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HomeMy WebLinkAbout0073 CAMP OPECHEE ROAD cam: . . �. 3 e r /� C .. �. . O � o .. Application numbe -Fee ... ... .... Nose, Building Inspectors Initials.......... ..r. ................ AUG 12 2019 Date Issued.*...................� Map/Parcel................................................................... TOWN OF BARNSTABLE - EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: ,3 0"..psk-g— of-I � /� -NUMBE/R STREET VILLAGE Owner's Name:lAa-111i� Phone Number Email Address: ..Cell Phone Number 1 Project cost$ yo Check one Residential %'�r Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize C� to make application for a building pe in accordance with 780 CMR Owner Signature: (�e Dater TYPE OF WORK Siding Windows(no header change)# 0 Insulation/Weatherization ❑ Doors(no header change).# QCommercial Doors require an inspector's.review Q Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name ��� ✓�v.�as,C//� Home Improvement.Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# .(attach copy) Email of Contractor 6�%�I/�i/ Phone number ., ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER......................................................`........ ` *For Tents Only* Date Teni(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 Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or>Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours 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 Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number. Cell or -ork�uffi6er S�4�- 9�9'S-kyk I understand my responsibilities under t es and regulations for Licensed Construction Supervisor in accordance with the Massachusetts State Building Code. I understand the construction inspectio roce ores,specific inspections and documentation required by 780 CMR and the Tow a to le Date Signature C; APPLICANT'S SIGNA TURE Q Signature_� Date All permit applications are subject to a building official's approval prior to issuance. CJ/e f,,qzn wuvea`Cli a�P/�Cav�ac/..J,& Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation `1-20659--- 02/18/2020 One Ashburton Place-Suite 1301 DAVID LINNELL ; Boston,MA 02108 DAVID J.LINNELL 2 CHEQUAQUET W QY_ CENTERVILLE,MA 0202 Undersecretary Not valid without signature Commonwealth of Massachusetts a � Division of Professional Licensure Board of Building Regulations and Standards Constructi &2 Family CSFA-071507fipires:08/11/2021 DAVID J LINNELL,JR, 2 CHEQUAQ ET WAYS CENTERVILL-6MA-02632 � r Q " Commissioner �� q ��'y�-' CERTIFICATE OF LIABILITY INSURANCEf 1A�.k.!RV DATE(MMIDDNYYY) --°'"'' 08/08/2019 PRODUCER THIS CERTIFICATE.IS ISSUED AS A MATTER OF INFORMATION Blackstone Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. BOX 3144 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Worcester, MA 01613 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA A.E.I.C. Llnnell Enterprises INSURER B. 59 Freeboard Lane INSURER C: Yarmouth, MA 02675 INSURER D: INSURER E: COVERAGES 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 OFANY 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTSR 1NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATPOLI (MMIDDIYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO R NTH PREMISES Ea occurence $ _ CLAIMS MADE OCCUR MED EXP(Any one poison) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMKOP AGG POLICY R PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY g SCHEDULED AUTOS (Per person) HIRED AUTOS I BODILY INJURY' $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) t GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANY AUTO EAACC $ ' OTHER THAN j AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY ��— EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ I $ f DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND ✓ TO(;b[A[LIMITSFJOM- ER EMPLOYERS'LIABILITY _ A A,NYPROPRiE-TORIPARTNER/EXECUT)VE WCC50050074472019A 8/1/2019 8/1/2020 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? yes, • E.L.DISEASE-EA EMPLOYE $ 100,000 if describe under SPECIAL PROVISIONS below E:L.DISEASE-POLICY LIMIT' $ 500000' OTHER } :a - I m` 9 i y { David Linnell is covered by the workers compensation policy. l CERTIFICATE HOLDER CANCELLATION # SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town.of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN 367 Main Street Hyannis, NIA 02601 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZE EPRESENTATIVE' ACORD 25(2001I08) J ©ACORD CORPORATION 1988 u m i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluriibers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: �,,-r ' / ed&3.1 Phone#: S� LPL � c- Are you an employer?Check the appropriate box: Type of project(required): 1.