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HomeMy WebLinkAbout0078 SYLVAN DRIVE � a Sy1 J TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a6?1 C Map. Parcel -` pplicationl#14 t Health Division Date Issued -3o,!`f IPA Conservation Division Application Fee Planning Dept. . Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village VX&A 0,1_3#-3,s Owner SQ -I V- A -3 Z-L Address Telephone Permit Request I_L .eI-ItI (Gc� SAL Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1 - 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 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing nevi --+ Number of Bedrooms: existing _new ZE Total Room Count (not including baths): existing new First Floor Ro5r Count , Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove:�U Yeses❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ew '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 Proposed-Use - -- _ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name S -1 ��-�ld�� Telephone Number Address License # r �'i� �r.� 2.S.o t Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE `DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. t ADDRESS VILLAGE g OWNER ' 4 f b ~ DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE k ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL GAS: ROUGH. FINAL t_ FINAL BUILDING D*T-&CLOSED OUT A S�0. 4TION PLAN NO. t,.<+r r. f Hie Commor€wea th of Massachusetfs Deparhnent ref fides&of Accidents Office of-rMlesfigations 600 ffiayhingtow Street Boston,MA 02HI r wnivxzass�gaWdua # orkei's' Compensatlioai Insurance Affidavit:$wilders/Con"ctoisMecfricianMumhers " ph- ant Information Please Print Leib ly Name(St�sinessl6rnizationlh>dividna�: Cy��=�—� h^ `C�(� Address_ `I"�S ` 47 amity/State/Zip: ' Av'v 6Z�o-"t Phone --Are you an-employer?Checkthmappropriatebox; --------__-_----.- --.___. __T W of pr.o'ect r rite l_❑ I am a employer with 4- ❑ I arm a.general contractor and I 6- ❑New c=st i ction have hired the su employees{full and/or part-time)-* ��� 2_❑ I am a sole proprietor or partner listed on the attached sheet: 7- ❑Remodeling ship and have no employees Tl scrh-contractors have g_ ❑Dt�lition: working for Me in any capacity_ comp-emplo ins and have worker€' 9 ❑Building addition [No,workers'Ct3tllp-fn4��ITATIAe COIril9_1I9SlTI'aIIC:�S 5-❑ 'Wee area cotporaticnand its 1t3_❑Electrical repairs or additions ed_] 3_ I am a homeowner doing all work offerers hwe exercised their 1I_.❑Plumbing repairs or additions myself [No workers'tom_ rig 152,§1(4 pand we MGL 1 ❑Roof repairs mmr*ance regnu�eci-]1 c-1��,§i(4},and.we hn•e no employees-[Na,workers' 13-❑other comp-insurance reguired:T 'Army applicant that ched€s boa-1 nmst also fill out the section below showing Their wnalceie coaxpeusRdoa pnliry iuf x =&n T Homeowners wbo submit{his affidavit in&cst g&ey ase doing aII vat sad then hug outside contractors mast submits Dew affi6vit mnc"ang snide tCcat mcturs that check this boor mast attached srt additional sheet sbowhig,the nsme of the Exb-CauftXtOn and sLgb.whether ornat those entities have mmpia3—_ If the mTa-< utcactors here employees they must P-vide their w-I-,-'camp.policy number_ I am art empkyt'r that isgrrr►`&d ag-workers coxtWgriw ion utsurairce for my'LwTloyegs. Bdat>`is StegoFicy aa.d}ob site informa6viL Insurance ComganyName: Iicy+ Gr Self ins_Lid ` Expiration Date: Job Site Address: Citylstatetzip: Attach.a copy of the wGrkers'compensation policy dedarstion page(shaving the policy number and ezpimflon date). Failure to secure coverage as teg6reduuder Section.SA of MGL c- 152 can lead to the imposition of criminal penalties of a fine up,to$1,500-da and/or one-yearimprisonammt as well as ciz ii g eualties- the form of a STOP WORK ORDER and a fine ofup to S7250_00 a day against the violator_ Be advised that a copy of this swement may be forwarded to the Office of Investigations of ifie DIA for iuvarance coverage vecffication- I do