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HomeMy WebLinkAbout0003 BENT TREE DRIVE . , ,. . . . ,. , . _ _ .. . w. . � . r .� _ .� . .. a a. �� .. � �I ` _. y I r - p t .. C HomeWorks T rnC Energy, Inc BUILDING DEPT. Insulation Affidavit OCT 212020 TOWN OF BARNSTABLE HomeWorks Energy has installed insulation at the following address that meets or exceeds Massachusetts building code and IIC requirements. Project Address: Permit Number: B-20-2958 Germaine Cardoza 3 Bent Tree Drive Barnstable Massachusetts 02632 Location Material AddVI Thickness Final Assembly R-value' Knee Wall Dow Polyisocyandr6te'(R'14)="';''!` '`! 2" 7 Basement Rim Joist 6"Owens Coming'Fiberglass Battini 6" 19 Knee Wall Floor Green Fiber Cellulose 9" 49 Attic Floor Green Fiber Cellulose 9" 49 Attic Slope Dow Polyisocyanu rate(R-14) 2" 7 Enclosed Exterior Walls Green Fiber Cellulose 4" 13 Sincerely, Adam.-Glenn CSL#1Q6148 _... ._. .F- .... -.... .d.... HomeWorks Energy lnc. _:. . ..__ _... _.. HomeWorks l nergy "4 "•" 101 Station landing,Suite 110 Medford,MA 02155 - , .....wxpermitting@homeworksenergy.com—. -- _._..__. .. ... (781)205-2201 Town of Barnstable Building naklvrn" Post This Gard-So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept Posted Until Final Inspection Has_Been'Made.1659. - Permit , �.herY5x , c �. is Required, � '.e Occupied,until a Final Inspection has been made. Where a Certificate'of Occupancy is Required such Building shall Not b � Permit No. B-19-1842 Applicant Name: LONGFELLOW DESIGN BUILD Approvals Date Issued: 06/04/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/04/2019 Foundation: Location: 3 BENT TREE DRIVE,CENTERVILLE Map/Lot. 168-032 Zoning District: RC Sheathing: Owner on Record: HERLIHY, MICHAELA G TR Contractor Name='.LONGFELLOW DESIGN BUILD Framing: 1 Address: 3 BENT TREE DRIVE Contractor License: 176959 2 CENTERVILLE, MA 02632 r<<,' Est. Project Cost: $6,100.00 Chimney: Description: ROOF Permit Fee: $ 35.00 Insulation: Project Review Req: Fee Raid':°` $35.00 Final: Date: 6/4/2019 ' Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be.deemed abandoned and invalid unless the work authorized by this permit is commenced within*six=months after issuance. All work authorized by this permit shall conform to the approved application and thelapproved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structuresshall be in compliance with the local zoning by=laws and codes. I a Final Gas: .p This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open forublic inspection for the entire duration of the work until the completion of the same. e J Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials`are provided on�this,permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing _ �' ��� Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site / '� Final• All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT p ;� S� Is' Application number..1.2 Fee..................... ........... .:_­_..._­�.................. UMMA8 4 • w Building Inspectors Initials .......... ...................... 6k Date Issued:........ . �o njtq Map/Parcel.........:...:...:.............................................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WIND O W S/DOORS/TENTS/STOVES/WEATHERIZATION -PROPERTY INFORMATION-- = Address of Project: 3 QEAI'C T&C-6- NUMBER STREET VILLAGE Owner's Name: rLt` 5Ir y�i�/1//fNr Phone Number Jam• �¢�� Email Address:FL;ft fOosjlNi Vk4r41*l,'CyM Cell Phone Number 1 t f 36g 3¢G6 Ou Project cost$ v Check one Residential_ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application g permit in accordance ugh 780 CMR ALJ Owner Signature: _ Date: �k A 0,-//, -TYPyE OF WORK . i•+.. ETA S is.