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Home My WebLink About0185 STEVENS STREET ZIA_) Town of Barnstable Building Department - 200 Main Street BARNSTABLE. * Hyannis, MA 02601 9 MASS. �A ze319. a.� (508) 862-4038 Certif icate of Occupancy,, . .Application Number: 88590 CO Number: 200800008 Parcel ID: 308025 CO Issue Date: 07/22/08 Location: 185 STEVENS ST Zoning Classification: OFFICEIMULTI-FAMILY RESIDENTIA Village: HYANNIS Gen Contractor: ROBERTS, MICHAEL Permit Type: CCO2 CERT OF OCCUPANCY COMM 2 Comments: FOR UNIT 1 E - Building Department Signature Date Signed .s. r TOWN .OF MAP.NSTABLE, UNIT 1E, UNIT 1F, UNIT 1G NYF.W Ai,AT �F,I��T PARCEL ID 308 , 025 CMBASE .ID 21994. PHONE AllDIL"s8 185 STEVENS ST 1-p HYANNIS MIADEVELOPKFF, I f ti;`C ?1 CT H5' 85830 DESCRIFPT ON APAR Mi FNTS UNITS t�E, 1F 1c, , =EI ° T7 if YI I30TLI TI ['LE j NEW, R SID)ENTIAL FLD_ - '- (Y 1 coiTRAC1O S, ROPEERTS, MIC14AEL Dejpartmefit Of ARCHITECTS- Regulatory Services I'��TA'� EEEB $T,315.00 BOND c_;UNSTROCTION COSTS 150,000 .00 „i /" BARN3PABLE, 1 , BUILDING�D,IVISION BYmot .. F e-�..i.�.f}a.�j��:. LJS EXPIRATION 'DATE. DATE ISSUED i _ dam. � THIS PERMIT CONVEYS NO RIGHT TO.00CUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC.SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OFTHIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. . . r MINIMUM OF FOUR CALL INSPECTIONS REQUIRED APPROVED PLANS MUST BE RETAINED ON JOB AND FOR ALL CONSTRUCTION WORK:- WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION 'PERMITS ARE REQUIRED' FOR 2. PRIOR TO COVERING STRUCTURAL HAS MEMBERS' BEEN MADE.WHERE A CERTIFICATE OF OCCU 'ELECTRICAL,PLUMBING AND MECH- (READY TO LATH). }F FANCY IS REQUIRED, SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS, 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE:, 4,FINAL INSPECTION BEFORE OCCUPANCY: lip® M li ® ® ® Maim I ammugai - BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS fA OK 2 NS iD - ? , 2 %7r 3 ( `'f— t)(C 3-7 HE PECTION APPROVALS ENGINEERING DEPARTMENT �-t K ! 155 0 . �I �.� 2 Q .�;$ a. ":� _ MROF HEALTH SITE PLAN REVIEW APPROVAL OTHER: " do had WORK SHALL T PROCEED UNTIL ' PERMIT,WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED VARIOUS VARIOUS STAGES;OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA TION. NOTED ABOVE. : TION.: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 6 Q Parcel a bD Application # o�6 f. d; 17 Health Division Date Issued Conservation Division Application Fee �d Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation / Hyannis Project Street Address Ip . 044 v Ia FaTV&j) Village P-on Y) n i Owner c�.L)IIr+ c� c, Address j- i� Telephone rK Permit Request 6a/m amd UI Zfo Ke a /,c! v � av .4s � ' a Sec. arZWC-�i� � Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation � p Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) _ Age of Existing Structure 6,P Historic House: ❑Yes No On Old King's Highway: ❑Yes Vlo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other o Z Basement Finished Area(sq.ft.) Basement Unfinished Area (sgft) -a Number of Baths: Full: existing new Half: existing new' Number of Bedrooms: existing _new = Total Room Count (not including baths): existing new First Floor Room Count N Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use � awdo Proposed Use APPLICANT INFORMATION ` (BUILDER OR HOMEOWNER) ;' _Name Telephone Number ,� � �J�-7 l (� � w Address II csdy-1, 1 License# r 50q:7 Coo - �ul Isz . l� 02=(a32 Home Improvement Contractor# Worker's Compensation # r E�l OJC Oa-)4gLI ALL CON TRUCTION DEBRIS ESULTINGViaOM THIS`PROJECT WILL BE TAKEN TO vr � SIGNATURE DATE a6 FOR OFFICIAL USE ONLY APPLICATION# r DATE ISSUED MAP/PARCEL NO. Fr 1. 