�I am a employer with / 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors . 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. IMORemodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me'many capacity. employees and have workers' Y P h'• t 9. ❑Building addition - [No workers' comp. insurance comp.insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No.workers' 13.❑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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site n.informatio Insurance Company Name�� J'A Policy#or Self-ins.Lic.#:GvCC i` d a �o 0 7'/Yj 6/y A Expiration Date: Job Site Address: C.� O City/State/Zip: �G�1G �19r� d-2 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 c der the .at_�! penalties of perjury that the information provided above is true and correct Lj�Si Date: R— 9 afore: .�'�� Phone#: 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 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 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 0 �M Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Z, Fee 1U 9 _ snat�tsrnet.& ~ �$ Richard V.Scali,Director ® > Building Division Tp�q, jut 312015 Tom Perry,CBO,Building Comm><ssion U OF 200 Main Street,Hyannis,MA 02601 q RNS lq B� 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 [000-3 W3 Property Address 7� L'G M CJ �l UI�P Residential Value of Work$ / Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address a�1 f Cl t-✓ Cam✓' _ �)�. [/r���' � .� Contractor's Name Telephone Number SO C' ;?60 Z2d Home Improvement Contractor License#(if applicable) l 3lfS�� Email: %!I-, Construction Supervisor's License#(if applicable) i6Workman's Compensation Insurance Check one: ❑ I am a sole proprietor 1 am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# OZZ Y1/32-2--I0 Copy of Insurance Compliance Certificate must accompany each permit. Permit Req est(check box) t Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Yc,-�- A ❑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 copy of the Home Improvement Contractors License&Construction Supervisors License is requiped. SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOlDTiR\EXPRESS.doc w Revised 040215 • s + BARNBTABM " MAW i679. &1 Town of Barnstable � Regulatory Services Richard V.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 I, Ch✓'^ Y)j/), , as Owner of the subject property hereby authorize p�"Fr '7 I ( C)i►J ff'-)G•6'U') to act on my behalf, in all matters relative to work authorized by this building permit application for: 73 4nq 14 ,oc � ee (Address of Job) Signature of er Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.but]ook\2PTO I DT-TR\EXPRES S.doc Revised 040215 , - �e C'o�raron ►alih a►f�rlrtssat:.ltaeseiis 1pepaHmend of Indirshi al Acdder s Office of Invesfigalimii .600 Wwkington Street Bostirrs,M4 02111 avarru'Masmg za Workers' Compensation Insurance Affidavit: BWdersJC-oa cbonMeetdcians hunbers Applicant Inf trnmation Please Frinf I*w'bl r. Name Orgmizetionllndiuiduail: Aaah city/st z _ 41-M Are you an employer?Check the appropriate boa. T3Pe of Pro jest(regnii-eft l. I a S employer with ` 4. Q I am a general'contractor and I P y� b. Q New 11 ns tion employees{full and/or putt ti:uej.= have hued the Salk-C41ItTaCtOiS 2.0 I am a sole prop� s1 d ota tfte a ed ht:et a gRemodeliar sip and have employees orloyees These sub-contra�rs have 8_ Q Demolition and have worls�s° wio�ing:for me in any t0pacity. emgl®yeas 9. ❑BAutlding addtuon [No tvor&ets'comp tnstuance camp- asurad .l required,] �. Q:' e are a corporation and its. 151.❑Electrical repairs or additions 3:❑ I am a home doing all vao rk o#Beers have ell excised their I .❑Plumbing repairs or adtkticros myself[No worlmrs'comp:: right of eaempfion per A+IGL 12.Q Roof rEpasrs insuMa ce required]l c. 152, 1(4j and we have;no �loyees.