hereby certify under thapa ns andpenal ies ofpedury t tat&zrtforrrtaiion prot*ided above is true and correct Siarrattire pate- Phone#: official use on[y. Do not omits in this area,to bg campleted by tire}:or town o i`ciaL . City or Town.:. PermidUcense# Issuing Authority{circle one}: L Board of Health y.Building Department 3.City/rowu Cleric 4.Electrical Inspector 5.Plumhing Inspector 6.Other Coutact Person: Phone#- 6 • Information and InstrucGons Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 stains 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 ally 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 in manse 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 certifcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no t-mployees 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 maybe submitted to the Department of Indus:'trial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit ilre 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 w,orkers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-ins mce 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 he 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 III (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 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 like to thank you in advance,for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Idduistdal AQcirlenN Office of favesfrga.t cas 600 Washingtau St=t Bos1;on=MA G21 I I TI'-L A 617=727-4900 406 or I-8 MASSAIR Revised 4-24-07 Fax 9 617-727-7-149 www.mass-gov/dia Town of Barnstable r r Regulatory Services `i ��oFTHE roty,� Richard V.Scali,Director ' Building Division sasxsz'As MASr Tom Perry,Building Commissioner 1639- ��� 200 Main Street, Hyannis,MA 02601 oTEe a www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION • P[easePrint � DATE: JOB LOCATION: O SSA I.yVim— oM V A— number street village "HOMEOWNER": , -1 a-JX- any name ^ home phone# work phone# CURRENT MAILING ADDRESS: city/ton state zip code w 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 proce ores and requirements and that he/she will comply with said procedures and requirements. Signature of Ho wner 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,RuIes&Regulations for Licensing Construction Supervisors,Section 2.16) 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/eertifcation for use in your community. Q:%TFU-ES\FORMS\building permit formsT)TRESS.doc Revised 061313 SET Town of Barnstable Regulatory Services MASS. ,` Richard V.Scali,Director iOlE0.39. 16 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, e as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work aul rized by this building permit�apion for: (Address o 0b) "Pool fences and al7or are the spo ibilityof the applicant. Pools are not to be filled before fe e is installed and all final inspections are pe d and accepted. Signature of 07Z Signature of Ncant Print Name Print Name Date QTORMS:OVJNERPERMISSIONPOOLS o�tHME T Town of Barnstable *Permit# Expires 6 mo jr m issue dale— Regulatory Services Fee L sAMSPABLE. Richard V.Scali, Director AjFp�.�R Building Division Tom Perry,CBO,Building Commissioner 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 Property A.d.."dress-- o t ❑Residential Value of-Work-$---S �S�— Minimum fee of$35.00 for work under$6000.00 Olper's=Name&:Address--45 `L4 kS� VVA CYl-�as Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: . Construction Supervisor's License#(if applicable) J ❑Workman's Compensation Insurance Check one: Q P R 18 Z014 ❑ I am a sole proprietor 6 W am the Homeowner L] I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) gi.0 Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken ❑-Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Co-Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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. F , A copy of the Home Improvement Contractors License&Construction Supervisors License is required. , SIGNATURE:�.