4 ADDRESS VILLAGE .5 t F OWNER DATE OF INSPECTION: a _--,FOUNDATION 4 FRAME t INSULATION '1 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i r� The Commonwealth of Massachusetts Department of Industrial Accidents I Office of Investigations G 600 Washington Street Boston,MA 02111 -� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): COcP_ou-- 9 =11c , Address: a 1 City/State/Zip: ann(S N CL_02_(d_)L Phone#: Are you an employer?Check the appropriate box: 4. ❑ I am a general contractor and I Type of project(required): G 1. I am a employer with 6. ❑New construction employees(full and/or part-time).* " have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ 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.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work. officers have exercised their 11.[1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]f c. 152, §1(4),and we have no employees. [No workers' 13. ther comp.insurance required.] tba- I *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. �~ Insurance Company Name: C-Ve_.M?f_-1J"" M0,.47(C )CY-6 r_S._...11`JL)r-C�.r Policy#or Self-ins.Lie.M F J C% 0 0 Expiration Date: Job Site Address:__ O'R5 Q5ki-)-co S ��4r VY11 ER 1;3 City/State/Zip: 15 M a Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).oZ 1 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 cerd u r th a and penalties ofperjury that the information provided above is true and correct. J Si nature:' Date: ! ct� Phone M Official use only. Do not w to in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of I3ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#:586925 20CEANSIDEIN ACORDr. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 01/31/2014 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(les)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 ONE T Dowling 8,O'Neil PAt]c°Ne Ext;508 775.1620 ac No): 5087781218 Insurance Agency E-MAIL ADDRESS: 973 Hyannis, M MA 02601 ugh Rd., PO Box 1990 INSURERS AFFORDING COVERAGE NAIC# Hy INSURER A:Arbella Insurance Company INSURED INSURER B:Everest National Insurance Comp Oceanside,Inc. INSURERC:Safety Insurance Company 217 Thornton Drive INSURER D: Hyannis,MA 02601 - INSURER E; INSURER F: 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, �N EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MR TYPE OF INSURANCE ADD SUBR POLICY EFF POLICY EXP - INS WVD I POLICY NUMBER MMIDDNYM (MMIDDffMI LIMITS A GENERALLIABIUTY 8500061423 01/01/2014 01101/2016 EACH OCCURRENCE $1 000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE? RENTED PREMISES Ea occurrence $100 000 CLAIMS-MADE F OCCUR MED EXP(Any oneperson) $5 OOO PERSONAL&ADV INJURY $1 00O 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $2 000,000 POLICY AF-- LOC $ C AUTOMOBILE LIABILIrY 2434628 0110112014 01101/201 COMBINED SINGLE LIMIT Ea accidenl 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X (Per acc AUTOS )SCHEDULED AUTOS BODILY INJURY(Pidenl $ NON OWNED PROPERTY DAMAGE " IX HIREDAUTOS, X AUTOS F Peraccldent $ $ A X UMBRELLA LIAR X OCCUR 4600061424 01101/2014 0110112015 EACH OCCURRENCE $2 00O 000 EXCESS LIAB CLAIMS-MADE AGGREGATE s2,000,000 DED I X1 RETENTION 10000 $ B WORKERS COMPENSATION BINDER369533 01/0112014 011011201 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN IER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $1 OOOOOO OFFICERIMEMBER EXCLUDED? N] N I A (MandatorylnNH) E.L."DISEASE-EA EMPLOYEE $1,000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) - it 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''�'LL�b�^'�.-'�--.