[No wodmts` 13.O.Other comp:insurance required.] iAuy t that chedm boa 01 m=also fill oat de section below showing their workers'=Tensafm policy in£oamation rioaaaeo rs who sub�ic tLis:affielavit lrttlicatiug'they sae deeigg ark wad.and dum Lae o mide f p]F=cons—,t slahffiit a iiew i M4oii t indiC817e1g&LdL tCaahacto2+ dM check this boa mwtzftached=wWMozW sheet dho=gthe na=of the mb cos tars and Ma wbe*w ar'nat those eafitie4 bm emptoyees.if the m b-conMKton bare em*yees they roust wwMe their workenl comp:policy number_ Iam an employer that is prcuiding ttorkers'conWensa inn inmranca for My employ Below is the parlicy and jolt site t it bvmation. �1 Taei lance Compny dame: Policy#or Self ins:Lic_ �Z /y Expiration I?ate: S. Job Site Addre$s: Attach a copy of the workers'comperpsation policy,declarationgage(showing the policy number and expiration date] Fadium tir secure e coverage as required under Section 25A ofMGL c.. 152 can lead to the imposition of criminal penalties of a fine 4 to$1,500.M and/or.:ot�year impriso t,as well as civil penalties in the foam of a STOP WORK f RDER and a fine of up to$250.00'a day against the violator. Be adc�sed that a copy of tllis state r may be forwasd®d to me.Offici of hwestigatiaas of&e DIA for insurance coverage veri tion. I do htmmbl+cerYi a e ptrial o perrallies mfpedj try that the information pr�u"Wed obwe is Mie and corm ate: _ d` 4. t ewe y, Aa►ittd�r iaa the dry,tQ ke��t�I+��y Qr�t�o,�'i�t ` City.or IT M PermWLicense 9 Issuing Authority(curdle one):: L Board of Healtfe 2.Bmlding;Departtnent.3.City/Town Clerk 6.Electrical Inspector.5-FIReQbing In ctor :6.other Contact Person: Phone#x: 6 f CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY1ry) (CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RlGH�TS UPON THE CERTIFICATE/ HOLDERS THIS ;/TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE !COVERAGE AFFORDED BY THE POLICIES :LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ,idEPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. �! IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the !the terms and conditions of the pollcy(iee must be endorsed. If SUBROGATION IS WAIVED, subject to 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 SCHLEGEL INSURANCE BROKERS INC NAME: PAUL SCHLEGEIL PHONE 34 MAIN STREET (A/C,No,Exp: 508-771-8381'I -- —� FAx -508-771-0663'-- No ADDRESS: SCHLEGELINS �--— - -'- -- - WEST YARMOUTH MA 02673 .-_ --U�ANCE@CMAIL.COM INSURER(SI AFFORDING COVERAGE T NAIC# — INSURER A:COLONY INS CE - - -- - ---- INGl1HEU Timothy Keating Dba Keating Construction INSURER e:CNA -- - ------ ..___ 54 Lower Brook Road INSURER c --- ----, ---- INSURER D: _.-------- South Yarmouth, MA 02664 INSURER E: COVERAGES I INSURER F CERTIFICATE NUMBER: iNCI IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR DE NIAMEDNA OBERFUH iHf_ POLIi=V F'cltl!1 NCICATED. NOTWITHSTANDING ANY REQUIREMENT, r('rT!FICATE MAY BE TERM OR CONDITION 01- ANY CONTRACT .OR JI ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE P OTHER DOCUMENT WITH RESPECT T1� FxCIUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.POLICIES DESCRIBED HEREIN IS WHICH T1IIs SUBJECT 70 Al I. THE TENFgS. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY E%P A GENERAL LIABILITY IMM/DD YYYY 1 (MM/DOM'YY)T LIMITS - - GL3594908 03/20/2014013/20/2015 g I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 1 I03/20/201 03/20/2016 J C!A!MS MADE Ix OCCUR PREMISES(E.occurrence) S 500,000 MED EXP(Any one person) ___(E 5,000 _ I PERSONAL&ADV INJURY g 1,000,000 !__ I GENERAL AGGREGATE 2,000 7EN'L AGGREGATE LIMIT APPLIES PER ' -- POLICY I JEC7 — 1 LOC PRODUCTS•COMP/OP AGG 2,000 - ' AUTOMOBILE LIABILITY 75----' ! tJ.AUTO - (Ea accident) ! S ALL O'NNEO - -- I SCHEDULED I BODILY INJURY(Per person) .S ---_ i AUTOS AUTOS � ! _ - --I PRIED AUTOS L AUOTO WNED I i ,BOOil.Y INJURY(Per accident) S - --- - I I 1 PROPERTY DAMAGE (Per accident) I S i I - UMBRELLA LIAR —---- !OCCUR S I j EXCESS LIAR -CLAIMS-MADE EACH OCCURRENCE S _ - DED RETENTION S I .. - AGGREGATE B 1 WORKERS COMPENSATION r �•---'---------- — ANUEMPLOYERS'LIABILITY 0224N37-2-10 03/09/201403/09/2015 WC.S A u- Y I N OTH. .4Nr i'R�PRIt:rOR/PARTtJER/EXECL!TIVE F— J -° TORY LIMITS ER '-I-ICERIMEMBER EXCLUDED'/ I03/09/2015 03 09 2016 E.L.EACHACCIDEN7(Mandatory in NH) --�--- S 100,000 i !1 yes,descnbe under - I E.L.DISEASE•F1,EMPLOYEE S DESCRIPTION OF OPERATIONS below I 1 OO,00 0 - I ------- --- . E.L.DISEASE-POLICY LIMIT �S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPESNATION POLICY CERTIFICATE HOLDER ' CANCELLATION - 7+ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE" WILL BE DELIVERED IN "ACCORDANCE WITH THE POLICY PROVISIONS. - AUTHORIZED REPRESENTATTV t ACORD 25(2010105) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of A 0 CERTIFICATE OF LIABILITY INSURANCE DATE IMM/DO�'(Y'YYI %'CERTIFICATE I5 ISSUED AS 'A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHITS UPON THE CERTIFICATE/ HOLDERS THI'S TIFICATE DOES NOT AFFIRMATIVELY OR. .NEGATIVELY .AMEND, EXTEND OR ALTER THE I COVERAGE AFFORDED BY:LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING THE POLICIES INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. y7IMPORTANT: It the certificate holder is an ADDITIONAL INSURED, the pollcy(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 reFificate holder in lieu of such endorsement(s). F34 CER LEGEL INSURANCE BROKERS INC NAME: PAUL SCHLEGES PMONE SO8-771-838L — -- ---�Fax _...