� - QAWPFILESTORNI building permit forms XPRESS.doc Revised 061313 The Commonwealth of Massachusetts Department of Industrial Accidents ..Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly N� at ee-(Businesi/Organization/Individual): Address:-----mil' CCity/State/Zip; """l�t�'�'1� ' w� ��j Phone#: Are 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. ❑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 workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 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.❑ 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. 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 Investigations of the DIA for insurance coverage verification. I do hereby certify under -the pains and penalties of perjury that the information provided above is true and correct Sienature: Date:- /" Phone-#:"-' 1`� — "► 2Z-�l�\� 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Town of Barnstable . Regulatory Services o�TM� Richard V.Scali, Director Building Division Tom Perry,Building Commissioner MAM cep��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print. JOB-LOCATION:}6�'F� L � OA- number street village HOMEOWNER°°'- Z1 ti o Qts �4 �—••-m"^""'�' name home phone.# work phone# CURRENTMAILINGADDRE^ SSI,,$- 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 florneowner---•-� 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. okTME • s�xsrnBie, • ,' ,� Town of Barnstable Regulatory Services Richard Scali,Director Building Division Thomas Perry,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 as Owner of the subject property hereby authorize 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. QAWPFILESTORWbuilding permit formAsmokecarbondetectors.doc. Revised 050412 0f1HET Town of,Barnstable * ermit E,rpires 6 months from issue date Y B,RxsrABr> Regulatory Services Fee Kk $ Thomas F. Geiler, Director IG3q� �Alfa �& Building Division "0 Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 i www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY q Not Valid without Red X-Press Imprint Map/parcel Number 29 Proper Address �p �' IVAlk D7. AM�l esidential Value of Work �C1� Minimum fee of$25.00 for work under 56000.00 Owner's Name & Address L LI �o910,-6'9�� Contractor's Name /' Telephone Number Home.Improvement Contractor License 9(if applicable) �/J / A C WWnruction Supervisor's License#(ifapplicable) 4(0/ Z FSS PERMIorkman's Compensation Insurance NOV 2 4 2009 Check one: ❑ I a a sole proprietor TOWN OF BARNSTABLE m the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping'old shingles) All construction debris will be taken to ❑ Re-roof(n.aistripping. Going over existing layers of roof`) ❑ Re "e 4 Replacement Windows. U.-Value Q. J (maximum .44) *Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e.{-fistoric,Conservation,etc. *.**Note: Property Owner must sign Property Owner Letter of Permission, Hame-Iffpfiovement Contra oi�s- ense& Construct Supervisors License is required. SIGNATURE: ` —�^ Q:\WPFILES\FORMS\Express\EXPRESSPERMIT.DOC The Commonwealth of Massach usetts -"- - Department of Industrial Accidents 1 Office of Investigations 600 Washington Street S Boston, MA 02111 - ,l j xy' www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly �'A' I L Name (Business/Organization/Indivi dual): Vt/ Address: �oUNA W C141 dye, 12 City/State/Zip: G C)2 Phone #: cs0�-/10 — /-01, Are u an employer? Check the appropriate box: Type of project(required): 1. I a employer with0 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub-contractors 6. �E]�Nemcconstruction 2. Z am a sole proprietor or partner- listed on the attached sheet. 