� tJ �2� ie.��1�.a 7_ .�u�.'7 ✓:',.� C 0• y$ e4 <SidM-1E R`Windows (no header,change)# 0 Insulation/Weatherization. ors(no header change)# . - , Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles)' Construction Debris will be going to G. L. NO Doh I r We3���.�t'S�,m�r • fAA CONTRACTOR'S INFORMATION Contractor's name M04- 90 ?0'116 �Q,J t 1K9 Home Improvement Contractors Registration(if applicable)# 17 0 S (attach copy) Constri coon Supervisors License# J ;, 6 1• 1 h-"`,;4�(rattach o°pyf Email gf Contractor TO[Oh ��� O'►�•(�M Phone numberl'�' 177I ALL PROPE AVE STRUCTURES OVER 75 YEARS OLD OR`IF THE SUBJECIT PROPERTY.IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER.......................................'............ti....... U. *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame, pr'ead�yShe �f each tent must be attached.,Provideiawste plan.wi the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes - No ,if yes, a gas permit is required. Kati al Gas Yes =r i �'No , if yes,a gas peniiitss•requit& � t" �. 41 Deirtg�sq" vved at your event please obt a Xeltl De,!//� errppTryo�v�l between the hours . t ter• f L jo of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel T•y<pe '^• G 4'Y:' .Testing Lab yfi ••94`a4,ii�•esr �..Nq f- ,.,• A.,;^y.<a i'..�,r r 3-•...� � f ''"•o'aefj .� Offsets from combustibles: front back left side] �,, right side 'HOMEOWNEW'S•LICENSF.EXEMPTION Homeowner's Name: .f6A-To f E4 CA o A� Telephone Number Ce r Work number�� I understand my responsibilities under the sand regulations ' .ensed Construction } S is.Q`r". `�eeordan wit :780 G ytbd Mapsac.I usetts State Building I understand the construction inspection pr ures,specific inspections and documentation requ y 780 CMR and the Town of stable. Signature: . ... Date A;€.,.t �; .s' fie• i A•'.i;1 a �'�..,v.� �}.+-p•tt •#. "y A{!4! ra*..P: e'o .q 4-J Y• 7`{II • r•:F.,�.?..+i'a Y: ?` ,•.X � ' APPLICANT'S SIGNATURE r Signatur Date �ti ,.,w ljpermit:ap.0licadons are subject to, .building Koff cial's ya�pr,oval�r_ioY{t to issua ce.jig 1J "'•...}•t.�Y.,w,'wd:y ��„°y1pa� twr^ e,p s O I The Commonwealth of Massachusetts Department of Industrial Accidents .57 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 Lezibly � 1 Name(Business/Organization/Individual): tloi V\ ej�/►l y Address: City/State/Zip: d d Phone#: 7 7 4 0 ) 'Aree ou an employer?Check the a propriate box: Type of project(required): P%U I am a employer with '5 9 4 E]-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 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.❑Pl }�ing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.oXoof 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: AMCQ_ _S[w�,�i✓1 Policy#or Self-ins.Lie. to 0S b h;_-7 S Expiration Date: 9 � 1 3 g Tc-e�. D r. 11 Job Site Address: City/State/Zip:�ry— 6 lQ-�NyA 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 certi d aims and penalties of perjury that the information provided abo a is a and correct -- (0 Si ature:-- -^� l.j Date: Phone#: 1 ` ✓ �-- I��� 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#: 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.apartmemts'and who asides therein,or the occupant of the dwelling house of another who`einploys 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 empldyment be�deemed-to lie an employer." MGL chapter 152 § '31✓(6).also states that}evertiy state or local lieepsin&-gency%shall wifhhold the issuance or renewal of a license or permit to operate a business or to construct buildmgs'in'the co i 'ii�'Stiwea'lth 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 itgpolitical 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(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-h=ed companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is•cpmplep,and,printed.legibly,The,Departmeht,has,provided a space at the bottom of the affidavit"for!you tofill out�in the event.tlie`Office of]nveshgahons has to conta ou regarding the applicant. Please be sure to fifihinvtlie permit/license number which will be used as a reference-rex..;In addition,an applicant that-,must submit multiple permit/license applications in any given year,need only submit;one affidavit,indicating current olie iriforination if necess ' and under"Job Site Address"the a 'li ant should write"all,lo"ons,in_(city or l� y; arY) PP ( itY 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. e i The Department's address,telephone and fax number: The Commonwealth;o£-Massachmeas- , Q Department of lnd.6t F 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 i " #tdtrrtt�� 0i4 r9 !t� u�'nttA�,x3it Divia,011ao€trri�4 u i Vf9r3(L�t i9.ir1r�� t t)fV;3 cl9 rl °>{l3aF ltiits MARK R'BOGOSIAfli 33 WATERSIDE AVEPNE FALMOtlTH NA 02NO II Cl,tstTllill�3t,•.astbu� t Offico Of Consumer Affairs and Business Re ui One Ashburton Place- Suite 130f �tlolt. Boston. Massachusetts Home Improvement Contractor Reg'strgtion LONGFEI LOW DESIGN BUILD TI,IX,,, Gorporation 866 s,1iIAIN STREET Registration: 176959 OSTERVILLE.A4A 02655 Expiration: 1or17;2019 a UPdato Address and Return Card. ta Office of ConsumerAflairs a 8114iness Regulation NOME IABPR0VF:h1F.NT CONTRACTOR TYPt~:Caruantli, - Registration valid for individual use only ReaistrP—vq.-). 9ZI do before the expiration date. tt found return to: 17tlGb; 70 112019 Office of Consumer Affairs and Business Regulation Lf)PJCit tLLt1t'J()p glC,p;suit 1) 10 Park Plaza-Suite 5170 Boston,MA 02116 " s:Nb9lt'� ttrA '17rya .., -----•--�=;.— /---.�.—,rt.____'_t ,. Undarsocretary Not valid without signature r r ;act CERTIFICATE OF LIABILITY INSURANCE DATE(MMI°Dn'YYY) 10/03/2018 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 have ADDITIONAL INSURED provisions or 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 CONTANAME:CT Charles Downey Downey Insurance Agency,Inc. PHONE , (508)485-0130 F�No: (508)485-6463 190 East Main St. ADDRESS: charlie@downeyinsurance.com • INSURERS AFFORDING COVERAGE NAIC# Marlborough MA 01752 INSURER A: APPALACHIAN INSURED , INSURER 8: COMMERCE INS CO 34754 Longfellow Design Build, Inc. INSURERC: STAR INSURANCE COMPANY 866 Main St INSURER D: INSURER E: Osterville MA 62655-2013 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER MMIDDIYYYYI IMMIDD/YYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 D MAGE O RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 5,000 A IG06AO12713 07/27/2018 07/27/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JEO LOC ' PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ 20,000 B OWNED SCHEDULED AUTOS ONLY X AUTOS RWL621 08/19/2018 08/19/2019 BODILY INJURY(Per accident) $ 40,000 XHIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE =1 E.L.EACH ACCIDENT $ 100,000 C OFFICERIMEMBER EXCLUDED? N N/A wc0869275 09/26/2018 09/26/2019 . (Mandatory In NH) - - E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $' 500,000 - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. , AUTHORIZED REPRESENTATIVE 367 Main Street Hyannis MA 02601 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD f W� 12-1111 '`�j V i f 4 T Town,of Barnstable *Permit# 2j c �I Tres t j s Regulatory Services em date • snxivsznsz.E, + MASS. 8's6;¢ Richard V.Scali,Director ♦0 ptEO MA'1► Building Division Ess PERMIT Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 JUN 12 2015 www.town.barnstable.ma.us Office: 508-862-4038 Office: OF-BAR TA,@L7L90-6230 EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY f I U„, _ �I Not Valid without Red X-Press Imprint Map/parcel Number l (J Property Address ] C�EA/7" ZZ Ef J?K Z � TE/t/i%L 3.2 ❑Residential Value of Work$ .LA2 00 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /`"/f eywd Lx Aloe Contractor's NameD/,CSC/���G�Li/�/�. Telephone Number Home Improvement Contractor License#(if applicable) S 9s Email: ���p�„t✓1� oT it'J�%L C�'''� Construction Supervisor's License#(if applicable) 0 9 99 OY. E3LWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [A-1 I have Worker's Compensation Insurance Insurance Company Name 5491L EGEL Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof.(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑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: ❑ 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. A cop of the me Improvement Contractors License&Construction Supervisors License is red. SIGNATURE: QAWPFILESTOPS44building pemf t formslEXPRESS.doc Revised 040215 77ie Commommalth o,f Massadjusetts Deparbnent o,f Indushid Accidents " - tD,, we oJr1mvsfigafi071S 600 Washington Street Boston,A 4 02111 nWW,Mas&govldia Workers' Compensation Insurance Affidavit: BBuilders/Coneractuis,Eiectrician-JPlumbers Applicant Information Please Print Ixw fIV Name l):_��GOL�`�e/r� /e�Sr.CU�ri oi✓ Ate: l(7 Geyve lAle`5 r 13AI lvs Ti*--11, CiWSt r DA k 4 9 Phow#: '03bl 6 Are you as employer?Check the appropriate box: Type of project(required): 1.2 I am a employes with 4. ❑ I am a general contractor and f 6. ❑New conshuction. employees{fan * have hired the sub-contractors 2.❑ I am a sole pmptietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition and have workers' watiCi,g for me is any capacity: employees q- ❑Building addition [No wodoers'camp.immvmmre comp.insuranceX required] 5. ❑ We am a corporation and its 10_❑Electrical repairs or additions 3.❑ I am a homeawrtes doing all work officers havoc exercised their 11_❑Plumbing repairs or additions myself.[No workers'comp- right of exemption per MGL 12.❑Roof repairs irozranre require&]T _ c.152,.§1{4),and we have no employees- o workers' 13.❑Other camp.inset-once regnire&I •Piny appficaut that cbe&s box#1 nmst also fill out the section below shovring their workers'compensation policy information. , Homeomners wbo submit this affidavit i mg they are doing slr work and dmu hire outside Mors—st sub=a new affidavit indicz=g such. - A=8Ctars iliac cbeck this box must att3dWd as additianai sheet dwvdng the name of the and state whedw arnot those eaddes hffm employees. If the sub-contactor have empIoyee%they mustpmvide their wodcers'comp.policy mmaw. lam an emp LO er tliat is proiiding workers.*cougmisa on insurance for my employees. Below is the pofi y and job site infoa WZation. Itisurance Company Name: Policy#or Self-ins-Lie # ,/37 T 8 7 7.b Fotpirstign Date: 1,23 /.6 Job Site Address:,3 elVr 7ie6to 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 tme-year imprisonment,as well as civil penalties in ifi,e fort,of a STOP WORK ORDER and a fine of up to$250.00 a day against the vaolatar. Be advised that a copy of this statement may be forwarded to 11m Office of Investigations of the DIA for insurance coverage verification. I do hereby cerhfjt, id thRpai s and penahies ofperjury,thatthe inforaratian provided abo, is true nd correct: Signature. Phone az Official use only. Do not avrite in this.area,to be computed by city or tonm of ciai City or To-nu: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.C ity1rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person. Phone#: MASS. Town of Barnstable ACED��p Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO . Building