�� m 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1240761M 124075 KKM JEW Massachusetts '- Department of Public Safety Board of Building Regulations and Standards Construction Sup&visor License: CS-073097 PETER A LAROCE 18 CEDRIC ROAD ' Centerville MA 02632 ; _.:xoiration ��r. ssicner 11/03/2014 E -- ffice of Consamer Affairs:&Business Regulation '` ME 1MPROVE�f91ENT CONTRACTOR' . e T glsratlo Aa YP Expiratt e Su'046Ment OCEANSIOE;;INC -00 PETER LAROCHE _ 217 Thornton Dr Hyannis; MA 02601 . Undersrrce-etary . Lieense or registration valid m for dividul use only before the eapiration,date: If found'return.to:. Offige of Consumer Affairs.and Business Regulation 10 Park Plaza-Suite 5170 f.ard Boston,MA 02116 Not valid without`signature 1 ti Town of Barns mile Regulatory ServicesURN ' MARI Thomas F;Geiler,Director P4 BWIding Division -Tom perry,Buis ug Commissioner 200 Main Steet,Hyannis,MA 02601 � "wsvpv'aown.barnstable.ma.us ' Office: 5 0 84 62-403 8 'Fax: 508 790=6230. :Property Owner Music Coffiplete,and Si gxa This Section Jl`UsWg A BUil.dce C r_ T, n ;'as Ozvncx of-tlie sub'ft psopetLy hetebp Suthotize.. d? i! 5!;f �. to act;o xny beJ Y, in ail tna.tte_,t=a:ti e to work ma&o&.cd;by Lis bmIditg.pe�niit (Address of Job) 49annIS **Pool.fences arid.ala:tms,are tlae tespor sibilitypf tYze appli'cax�t fools ate:fiot to,be;fillec3:o:�utilized before fence is Installed and,-allfxna1 mspections are peifoEmed arir accepted, Cez Signatute.of Owriet Signatuze of Applicant Punt Naliie pint'Name, cx!E�'ca n S icL QQD Main Level 1 Fs. � vsf 42'.1" 15' _ 4' 10". 5' 1" 5' — 6'6" Kitchen co cowas - h d o .01wayl4' C�Isffu • (V - I°:•'M1� � r .9r 21 r. N p M to j P Living Room O Master Bedroom U1 , 3 21 Ell 3r 8 n - , . .- c -37'10"Atrium ' r � / �Qno� ,Qoryrov�� o� U Aoo'01S - -r7 ocJ • ��.� ,92 PAs. ..5�ioer-.eac•� �-� � �' Xi9 Main Level 20140095 ESERVE 3/26/2014 Page: 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Lf Map.` Parcel L �tion # Health Division Date Issued Z Conservation Division Application Fee e Planning Dept.. Permit Fee OL Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 46a j IJI �S OQ� Village4 L( 5 Owner_Nk, v t L Address W011M47�U� Telephone -Permit Request yJ 'Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District IU1n��J Flood Plain ;Groundwater Overlay Project Valuation JCM Construction Type Lot Size Grandfathered: XYes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family�j❑ Two Family ❑ Multi-Family (# units) oGT Age of Existing Structure 1 Historic House: ❑Yes �(No On Old King's Highway: ❑Yes No Basement Type: ❑ Full ❑ rawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing o� new Half: existing anew: Number of Bedrooms: �- existing _new U r C Total Room Count (not including baths): existing 5 new First Floor 1.00m Count Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other - �� Central Air: Yes ❑ No Fireplaces: Existing New Existing wood/coal siioye: C!Yes No v Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing : ❑ new size _Shed: ❑ existing ❑ new size _ Other: hone_ Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use._ _ a.D2r+1YWrX-J:s - _ _Proposed.Use-_ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number �� rnrn `Address oGl� �� , , � License # 1.61f �-U � �t,lpef"Vl�1e, Home Improvement Contractor# Email *10& : eYYI.,Worker's Compensation # ALL CONSTRU TION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED I c MAP/PARCEL NO. ADDRESS VILLAGE t ' OWNER DATE OF INSPECTION: } FOUNDATION FRAME INSULATION FIREPLACE ` ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL GAS: ROUGH FINAL a ANAL BUILDING s DAE&CLOSED OUT A,515ATION PLAN NO. y The Commonwealth of Massachusetts - Department of IndustrialAccidents -9. Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electiicians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): (S l( ��( Car R, Address: I City/State/Zip: �o Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I employees(full and/or pait:time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g; ❑Demolition workingfor me in an capacity. employees and have workers' Y P t3'• 9. El Building addition [No workers' comp. insurance comp.insurance$ required.] .5.,❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 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' 13 El 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 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. ff Insurance Company Name: 1.