7. deling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' y9. ❑ Building addition [No workers' comp. insurance comp, insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.El am a homeowner doing all work officers have exercised their I LE] 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' 13.0 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, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have 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 andjob site information. OIVJ,6� 1Insurance Company Name: �} / l�� Wp, Policy#or Self-ins. Lic.#: T Q Expiration Date: �6 /0 Job Site Address: / Sr,,LmN ��'. 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. 1 do hereby ceYti�fyider the pa nd p alties of perjury that the information provided above is true and correct, Si nature: _. Date: Phone#: 30 r r 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#: s .- ISSUE DATE 7r r t t � � � �[� 1.!,11 03-04=2009 ];--. .s ''r;,z .4 Dn .fir Y, 4 ,.�- 3 e•r.=,-. :�i-.r=e 1+ :. . i..:.,.-..are •.., —:.+w -e:cj,: =.:z.:-y THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY PRODUCER AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEIND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. MARK T VOKEY INSURANCE AGENCY COMPANIES AFFORDLNG COVERAGE PO BOX 1241 COMPANY A HARTFORD UNDERIVRITERS INSURANCE CO WEST CHATHAM MA 02669-1247 LLTTr.R INSURED COMPANY B KEITH,WAYNEF DBA SOUTHVIEW LETTER CONSTRUCTION 35 SOUNDVIEV4 AVE COMPANY C LETTER CHATHAM MA 02633 COMPANYLfiTiER D (�'Rpj"'f ar aqS -3-s x `� 1 r ? ' COMPANY i4 �2_.I" 4'_+'sC �+ shH �.::��'�' tET7ER THIS 7S TO CERTIFY THAT THE POLICIES OF INS 'IT 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 DOCUME, WI 31 RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDI)BY THE POLICIES DESCRIBED HERCIN IS SUBJW TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.I INE S SiiOW.1 MAI--E BEEN REDL'CGD'Bl'PAID CLAIMS CO TYPEOFINSURANCE P0LICYNv'UAIBER POLICY POLICY LIMITS LTR EFFECTIVE DATE EXPIRATION DATE (MM/DDIYY) (MMIDDIYY) GCNGRAL AGGRCGATE S GENERAL LIABILITY - PRODUCTS-COMPIOP AGG. - $ 000MMERCIALGLNFpkL.LI.4EILITY PERSONAL&ADV.LNIURY $ 0 CLAIMS NLADE C. OCCUR. EACH OCCURRENCE 0 owNGRS&CONTRACTORS PROT. IIRE•DM6V ClE(Any Om Fvc) 0 MED.EN PENSE(Auy o„c pmon $ - COMMNED SINGLE LIMIT 4 AUTONIOBQ.E LIABILITY 0 ANl'AUTO BODILY INJURY S 0 ALL OWNED AUTOS 0 SCHL�L`iZD ALTOS BODILY INJURY $ 0 HIRED AUTOS (Per Aceldeut) 0 NON-OWNIDAUTOS - PROPERTY D:V.IAGE S 0 QARAGE LIABILITY Cl - EXCESSLIABILEIY EACH OCCURRENCE S 0 UAIBRELL.FORM AGOR OATS 4 0. OTHER THAN UMBRELLA FORM - _ STATUTORY LIDJITS X .. EACH ACCIDENT - $lCIQOOO A WORKER'S COMPENSATION DISEASE-POUCYLIMIT $$QO,000 AND TBD 02-26-2009 02-26-2010 DISEASE--EICHEMPLOYEE $I00,000 EM PLO-VER'S LI ABI LITY OTHER' THESOLE PRO PRIETORIPARTNER(S)ARE INCLUDED EXCLUDED X DESCRIPTION OF OPERATIONS,WCATIOIStb,ZHIC7.ES,SPECiAL ITEMS THIS]S TO CERTIFY THAT THE P011C1CS OF INSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE WSUF-ED NAA'CED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY RE�QUIRGVIENT,TERM OR CONDITION OF ANY'CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH MS CERTIFICATE A1.4Y BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OP SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO TI(E CERTIFICATE HOLDER AFFECTING'WORKERS COMP CO\ERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAN r� THE ED ENDEAVOR TO THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY tv11,L E1DEA L'OR TO MAIL TND AT-HOME SERYICESINC to 4Y WRITTE.VNOTICETO THE CERTIFICATE HOLDER NAMED TOTHELEFI> 2690 CUMBEHLANDPAFKFYAY B LIABILITY OF W!'UT FA]uRrTO (KIND (UPON TItECOMPANi'`In AGENTS ORGRE(PRFSENTAON OR TI\'Es SUITE 300 ATLANTA GA 30-19 ALmtoRuco RaPatsENrsn�•e ;0,4"f1,4 Cr4sT l- fLER MYN raur HUME IMPR0V.0 tr-C(7NTRACT e PLEASE•READ THIS CI►�'a'`� !_^ Sold,Fum shed= hi4- �efalled by_.' SNarrcb Nsme :Boston `::. Date �./Z :C3- �, ...,.,_•tom �. _,__ . :....� .. ..(. : . . , ... ... .... .. ..... _ _ ):I ..: -Td3•D•/!t I3om*Strvic�:-lnc:" dlblal TJte:Home.De fo-At -.ome;Serviccs• 345ACmeuwood-Street;.Uni£2;.l.rorcester,:W:A:tCp7::- Braach Number:.3l,. Toll,Fsee(800)-657-514 i-Fax(508)756-8823 41. 