Commissioner 20.0 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. QAWHILESTORMS\building permit foans\EXPRESS.doC Revised 040215 Town of Barnstable Regulatory Services �oFZNE rGyti Richard V.Scali,Director Building Division i ST'ABIE. Tom Per Building Commissioner Mnss. Perry, g 9 1639. � 200 Main Street, Hyannis,MA 02601 �prEo www.town.barnstable.ma.us Office: 508-862-403 8 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 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 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:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 CERTIFICATE OF LIABILITY INSURANCE DATEIMM/OOY"""'. 05/27/2015 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 ondoreement(s). PRODUCER NAME. PAUL SCHLEGEL SCHLEGEL INSURANCE BROKERS INC ►BONE FA ,—•.'-..—.___.___....__... (AIC.No.Ee�:_ 508-771-8381 T taG%-•,.1508-771-0663 34 MAIN STREET ADDRESS: SCHLEGELINSURANC@GMAIL.COM WEST YARMOUTH MA 02673 IRSURER(S)AFFORDNOCOVERAGE 1 UA1Cu INSURERA:NIt INSURANCE,_.COMPANY 14786 _._. —_...�__�._..—...— .... �_.�.�.�._._�-,__.._....... INSUREU INSURER B:AIM MUTUAL Actilson Segolini Dba Segolini Construction INSURER C: 117 Minton Lane INSURER INSURER E: I West Barnstable,.MA 02668 msupeRF: j COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CER"FIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT, OR OTHER DOCUMENT WITH RESPECT TO WHICH 111o5 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE 'POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE MWo'S,. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -._- -:-____.._.__.._.�_._...__._ POLICY Er�-�' YOLIC�Y^E1lP•'- __.__..._.._.,._.�._. _-_...._.—___.__�.____........ _ LTR r TYPE OF INSURANCE IN" WILD POLICY NUMBER (MMIDDWYW) I (MM4)DNYYYI LIMITS A 'GENERAL LIABILITY MPT848611 (05/07/201SIO5/07/20161 FACHOCCURRENCE s 2,000,000 _ ___ X COMMERCIAL GENERAL LIABILITY PREMISES mewence) S 500,000 __,CLAIMS-MADE �K_(OCCUR ! MEotxP?AnronePors�n/ s 30,000 -__ :___- _--- PERSONAL A ADV INJURY S 1,000,000 GENERAL AGGREGATE Is 2,000,000 GEN'LAGGREGATELIMIT APPLIFSPER: PRODUCTS-COMP:OP AGG �S 2,000,000 JEGr I I POLICY PRO LOC i S _...... j AUTOMOBILE LIABILITY Ire ecci0cn11- —._.— - $ _- IAN•lAUTO ! ` i BOOBY INJURY tPer pe, W) s . AIL OY,?iF0 �I SGNED ED ( ,Ufos AUTOS f I , BODILY NJURY IPoraanlam) S _ I I 'A -0 -D ec wgeDAuros � ( f � PRodltet�dn`Mae E I ( Per uOeM) s 1 I UMBRELLA LIAR - 1 (OCCVR i � � Iv1CNI OCCUNRLNGE 5 I (EXCESS LIAe V CIAIMS•MADE ? _ I AGGREGATE i Olio ; RETENTION S B WORKERS COMPENSATION AWC-400-7026025-2014A 05/23/2015 05/23/2016_ AND EMPLOYERS'LU°IUTY _ TONY LIMITS_ �yERd YIN ..._..__.__.....,_..__..._...... .r:YMtOPRIETORrPARTNERIEXECUTIVE ❑ I. i E L EACH ACCIDENT_ S 100,000 OFFICERWMEMMER EXCLUDED? NIA IMandatory in NH) I_ El DlsEASE-EA EMPLOYEE»Y S 100,000 CF'SCH-PIION OF OPERATIONS DeIaw 1 i F.L DISEASE-POLICY LIAIT I S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Anach ACORD 101•AtltlitlonM R—ko Sclledute.IT more space is requiad) .� ADILSON SEGOLINI HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY THIS CERTIFICATE MAY OR MAY NOT BE IN EFFECT AT TIME OF PRESENTATION OF THIS CERTIFICATE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE MATH THE POLICY PROVISIONS. AUTHORIZED REPRE Nip YE ©1988.2010 ACORD CORPORATION. All rights reservoir. ACORD 26(2010106) The ACORD name and logo are registered mark of CORD i ,�,_,_,.�-.�.rn_...., �� Qom, / QQQ� JJ .:....'--•--...-.—,r.,.-..._ .,. .:--•—�._ UFL6 1Q6777//7'0007L!/PCI,L��O/U/�GCLdOIIC�LI,JG'�J - n. "� Office'of Consumer Affairs&Busi,dess Regulation icense or registeation.valid for indivitlul use.ouly ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration:` `5g5g7 Type: T k.