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Home My WebLink About1246 BUMPS RIVER ROAD T n �� ` o ` � ! Y,. s '�t/''/�/] ,. .. ;.. �. .... �. -. ,.: � '+ . . � � ... �• ;, �' � �. ,,,. ,. m '. t� s �: n o - � E �� g Z _ � _ � _ r„ o . �' ff f.l � K z.<.r n .. > " � _ - � vi:. �� , ,. I i � _ �I e u f, ..._ o , e f 0 a u - - OLC) Town of Barnstable *Permit# Expires 6 months m ue date Regulatory Services Fee + s,►xNsrnst.E, MASS, Thomas F.Geiler,Director � 1659. � prFD MA't� 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 Address 11Q ❑ Residential Value of Work . , (006)�Q�)Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address f i j s, "JeA KI Pa, ft�x icfl 7`0' Rc-50- Ma,r -t��s L fs Ill f� Contractor's Name ( � � Telephone Y �-PRE Home Improvement Contractor License#(if applicable) MAR 14 2013 Construction Supervisor's License#(if applicable) . siWorkman's Compensation Insurance WN OF BARNS Check one: T'Q ❑ I am a sole proprietor VI am the Homeowner FYI have Worker's Compensation Insurance Insurance Company Name�� —� �/� ��✓ Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ st(check box) VRe-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 #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ 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 copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: ---�—�-t' .-,� i .` The Caasm n iveal'th of assachusetts Depwrftmt of indxrsbialt-4 ccidenft - t✓ Office of Inve4.stigations 660 Washu4gton Street Boston,MA #211.1 wrt wv trial g v1dirt Workers' Compensation Insurance Affidavit BuUders/Con#rac#nrsJEfectric ans/Pittmbers Applicant Information Please Print L `bl- r Name(Btr tioo&&vidual): � p� &X 199 �e A�res�: /L �-7 • City/stat&zip- Mar,<4M3 Phone A an air employer?Check the appropriate b -- Type of ro'eet r I am a general c�naractor and I 3'p p' J (required): �D atn a empl with i5_ ❑I+Iew cansfructian emplo a�d�ar part-lime)_* have hied the sub-contractors palm paw_ listed on the allwbed sheet. y- ❑Remodeling ❑ I am a sale etai or ship partner- no 1 sub-contractors have g- ❑Demolition.� s employees and have workers' wotdring forme in any capacity. 9�. ❑Building addition ,o wod=s'comp_insm-mce comp_tasvcance-.l 5. ❑ We area coLporation.aud its 10.0 Electrical repairs or additions required_] 3-❑ I am s homeowner doing all wok tffi ress have exercised their i l_0 Plumbing repairs or additions myself.[No workers-comp. right of exemption per MGL 17 0 of repairs imcas ante required,]T c.152,§1(4,and we have no • 13,VOther '1"' employees-[No workers' comp.insaraom required.] 51' e. 'mil'app&=that checks box 91 ono,;also fill out the section below sbnwing their woakers'compensation policy inf6mution— I Hameowms who submit this a 5dwit indicating +they ate doing in world=A then hire outside cons m mrs mast submit a new affidavit indicating such IContraam that cherk this box mast attached an addiiinnal sheet showing the name of the s6-cm3h-icbm and Mte whetber or not chose entities bare emglovem If the snb_cuntraaets have employees,thgy must pmvide their wurkere comp.13*Ucp number. I afn apt araplr�ar tPrrit is providing tvor�kers'campertsrrtixrrr i�assrt�ruece for gray errzpluy�t:�s,� B�toev is fire psliry trt�d jab arts ixfort�rrrfei�ar. . Insurance Company Name: l r, Policy-cr.Serf ins.Uc,t. /�� YV(�T7 O Expiration Date: 3 '7— j-14 Jab Site t ddlie'ss: — Ci •1StatdZip: ®Y I�J(�i I Ile / v t Y 1 Po?6 3off+ Attach a copy of the markers'compensation policy declaration page(showing the policy member and expiration date). Failure to secure coverage as required under Section 2 5A of A+GL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500_00 andfor 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 im-es4ptiams of the DIA for nY=slf Lce cmmrage venfi ation- P do hereby ceili y reorder thepains amd pmah ees ofperttty i�t tJie ir�arrrrtrtfrrn prrn�i'dad abm is tms'arid correct Siomtare:` Date: 0 aI sw only. Der not write in this irreeer,to be ampteted by city or tmm oAki a1 . CUT or 'own: Perwit/Ucense# Lssuing Antharity(drCle erne): . 