5 M1»8460, #C 024 i9,.RI Cont Li 16427 Federal D522;.A tiomc ImprovciYieot C>nlntctor Reg#26R93 . CT Installation Address: (A0 . .:. �—" ���J�� •-.state-.... 't` ,::,Zip.. Purchaserts): Work none: Horne Ylwn,�:" ' Cc11 phone UomeAddress: (If different froze Installation Addicss)„ ,:: .City. .. _Sts a,"', ._._ dip,•;. E-mail'Address(to reeeiveprojeet-commwiicationsid.&Home•-Depofupdates):•'.-:.: :[DO NOT wish to receivcany marketing emails from'Thc.T3otne Depot :> _ Project'Information Undersigned'("Customer.`');66;' Wners of the property.'lbc&ited at the sboVe itistaltatton address;agrees.to buy, and THD At-Home Services,Inc.("The Home Depot"}agrees to'&rriish;.detiv(- and<amingefor-tri'e'installa Yon°("Iiastallation )of all,materials,described_on•the below:azid on the,referenczd,Spec ShG*s), an of:which arejncorposated.:int).-this Contract.by-this reference,along with any applicable Stetc.Supplement'sud P�yment.Summsry;attached hereto.and any-�Tiq e.,OrQers{coDcctivelq, ..Contract"}. . . _ Job ii. Imce�n.raer � p'oductc Sec Shee s # Pro ect AmoutiF ho [} ofing Siding Windows ''Insulation' . I ��3•V:%V` UtfCrY/'G''OVCrS'� ntry'DoorS ❑ •• ,r; '%� � �; - . RoofiiUs. ng .1'9utdows.. Qlyntry Doors Q.:..... . �, $ f ©Ro�tmg, 'Siding: Windows' ;hrsulatiap,,. . :.. '.(�Cxuttcts./.Covexr•.�]E¢tryDoon;.��� .-i ,_ ' '$. ; []Roofing DSidi>tg. Wmdows insulation 777 > - QGntters/Cpv -[jLtryDoors Minimum 25%•DepositofContractAmouutdue upon cxceutiop ofTlils contract. F otal Contract._ t"`$ 1►Zaine Purrbnscrs may nut deposit more own one-third of the C'onkract Amount� • Custoruei agrees thatnmediately upgn completiop of tltp wort for'eacli'Product..Customer will cxearte a omgileaorr.Ceitifi ate (one for cacti Product.ss':dcfilied b)! u.tndiiiddil Spec S)ieet)_':md:yay.any,bsilanoe due, As appficabtc,'.ca< Gltstomei'6.itcr:tbis Contractagrces to bejolntl}'anfl scvCrdl)y obli'gated.and liable hereuutli r The Home.Dt poC.reserves the:right to,iastle)Change-,Order or termiltate tots Contract or,aay igdividual.P,rgdu(t(s)included•her6n,at its discretion,if The Home Depot or itti audtorized setviee ptovidet'determin�s that:it•can otp otm.-its•obligw Ionadue•to a-stractaal problem with.tbe home,environmental•hazardw such as mold a�bcstos.4r.lead.vorkJeq .. .. , , - c, oac safe uir ty_ conc erns p sin errorsrbecause , Payment rnmarV>-The T?ayttterir.5ummary'# � included^•as'patx of•thi.<'.Contra sets forth--the':toial Contract amouttt'and a eat¢re wired Porthede sits:'and•inah ,+- abT, „::: •,-,,_:;,P Yin Q Po paym4nts by Product(rs dpp1ic ) NOTTCE TO CUSTOMER "^" You are'cntitlefl to'i completely filled-in cope ofthe Contract'af`ttieYime'you-sign: bo1►of sign`a Comp e:ion Cert,Gcdtr{note: there is one Completion Certificate for each listed Product Asdcfln'ed liy ividuat is complete. Sp .Shects)before `vork on xliatrvaitct in the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of matt rials,labor,expenses and services provided by The•Home Depot or Authorized Service Provider through the date of termiit ation,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WIT:IHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THF, DEPOSIT PAYMENT:OR OTHER PAYMENTS MADE,.WIT)iOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF.SUCH AMOUNTS. recce tune and Authorization: Customer agrees and understands that this Agreement is the entire agreem trt between Customerand The Home Depot with regard to the Products and Installation service.3 and supersedes all prior discussions and agreements,either oral or written,relating to said Products and lmtallation_This Agreement cannot be assigned or amended exec at by a writing sighted. by Customer and The Home Depot,Customer aclmowlcdges,and agrees that Customer hati read,undendinds,`ohmtarily accepts the terms of and has received a copy of this Agreement. cccpted by: . Sn stomSCu Date SalcsC r► l>etc I Telephone No. Cus er's Signature Date Sales Consultant License No.. CANCELLATION: CUSTOMER MAY CANCEL THIS (as:pPhmw le) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING TMS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS AND CONDITIOM ARE STATED ON THE.REVERSE SAFE AND ARE PART OF Tt M CONTRACT 7-15-09 CSC; Whit._ R.