`. Off ce of Consumer Affairs.and Business Regulatio 4 I' Uon .5/15/2016,' DBA' 10 Park Plaza-Suite 5170 xpira Boston,MA 02116 ( ' SEGOLINI.CONSTRUCTION ` s ,i ' ADILSON SEGOLINk , 117 MINTON LANE r. 1 ;WEST BARNSTABLE,MA=02668 r ecrefarsignature' Uncle s N alid without y �' .. C N - w R N - - (� CL V acM. in ILxJ o_ " w M �. ``��.uc:v L 00 CO N n `• �� �� ` Ea+ n 4 ! a .iagi 4',. c O. H C,• 0 U o H vCDi > > � WZ � \ E '� w y O U ° 0 U (�� 2 71 NeiArb ► v1 n. -s - LAv a,( h6YY\-R- 99,41)4 �. L n7 _ L� 1 { TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 1,"'' Map_ Parcel ®�y Permit# Health Division 9 — S �3 / Date Issued J 0 Conservation Division ) , " Application F; ro?.� Tax Collector. 16 bo Permit Fee jo Treasurer SEPTIC SYSTEM MUST BE a �N Co Planning Dept. Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE ANE. TUT REGULATIONS Historic OKH Preservation/Hyannis Project Street Address Village Owner 0- /' � �'�L ��� � / Address VI 'Son SE6 A-Si iAn wol �� � 7 ® _ Telephone CG l 7 / _1 ? � � � 1J� �An1) W tG�-t Permit Request L In 00 L; W/NO0 tv � �'� �� OO/Z I/J5T/4LL, 2 x- a /- W/Thy A-leC__ 4c—S CooqX� 1`D 6 &l�94!57_ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0 O Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ?K11 o On Old King's Highway: O Yes Xflo Basement Type: )"Tull ❑Crawl ❑Walkout ❑Other C Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new otal Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas O Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: O Yes 0?No 4J Detached garage:O existing ❑new size Pool: 0 existing O new size Barn:❑existing D new4) size.:- Attached garage:❑existing ❑new size Shed:O existing O new size Other: On Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ + ca � Commercial ❑Yes O No If yes,site plan review# --- Current Use .. T proposed Use Y-- - -- BUILDER INFORMATION Name /�ii�/� / �C ®/ O Telephone Number �0 y,32 ' Address a 0 A/-&_21/7-;94-, License# 00 / 7 ® 2— 1J,q1e,J,U f C t2i 026 Home Improvement Contractor# //6 ® 1 '7 Worker's Compensation#WC 23 1,32 3S6 /4,/DI2 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO G SIGNATURE DATE / �Q - FOR OFFICIAL USE ONLY s < PERMIT NO. . c' DATE ISSUED MAP/PARCEL NO. f ' ADDRESS VILLAGE S y OWNER r s DATE OF INSPECTION: f � FOUNDATION FRAME INSULATION � FIREPLACE . ELECTRICAL: ROUGH FINAL 1 PLUMBING: ROUGH FINAL. GAS: ROUGH FINAL FINAL BUILDING •- `'� :��r� ",'_.��. :-%' 1 ` ! 0 DATE CLOSED OUT ' ASSOCIATION PLAN NO. i _ The Commonwealth of Massachusetts Department of Industrial Accidents office eflores0adoos 600 Washington Street = 3 T Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit name: A&L 12 �j location: '�6,AJ7" city 41/JS -rl�/a G` shone# ❑ I am a homeowner performing all work myself. ❑ I am a sole% netor and have no one worku m* capacity %/5Z--- I am an em 1 roviding workers' compensation for py employees working on this job. ......: : :......:::.:.:.::..:.......-...................::.::.:::.........:..............,..............:t.:....... ::.. . . ........... ... ........................... :�' ..� ... 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'= ??' <' -1•T •:.;�;•T::•.;•T}:•}:•?T:?•;}}:•}:;:•:T'.::r::i::)i:;::::::.`�:;::};.:i:t;;•:?::5::�::i:+rr:TT:;T::r}}::•>:;}::<•:iii::i::;T:;:i:;fi:::x•}:;:;:; ::::•'i::?:i;:i ::;i3:::>::::,•;:}::;:;T::;i•}T:i:•:>.::i �•r.. 4.•:•r: ,.......n•:.t:..x:n..•;..•::::::•....}....:-...•........ ..r::.v....::::::::::::::.v::::::vn}v::v:.-.:,...:T}•::::::::nv:.v:•ti;•+.•i:{6}:}{ ......... v..:.v:+vTi{'ti:i ri nrarsa Fafime to secure coverage s:required corder Sectlon 35A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,90.00 and/or one years'imprisonment as well as duff penalties in the form of a STOP WORK ORDER and a nne of$100.00 a day against me: I understand that a copy of thb statement may be fornarded to the Ofnce of Investigation of the DIA for coverage verification. I do hereby certify the pains and p nalties of perjury that the information provided above is trtu.and correct SimDate ture Z�—� Print. AVIZ 11- le Pcg x/z' aze, Phone# D — —837� ofncial use only do not write in this area to be completed by city or town of vial city or town: permit/license# ❑Building Department ❑Licensing Board (�check if immediate response is required ❑Selectmen's 01$ce , OHealth Department contactpeoon: phone#; _ ❑Other. O viud 9195 PIA) r Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 section 25 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,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 inmuwce requirements of this chapter have been presented to the contracting authority. V Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and "d supplying company names,'address and phone numbers along with a certificate of insurance as all affidavits maybe s. submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and ur it date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is Accidents. Should you have any questions regarding the"law"or if you being requested,not the Department of Industrial are required to obtain a workers' compensation policy,please call the Department at.the number listed below. City or Towns 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 permitllicense number which will be used as a reference num_lier. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 Imestlgadoas 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 . I : �FVE r � Town of Barnstable s • � Regulatory Services • BA STABLE, • Thomas F.Geller,Director y M"ss ��' 059. `bAt fD�y a Budding Division • Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,'demohtion,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other - requirements. Type of Work: 14,17&72- Estimated Cost Address of Work: S Owner's Name: Date of Application: 4zzz I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑Job Under$1,000 []Building not owner-occupied x []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IlVIPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM.OR GUARANTY FUND UNDER MGL c.142A. - SIGNED UNDER PENALTIES OF PERJURY I hereby app y for a permit as the ageAt e owner: - 0d / / Q2 - 1 Dat Contractor Name Registration No. OR " Date Owner's Name Q:forms:homeaffidav To: Page 2 of 3 2003-10-01 19:02:13(GMT) 16175078279 From:Michael Queeney 18/81/20fn 14:7 bU889611319 LATFYIM CYNTEXS PAGE 82/fl7 Town of eatable Regulatory Service& e =a nomm R C,eHc:,D ireetaa te. BuHdiug DIVidon T=reM,MCC Zoo Adair Sftet,7fyanana MA 02,01 ogice: 508-s5z-aM' 3 �yU 513t� Property 4w=Must 'Complete and Sign Ibis Sm--don if using A Bvrd+der � ��nU .� 2�i' ",as Ow�c�ftho at>b�ectptaperty ' h..bp /� '%Y in au on ai ybctsalf, ssm ail attexe x&tiw.'tn wo&=*mized b7 this bs>Qiffiag F°n^t VPK-*n fog (AA&css OfJo7b) Sigces>r M of Ow= T7'•t� N {S 1G(n6t. .,� e� Pcut.2�?aaae � - • ° a ; 03oard of Buildagg Regulations rnd`St�ndaeas ti} NOAE;:IMt?ROVEMENT TCOIVTRACTOR` R6gistratl6rr`:-4160t7 'a i Ezpiratioa ''5/10� oe lndivAauaJ : PHCL P R.PQND JM' Pl�idpy �QNa = 2i3 DiR4E -A °th'Y ;. ,. f ARilVirrH it 02845. Adminittr tijr �t �fe ��rixa�acuea� o��f�aaoaelu.�ae�a BOARD IF BUILDING REGULATIONS Ucerise: CONSTRUCTION SUPERVISOR �, � •1', Number CS 001702 Btrthdate 09/4:9%19W Expires 09/1'9L20Y55 Tr.no: 4890 Restricted 00 PHILIP R POND JR r 28OLD HERITAG" WAY �+ HARW ICH, MA 02645 Administrator 1 t b pOo�rr 2 K12 O zix r�t�T-