(�r l(iY\. Policy#or Self-ins.Lic.#: �u P-),-091 P'Jv—o—l-3 Expiration Date: Job Site Address: w� - - 4 r City/State/Zip: Qe6o Attach a copy of the workers',compensation policy de:oration page(showing the policy'num er and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepair and aloes ofperjury that the information provided above is true and correct Sip-nature: - Dater Phone#: t. 1 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#: 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call.the Department at the number listed below: Self.insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit(license applications_in,any,given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses-. A new affidavit must be filled out each year:Where a homeowner 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 hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSA.FE Revised 4-24-07 Fax#f 17-727-7749_ www.mass.govfdia Massachusetts -Department of Public Board of Buildin Safety g Regulations and Standards . Construction Supert-isor License: CS-018226 STUART A BORN •�` ��• 297 NORTH S1ElN TREETI y A1'ANNIS MA 026011NA Commissioner 'Expiration 10/31/2015 , i �IMHE r Town of Barnstable Regulatory Services akRNsi r MASS.g Richard V.Scali,Interim Director + i61q. �e 'moos" 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 Property Owner Must Complete.and Sign This Section If Using A Builder I, 4,Jj)*-y/ _ ,as Owner of the subject property hereby authorized 72/4J— �nh,s to act do my behalf, in all matters relative to work authorized by this building permit 37 (Address of Job) *Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or.utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date } Town of Barnstable Regulatory Services OpZF1E t Richard V.Scali,Interim Director Building Division t aALIMSTAEM t Tom Perry,Building CommissionerBLAM - s� , �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB.LOCATION- number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Appi-oval 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 1091.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness,often results in serious problems,.particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\bui1ding permit fonns\EXPRESS.doc bin NOTICE NOTICE T TO TO' E _ EMPLOYEES EMPLOYEES . of The Co'mmonwealth• Massachusetts T OF INDUSTRIAL ACCIDENTS DEPARTMEN . 600 Washington Street,,Boston, Massachusetts 02111 617-727-4900 - http:/twww.mass.gov/dia s re uired by.Massactts huse General Law, Chapter 152,Sections 2'1, 22&30,this vnli give you nbtice fat I (we)have provided for payment to our injured employees ees under the above-mentioned chapter by insuring with: Zurich Insurance NAME OF INSURANCE COMPANY 2420 Lakemont Ave,Ste 100, Orlando,FL 32814 ADDRESS OF INSURANCE COMPANY 12107/2013 to 12/0712014 =US 4971P50-0-13 EFFECTIVE DATES JOLICY NUMBER yowling and O'Neil Insurance Agy,Inc. 973 lyannough Road Hyannis,MA 02601 $08-775.16Z0 ADDRESS PHONE# 4AME OF INSURANCE AGENT 608-775-9316 3ufrleld Management Corp. 297.North Street Hyannis,MA 02601 EMPLOYER ADDRESS. EMPLOYER'S WORKERS'COMPENSATION OFFICER OF ANY) DATE MEDICAL TREATMENT a of employment to famish The above named insurer is required in cases of personal injuries arising out of and in the cburs- With the provisions of the Workers Compensation Act A adequate and reasonable hospital and medical services in accordance Report of Injury must given to the injured employee, The employee may select his or her own physician. The copy of the First reasonable cost the services provided by the treating physician will be-paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employes are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE .POSTED BY EMPLOYER