•.nrn TOO'd SIRRV H 10d3a RWOH cl:o> soot-VZ-100 The commonwealth of Alassacllusetts Department of Industrial Accidents Office orInvestigati©ns 6;),0 Rashington St,Yeet BosIon, X-14 Oy_t 11, 11;W W.mass.00 y Id i11 Workers' Compensation Irl,�zu-rance Affida—vit: Builders'C,-,ntractorsr`El Please Print Le eibiv rs A licant Information t l Name(Business/o,�anization.'tndividttatj; ice ' �vL't,t ip k' Address: '�' v �� . 'T - ,5 City/State/Zip: G% ' - 3 C'.5 Phone#: Type of project(required): L3.0nerd n employer?Check the appropriate bo 6 Q N construction „(� 4, am a general contractor and I I. a employer with have hired the sub-contractors � n oyees(full and/or part-tim 7. Remodeling listed on the attached sheet. a sole proprietor or partner- These sub-contractors have 9. [�Demolition and have no employees employees and have workers' 9 Q Building addition ing forme in any capacity. camp-insurance.t workers' comp. insurance 10 Electrical repairs or additions 5 ❑ We are a corporation and its Plumbing repairs or additions ired.) officers have exercised their I L ur] g P a homeownerdoing all work right of exemption per MGL 12.❑Roof repairs elf. [No workers' comp. c. 152, §1(4),and we have no1 ❑etherrance required.]t employees. [No workers' camp. insurance required.) tion icy *Any applicant that checks box#1 must also fill ll out the are ion befall wok and then hiow showing their re outside contractors mast submit information, affidavit indicating such. Homeowners who submit this affidavit g *Contractors that check this box must attached an additional sheet showing tworkers'o oathe suboi'onnu*cnt�e and state whether or notthose entities have employees. If the sub-contractors have employees,they must provide their P policy ees. Below is the policy and job site 0 I am an emplo yer er that is providing workers'compensation insurance for my employ information. S Pew � 5 Insurance Company Name: �" 3 % 110 l Expiration Date: Policy#or Self-ins.Lic.#: C (3 -c G, CitylStatelZip Job Site Address: — in er— Attach acopy of the workers' comz 2 pensation policy declaration pale(showing t��policy imposition of criminal penalties ofa Failure to secure coverage as required under Section 25A of MGL c. 1 a can lead to P fine up to$1,500.00 and/or one-Year imprisonment,as well as civil pethis15tat statement may be forws in the form, of a arded to theOffice ORDER and d a Erne P of up to$250.00 a day against the violator. Be advised that a copy of Investigations of the DIA for insurance coves e verification. 1 do hereby certify u the pains and penalties o perjury That the information provided above is truce and correct. - Date: — SiJnature: j Phone#. U �� Official use only. Do not)',ite in this ar, i-to be completed by city or town ofjciat Permit`License City or Town: Issuing Authority (circle one): nt 3. City/Town Clerk A.Electrical Inspector 5.Plumbing Inspector 1. Board of Health 1. Building Departme 6.Other I Phone 4: Contact Person: 4 .� INlassachusetts- Depai-tment of Public Safety Board of Building Reauiations and Standards Construction Supervisor License License: CS 94607 Restricted to: 00 :err.- 1n WAYNE F KEITH 35 SOUNDVIEW AVE CHATHAM, MA 02633 - ' i' ---e, Expiration: 10/62011 ('vmmissiunec Tri#: 4362 ✓�e�iio9nmroxureaC� °o�ltu License or registration valid for individul use only Office of consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: `157610 10 Park Plaza-Suite 5170 Expirations;;-_1.0/2212011 Trll 288775 Boston,MA 02116 . SOUNDVIEW CONSTRUCTION Wayne KEITH 35 SOUNDVIEW AVE--.:: W.C2669 Undersecretary .:: No valid ithout signature HATHAM,MA 0 } t „s"b • ' t,c�e tea. �►�mow•sw ! - od Sambw* B.'d of .. C7t4@.#��9�t82�1an130! �Stoa,ata.Q23fl® .