ertificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ;&Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *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. AVz of the Home Improvement Contractors License is required. SI NATURE: Q:Fomis:expmtrg Revise061306 Qom.; The Commonwealth of Massachusetts 'e Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers" Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name dividual):_ Aa-�/z 67 •Address: City/State/Zip: ` ewln�S_ _/9 '0,)K01 Phone.#: ?S'� Are you an employer? Check the appropriate box: Type of project(required)-. L❑ I am a employer with 4. El 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' [No workers' comp,insurance comp.insurance.#' 9 ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions •3I am a homeowner doing all work officers have,exercised their 11.❑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' .43.❑ Other 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 anew affidavit indicating such. LContractors that check this box must attached an additional sheet sbowing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provi&their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below isihe policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), Failure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of 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 Inves tions of the JIA for insurance coverage verification, I h reby certify' ter the pains•and penalties of perjury that the information providedID �V . . tru and correctSi attire: C� Date: � o� _ _7 Phone #: Official use only. Do not write in this area,'to be completed by city or town o_JJ City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: i' s�4 Town of Barnstable OFZIiE Tp� " Regulatory Services Y BARNSfABLE, Thomas F.Geiler,Director MASS. 1639• p,0 Building Division 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: 2 yC JOB LOCATION: 2 j �y�� 1-721-9 021 0 �Y/ numb r street village "HOMEOWNER!': r Y`Cli/pq � V/7 name home phone# J work phone# CURRENT MAILING ADDRESS: ( o2 `— �e 17 /,7 -3 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 req ' ements Signature of Homeo r 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