___..—___._....___.. tAIN STREET �A�•NOEt) 508-771-0663 AIADOREss: SCHLEGELINSURANCET 'YARMOUTH MA 02673 @GMAIL.COM — ---- INSURER S AFFORDING COVERAGE _—`_._— ________--- INSURERA:COLONY INSURANCE __-....___ -_ INSIIRLU Timothy Keating Dba Keating. Construction INSURER B:CNA 59 Lower Brook Road INSURER i- - --- - --- -INSURER D INSURER E: ---- ---- South Yarmouth, MA 02664 --- ------ INSURER F: --......__--------- -.-...------._COVERAGES CERTIFICATE NUMBER: I1'FIIS IS TO CERTIFY THAT 11�E POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INUUR(J NIAMDEDNAB BVERFOR THE: POLII N f'(;I21+Jli iNCICATCD. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 WHICrI Tr!Iz> C(P'NFICAFL MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT' F,(10SIONS AND CONDIT IONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TO ALL. THE TEPLIS. __ _ I TR , TYPE OF INSURANCE Uff INSR NND POLICY NUMBER POLICY EFF I POLICY EXP -- ----_. A ; GENERAL LIABILITY (MM/DD/VYYY) (MM/DD YYYY)T LIMITS --. GL3594908 03/20/2014 03/20/2015 EACH OCCURRENCE g I COMMEPCIAL„ENER.AL LIABILITY 5 1,000,000 ' — r 103/20/201 03/20/2016r R �— - . I CLA!MSMApE I.. OCCUR i ._ PREMISES(Ea mcurrencei 5 500,000 - I MED EXP(Any one person) E 5,Q Q Q PERSONAL&ADV INJURY E 1,000 ,QO Q ATE I 2,OOO,OOO _ •;fi'JL AGGHEGA GAI TE LIMIT APPLIES PER GENERAL AGGREGATE -- I I � I -- - i POLICY ! I ECT ,LOC I I PRODUCTS_COMP/OP AGG E 2,000,000 AUTOMOBILE LIABILITY 5 I a.rJ�n,U10 I (Ea accident) 15 ALL OWNFO ',SCHEDULED I I BODILY INJURY(Per person) 5 -- _- _I AUTOS AUTOS -�NON-OWNED BODILY INJURY(Per accident) E !MIRED AUTOS AUTOS _ (Per accident) E UMBRELLA LIAB ! S j I OCCUR -j EXCESS LIAR I EACH OCCURRENCE S CLAIMS-MADE DEL RETENTION E i AGGREGATE S g j WORKERS COMPENSATION ANU EMPLOYERS'LIABILITY 1 0224N37-2-10 03/09/2014 03/09/2015 WC s A U. p7H- J :..-NY PROPRIE I OR/PART!JER/EXFCUTIVE Y/N TORY LIMITS ER I03/09/2015 03/09/2016 - - '�I ndm MEMBER F%CLUDEO� )y TIN/A - E.L.EACH ACCIDENT S 100,000 IMnndalory in NH) L-.�1 t �-_----- .yes DESCRIPTION OF - I E.L.DISEASE FFJ.EMPLOYEE 5 100,000 UE93CRIPTION OF OPERATIONS below - —__ ! E.L..DISEASE POLICY LIMITS 500,000 _J_ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ARach ACORD 101,Additional Remarts Schedule,it more space is required) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPESNATION POLICY I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIV ACORD 25(2010105) The ACORD name and logo are registered marks of A 0 1988-2010 ACORD CORPORATION. All rights reseryed. Massachusetts Department of Public Safety Board of Building Regulations and Stand ards Construction Supers isor Specialty License: CSSL-099351 Tim B Keating 54 Lower Brook RoadU7664 / South Yarmouth NU Commissioner Expiration 05/11/2016 ----- Consumer ,°�` iCd Licensear registration valid for individul use-only-\ Office of Consumer Affairs&B siness Regulation g Y_. HUME IMPROVEMENT CONTRACTOR before the expiration date. If found_return to: E VBoRegistration:, ; 143053 Type: Office of Consumer Affairs and Business Regulation s Expiratiosr 6114/2016 DBA '. sto n,MA 02I16 KE ING CONST f � �� TIMOTHY KEATING �3 i } 54 LOWER BROOK�Q SO:YARMOUTH, MA 02664 Undersecretary s Not valid without signature 5 k Engineering Dept: (3rd floor) Map I Pay-rel 0063 da ermit# .-,y-G ZI House#J #7S, � ' r Date Issued Z Fee'. Q� PI d .) THE 19 . BARNSTABLE. 59. 1 • QED DAPS s�� TOWN OF BARNSTABLE Building Permit Application Project Street Address r Ln 3 Village Owner Address Telephone ; 5,821 Permit Request 0 $ -\ ' First Floor Pon square feet Second Floor square feet Construction Type J AEstimated Project Cost $ 7e�o Zoning District C F U+c Q u i Flood Plain Water Protection Lot Size 3 C F `' Grandfathered ❑Yes ❑No r i Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes UKo On Old King's Highway ❑Yes I1io Basement Type: ❑Full ©<rawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) I Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New f First Floor Room Count Heat Type and Fuel: 516as ®'Oil ❑Electric ❑Other Central Air Yes ❑No Fireplaces: Existing `✓ New Existing wood/coal stove ❑Yes ❑No Garage: [r'Detached(size) Other Detached Structures: Q Pool(size) Q Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes f�No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO VSIGNATURE �aC' C , ��f _ DATE B I INQERMIT NI FO ,THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY , PERMIT NO. V � � y .� f • • ''� •[A�'• ,4 ; •1 . �` a. _ '- f , - ' ' - '.Sys r•}. DATE ISSUED: MAP/PARCEL NQ. ADDRESS > . _t „ VILLAGE OWNER 3 ti 10 DATE OF INSPECTION: FPUNDATION FRAME t INSULATION ' FIREPLACE ELECTRICAL: i ROUGH FINAL PLUMBING: ROUGH FINAL ; GAS: ROUGH FINAL FINAL BUILDING 1 — DATE CLOSED OUT M^ ASSOCIATION PLAN NO. a i of IN "�► The Town of Barnstable MSUM ,�' Department of Health Safety and Environmental Services OrE tom'' , Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissione For office use only 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, demolition, 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: zzr Est. Cost ,Address of Work: - /�wner's Name . Xateof Permit Application: 1 hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL G 142A SIGNED UNDER PENALTIES OF PERJURY ` I hereby apply for a permit as the agent of the owner. Date Registration No. OR f The CUmitttflnivealllt of Afa., achusells -.-. Dc�partnu•»t of Industrial.4ccidettts 1- OffleeVI1nYestfgatfons 1W . h(!i'l 1�'ashinrtan Street Bustoit. 111aa:t. 02111 ` Workers' Compensation Insurance Affidavit Al�pltc:tnt information••/ `� .__.._ .._..._.._Ple•tse PR11VT:leb�],��`_... _....... 10 name• �i;�1�7�!/� � l/�� /�/ .. • c,ti on, f v a�r p n 7f) - � I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity .. .._..•.—.s..._. � _ _ — +�./-"fig... Y... _ __ -- _ C: I am an emplover providing_ workers compensation for my employees working on this job. comminv n:tme: addresv� city: •nhnne#• insurance cn. roliev 0 . ,—..... . .-N ..M......-.a...�..!•...w•n...^..ww..r•.a._..f....... araa�..r ..._......�...�. .. [I 1 am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company naue: address• nhnne#- insurance rn. noliev 0 cmmPnn,• nnmc: addresc• rity. rhnne#• insurance co. nolict•# Attach additional sheet if ne'ceSsa_ry a F ^- * - + `'.' ." --- •' __ L£ .•�. _ '7!-�Y �':-• '" -' _' Failure to secure coyerace as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of a tine up to 1.500.00 ndiur one,ears' imprisonment as,well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be for,vnrded to the OMce of investigations of the DIA for coverage verification. I do hereht•ccrtij- tdcr the pains and penalties of perjure•that the information prorided above is trueIndcorrect.(' Sianature �� Date Gl' J z - 7 Z Print namef1!� � /��U�! Phone# 177- " ram` D �/7 ' oRciai use only du not,write in this area to be completed by city or town official city or town: permit/license# rIBuilding Department C]Liccnsing Board G check if immediate response is required ascieetmen's Office I �Ilcalth Department �. contact person: phone#: rJOIltcr. 5 a 1 information and Instructions Massachusetts,Geiferal Laws chapter 152 section 25 requires all emplovers to provide workers' ctmi cnsation for ;1. employees. As quoted`firom the "Idw". all emploree is defined as every person in the sen,ice'ot cittiitl cr`undcr any contract of hire.'express or impiied.-oral or written. ` An etyzplurer is defined as an individual, partnership, association, corporation or other legal entity, or ally two or-inc the fore-going cnzaued in a joint enterprise, and including the legal representatives of a deceased employer. or the receiver or tnistee of an individual , partnership. association or other legal entity, employing employees. However owner of a dwelling house haying not more than three apartments and who resides therein, or the occupant of the dwclling house of another who employs persons to do maintenance , construction or repair wort: on such dwelling_ ?i to shall not because of such employment be deemed to be an employ • �• building a urtenant there P grounds or or rnt the _ro PP MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance of- renewal of:1 license or permit to gperate a business or to construct buildings in the common-wealth for an} 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 wort; until acceptable evidence of compliance with the insurance requirements of this chapter been presented to the contracting authoring. Applicants ilicants Please fill in the workers' compensation affidavit completely, by checking0 the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tlie 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 require to obtain a workers* compensation policy. please call the Department at the number listed below. City or Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P! be sure to,fiil in thepermit/license number which will be used as a reference number. The affidavits may be returnee the Department by mail,lor FAX unless other arranuements have been made. The Office of Investigations would iike to thank'}'ou�in advance for you cooperation and should you have any questi, please do.not hesitate to _ive us The Departinent's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Ma. 02111 .fax is (617) 727-7749 1 K,. N U M B E R :- . RECEIPT DATE RECEIVED FROM Address /1 ..DO S DOLLARS FOR r ACCOUNT HOW PAID !� G ' ' t a BEGINNING CASH d BALANCE o AMOUNT CHECK / c PAID 2 Mnoe iN u.s.n. BALANCE MONEY 3 ®WiISonJones,1999 DUE ORDER • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE / •� , JOB LOCATION F Number treet address Section of town "HOMEOWNER" -7 7, ' 2? -- Name Home phone Work phone - PRESENT MAILING ADDRESS .51' City town State Zip code The current exemption for "homeowners" was extended to include owner-occupies dwellings of six units or less and to allow such homeowners to engage an in- . divilu­al for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, 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 Off..ic'_ on a form acceptable to the Building Official, that he/she shall be resnonsir for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes . responsibility for compliance with the, St Building Code and other applicable codes, by-laws, 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. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35 , 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 01 Construction Control. d HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 Home Owner engages a person(s) for hire to do such work, that such Home Owne: shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for . licensing .Construction' Supervisors, Section 2. 15) . This lack of awarenes often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home " caner-' actir. as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, man communities require, as part of the permit application, that the Home Owner 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 to amend. and adopt such a form/certification for use in your community. Assessor's map and lot number ..... J...... ......... ' eq If THE � Sewage Permit number ......... :...... :......:........................ SEPTIC SYSTEM MU �P INSTALLED IN COMP IrAB6 LE, Housenumber ......................................................................:. WITI� a 90 TIT.._.r- Opp i639.ENVIRa�0� �1 O'�6-�'"b�. 4 !!! TOWN OF BARNSTTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .......:.... tTz.... ... ... ... ......... f: ?�~Z—� TYPE OF CONSTRUCTION ...............5 ............................................................ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .../..^3..........�.... .... . ................. �......... .fol................................................................ ProposedUse ............ -'Z •c.r✓I ............,z ........................ :............................................................. Zoning District Fire District Name of Owner �� ............ ......... . . ,r Address ...:....................... .......<..../... .r/.. ...... Name of Builder .... ... .... .........--s..........Address ..... Y! �.../P......................�-/ .Name of Architect ..................................................................Address ................................................................................... Number of Rooms ........... .......................................Foundation ..... ...............................- ?............... Exierior ........G/.. J .. .... .......................Roofing ................................................... Floors .......... :.. ..............................................................Interior .......... — ......................�.......-.....`................................ Heating ...........................................................Plumbing ....�� ............................................................... Fireplace ..................................................................................Approximate Cost ........ 9 ... .,�.......................... Definitive Plan Approved by Planning Board ---------------_---------------19--------. Area ...�4... ... .................. Diagram of Lot and Building with Dimensions Fee ( !'. SUBJECT TO APPROVAL OF BOARD OF, HEALTH f y U C � I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ........................... ............. ....................................... PENDERGAST, JAMES 22179 Addition No ..........:_,. .t°�rmit for .................................... Single Family. Dwelling ............................................................................... Location 3 Camp O pee che.e Road Centerville ............................................................................... James Pendergast Owner .................................................................. Frame Type of Construction .......................................... Plot ............................ Lot ................................ tw I tk Permit Granted ... ...MaX....6.................. .19 8019 . Date of Tn'pection ............,....... Date Completed ..............z 19 t - PERMIT REFUSED N.I...... .::..................................... 19 1 .. 4..............h............................... . . tv M ......... .. ..r.'......................................................... .a' . ` ............................................. C) ........ . ............................................................ Approved. ................................................ 19 ............................................................................... ............................................................................... Assessors map and lot number ....... Sewage Permit number ...ok.................................................... Z BAHBST�LE, i House number .................: NAB ....................................................:. :o C i639 \00 �FE MAY a' TOWN OF BARNSTABLE BUILDING INSPECTOR a APPLICATION FOR PERMIT TO 9f 7`�......'t t'��/ ......+ :......... ITYPE OF CONSTRUCTION ........................... f.. �'....::� z:=.-:: .............................................................. '1 / ,...............19.. .... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location -�........ ... �. ':.. '�..'................:......'. �....... /.. .......... .. ..........:............ ...................�� i�i,' c, / �' Proposed Use ................. . ........ .. G..c....a......;....r_ ...... ...`............r:.................................... Zoning District ........................................................................Fire District Name of Owner .....r...:.:...L ` ............ :...! '.�. .. ::^:........?...Address .........`' r.......... :.. ..::......... ...:............ ....... i Name of Builder ...�c......(/�`u' �..... :i ?.....Address .........a.... ............ Nameof Architect ..................................................................Address .........................:.......................................................... l / Number of Rooms '`- .............Foundation ...........'.:. p f.`_ ' .. .................................................... Exterior .............. ....... '.�.i/, t, r. .r.....::_ .....................Roofing ...........a. ..G ........�..�........... .................... :' y• Floors .. v-r_. `... i............................ ...........:............................. Interior Heating /-, ..,.,.1�...�.' J .......Plumbing ...... ......................................... I...............��.........J Fireplace ..................................................................................Approximate Cost ............. .... Definitive Plan Approved by Planning Board -------------------_---__ .! „rr-.Il„ :�.3,,,,,.,.,,,,,,,.• ------�9--------. Area ... Diagram of Lot and Building with Dimensions Fee � SUBJECT TO APPROVAL OF BOARD OF HEALTH P/ o� I C � { I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction..- Name . PENDERGAST, JAM ES ` =1 0-3 q ` VC51 No 22. 7,�..,-P. rmit for Addition ............S.i.jag.Ie...Fami lY...pW.P-1 .i,rmi ....... Location ...7.3....Camp...Opeech e...R a.d...... .................. ........... . ................. James Pender st Owner ....................................�1. .......................... Type of Construction .Fr3me. . l . .. .... ................................ ............................................. ............................ Plot ............................ Lo"t ................................ Permit Granted ...May..6.t.....................19 80 Date of Inspection/....................................19 Date Complete ......................................19 (PERAITI[FREFUSED ................................... ........................ 19 ......... .................. . ..... .... ...................... ... .... ....................... ....... ........................................... Approved ........... .................................... 19 ...............................................................................