1..Betard.of Hetltlr Z.Budding I3epartme`nt 3.III t3wn Gloria d.£lectrit sl Iet3ar 5.Plumbing Inspector 6.Ckher.. :... . _ �oFT Town of Barnstable Regulatory Services r + HABNSTABLE. ' Thomas F. Geiler,Director 1 Building Division . Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.m.a.us Office:. 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION a Please Print DATE: 3-13 o JOB LOCATION: — JWC . Niff //C number c' street Q}/��'� 7�J/_ ?�p�(�Q v�illaagd �/ HOMEOWNER": �)a l Pi'el� `/�V^ / 6 c/(J—l4 5` 4�—/5 /,-:2 name home phone# work phone# i CURRENT MAILING ADDRESS: For eox ' / 1 (� -f E 0�2 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. gnature of Hom er 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. . OF THE rOw Pv ti O � s " + BARNSTABM i 'HAS 1639. Town of Barnstable 9� �� .. ArED MAC s Regulatory Services Thomas F. Geiler,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. Q:\WPFILESTORWbuilding permit forms\EX'RESS.doC _ . ... . CERTIFICATE RTI F I C T DATE(N MIDD/YYYY) A E OF LIABILITY INSURANCE 03/14/2013 THIS CERTIFICATE 18 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 pollcy(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 an this certificate does not confer rights to the Certificate holder In lieu of such endomement(s). PRODUCER A BLAIR AGENCY,INC. PNOM FAX 145 SOUTH MAIN ST No): CARVER,MA 02330 INSURE 9 ARFPRPINQ COVERAGE NAIL a INSURED INSURER A; FARM FAMILY CASUALTY INSURANCE CO J A JENKINS AND SON CRANBERRY,LLC INSURER B PO BOX 199 e1sURM c! MARSTONS MILLS,MA 0264M199 INSURIERD; INSURER E: INSURER R 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 CLAIM$, LTR TYPE OF INBLIR/WCre POLICY NUMBER P P SUER OLI P GENERAL UABILrry LIMITS EACH OCCURRENCE g COMMERCIAL GENERAL LIABILITY i PREMISES oomrranta $ CLAIMg-MADE OCCUR � MED EXP(Arty one perem $ PERSONAL&ADV INJURY S OeNERALAGGREOATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/QP AGG S POLICY PRO- LOC S AUTOMOBILE LIABILITY � I I 1 ! i Ee $ ANY AUTO �........_ ._..... BODILY INJURY(Per Person) $ ALL OWNED SCHEDULED AUTOS AUTOS NED 13001LY INJURY(Per aCaiderdl $ NON-OHIRNC ED AUTOS AUTOS P� QelltDAM S $ UMBRELLA LIAR OCCUR i EACH OCCURRENCE $ EXCESS LJAB i ..........i CLAIMS-MADE AGGRSOATE 6 DED RETENTION $ WORKERS COMPENSATION *YSTATU X 10 AND EMPLOYERS'LMBILITY Ta AANY ER/EKECUTIVE OFFICC/MEMBEREXCLUDED9 N/A 20DlWB820 0310712013 03/07/2014 F.L,EACH ACCIDENT atorV (reea.dwc In and E.L.DISEASE-EA EMPLOYE S 1.000.000 If yee,deaalbe under 1^, E.L.DISEASE-POLICY LIMIT $ 1 000,000 DCSCRIPTION OF OPPRATIONS I LOCATNNI9/VEHICLES (Aftech ACORD IOI,AddMloeel Remedm Schedule,U more epate Is mquvva) a , OPERATIONS PERFORMED BY NAMED INSURED . w ZE FRED JENKINS IS COVERED BY THE WORKERS'.COMPENSATION POLICY J " zt "Nv O CERTIFICATE HOLDER CANCELLATION ; TOWN OF BARNSTABLE SHOULD ANY OF THE aBOVE pESCRIBED PLICIES'BE F1ICEL.LEo BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL"M DELIVERED IN BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 200 MAIN ST AUTHORIZED REPRESENTATIVE HYANNIS•MA 02001 Qf 198 10 ACORD COI TION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD i