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T Town of Barnstable *Permit#
0 Expires 6 mon s jrom issue date
Regulatory Services Fee v
RMWSrnsi.E.
MASS. $ Richard V.Scali,Director
i639. �0
ATFo��a .
Building Division o
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X--Press Imprint
Map/parcel Number _6( L (�
Property Address 1
(Residential Value of Work$ ' SO-6V l U V Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Cif i rt'1 Cn�
Contractor's Name C E_v Telephone Number ISO 977
Home Improvement Contractor License#(if applicable Email:
e, C
Construction Supervisor's License#(if applicable) 0q
❑Workman's Compensation Insurance ,
Check one:
PERMIT
❑ I am a sole proprietor
❑ I am the Homeowner NOV 13 2014
VI have Worker's Compensation Insurance
VTOWN OF SARNSTABLE
Insurance Company Name
Workman's Comp.Policy# C Vy G OD O�Ld p��1, ,�06
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 110
Replacement Windows/doors/sliders.U-Value ,�(maximum.35)#of windows_
#of doors: r
❑ 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
),re aired.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
The Cainmamwa &of Vassachas
Depivft tent of h das&hd Accidents
600 Wswhu gton W-eet
B&sfaq,ALI 0-111
Wf4;f1?7Fi=gC3w'd1a
Workers' Compensatiunlusarauce Affidavit:Builders]Contractors/El.ectdcians/Plumbers
_ pli a�at Tufarmatian Please Print Le_ibly
Name
Actress: Pp-rG\V J
CityltaixJZip_ Phone a
Are yau an employer: Check the appzapriatebnx: T of. oiect .r
4_ I amt a: ert�al snnfi�actor arid I Y� lam' � � ��-
1_VI am a employer with_ ❑ $. t?_ ❑hIew oDiasauctioa
�foyees{full amworpart-time}* liave hired the sub-coIItmciors.
2_❑ I�sn a sofe proprietor orpartaer
Iis�d on the attached sheet; 7- ❑Modeling
sg�a�rave aQ employeesThese sub-contractors have g_ ❑Demofifiou � 'i
,vor - 1`or me in an c cr r_ employees and have workers'
Y 4_ ❑Ruild g addition
!ItTo wo leers' corup:is��t,Tan�e cam-assurance
5-❑ "We are a corgarationandits IG-❑Electrical repairs or additions
eci_
I F] officers have exercised fheir 1.1_. r airs or additions
�_❑ 2 a.m.a romt�vner doing all wont o
right.of e�empfionger TvfGL ❑Plumbing ieP ,
DryseSf wo worlrs'comp- 12.❑Roof repa ,
insuraiace reT ired_l F c- 152,§1(4} and we bxve no y
,
employees- o workem'
nxF ogees-
comp-m=-ac;e equire -J.
sppiiamf tbAt cbEc s boa rl umst also fill oiat the section b9o-w sho-n their volkeoe mmpensatioa pniicg infh
1 u n w nos rrbo sabmit dais 2ffU fin icsti g they ara&Mg zTI Wro �tiim hire oU si&e cootracmrs psi s��a W€ffi in it- m)cTi_
=ctaiu:Rr Ears test ch x1c this box mnst silaChed sa s3diriansI sleet shoscmg the name of{tie sd�oo ractxs sts�whet er trrnut Ymse Vibes fi Avg
Mpjg rs_ T th'snb-co-nt MCt4:Y s b.Z e empIoyees,the}DnM p=de rh_r works'comp-POhcy number_
I cKt arr�n� thrct isgrm�idixg tt�orke-rs'co�ru�,lzv.tt aresrcrEutcs for-m�e. y�Ezs, SslotF is th�.ga7ic}rutd job sits
Gompam1Fl�Zame_ �,L. tti, Y`nu�l,c�,�/1 •
Iblicy'f cr Self: .� Ii� I 1 wL ��6b—2(�a0 —�.c)1�j�1 Fxpiratiaul�ate= v
Job Site Addxessl cqj�- w C�,,— Cit-v`Sta ziP: > Y-.- o&63-;I-
AttacJx a.copy of the-�i-arkers'comp ensaticu poliLT. declarstion page(showing the p licy rfuiaber aad expsation date).
Failure to secare coverage as required under Sectioa 25A of MGL cc 152 can lead to the imposition oferiminal penalties of a
fine up to$1,50D_(}0 andlor one-year imprisonment,as wen as civil peualfies in the form of a STOP*WTORK ORDEP and a fins
of up.to$250-00 a day against the violator_ Be advised That a copy of this sfdemeut maybe forwarded to die Office-of
Investigations of ffie DZA EDr insaT,-a+,ce coverage verification_
I de-he-reby certify under Asprnns and penaLxas ofpedwy that the irrformatian prmided)abm,e is huu.tmd correct
Simatme � Bate_Jj
Phone f=- ;
O,j Ecia[use are£}. Da trot trite in tMES Area,&bs campie.•ted by sit}:or town officiaL
cites or Town: _pmmitlLacerse#
Issuing meth aratlt(drde one):
1.3aard of Health 2.$nR`dzug Department &City-,`fown Qerk 4.Electrical Inspector S.Flumbiag Tnector
.&Other
Cont�tct Petsan: Phone#:
6
e
1 _
: Information and Instructions
y Massachusetts General Laws chapter 152 rewires all employers to provide workers'compensation for their employees.
Pursuantto this statate, an wTloyee is defined as"-..every person in the service of another under any contract of hire,
express or implied, oral or written."
An empInyer is,defined as"an individual partnership,association,corporation or other legal entity, or any two or more
of he 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. i-lowever 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 situ that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to-opera-te a business or to construct buildiugs•iu the commonweaith for an:y
applicant who has not'p.roduced acceptable evidence of conaplia'n.ce Qrith the i- surance:,coverage mq'uired."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor,aay•of,its political subdivisions shall
enter into any contract for the performance of public work until acceptable cnrideiice of'comphance vih the insuTance
requirements of this chapter have been presented to the contracting authority_" _
Applicants — —
EE Please fill out the workers' compensation a_5davit completely,by checki-n.g the boxes that apply to yror sitta en and i.f
1 necessary,supply sub-contractor(s)nz?ne(s), address(es)and phone L m be.,-(s) along w h tHe-i cer of
insurance. Limited.Liability Companies('LLC)or Limited Liability PartDerships C_LP)erith.no employes other thane he
nembere or paiinei=s,`a're not refit�d to carry workers' compensation i ;L arc:._ If an LL.0 or LLP does have
employees, a policy is required_ De ad-v- ed that this affidavit may be slbiaifted to the Depa�erit of indusiral
Accidents for confirmation of ij�sLr-ance coverage. Also be sure to sign and date the aiffidav t '11e affidavit show1d
be returned to the city or town that he acplicatioa 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 obt^in a workers'
compensation policy,please cal the Department at he number listed bolo. Seri nsured companies s�.ould enter we r
sell-insurance license number on he appropriate at.
City or Town OtFacials `
Please be sure that the affidavit is csmplete and printed legibly- The Department leas proFaaea a space at the bottom
of the affidavit for you to nll_out m the.eveat the Office of Investigations-has to contact you regarding the applicant
Please be sure to fill in the permi/Ecease number which will be used as a refe-ence number. Tn ad.d tics,2-n appL cant
that must submit multiple permit)icense applications in any given year,need only submit bne aL" - it indicating curre_r_t
policy information (if necessary)and Linder"Job Site Address"the applicant should v,,-ite"all locations M._ (city or
town)."A copy of the affidavit that has been officially stamped or marked by fte 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 m,.1st be filled out each
year-Where a home owner or citizen i q obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT rewired to complete this affida-it.
The Office of Lavestigations 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 _x number:
Th4 Com7ZLanwt,-al&of Massadla stt
Dcppart rent afhidus rlal Aocidrnts
Q-�ee Qz Xxt��t[��Farr� '
640 Washungtan St
&aston_ 02111
1�L h�61 7 727-4}GG w 406 or I,RT7,NL4SSATE
Revised 4-24-07 Fax r 61 727 7 491
� .Ift2S� a�rf 'a
9/5/2014 4 : 15 : 43 PM 8618 Q 02/02
. 1cc� CERTIFICATE 4F LIABILITY INSURANCE �0905�
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA71ON 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(Sh AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT-If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED subject to
the terms and conditions of the policy,certain policies-may require an endorsement. A statement on this certificate does not corder rights to the
certificate holder In lieu of such endorsemert(s).
PROOLICER 04331-001 CT
Eastern Insurance Group LLC Wff, . (800)=-7234 � ,N,,: (508)633-6089
233 West Central Street aDocs@oastembmuance.com
Natick,MA 01760
! A. A.I.N.Mutual insurance Company 26158
INSURED INSURER
Steven L Mellor
199 Percival Drive
West Barnstable,MA 02668
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.
ILgk TYPE OF INOURA CS POLICY NUMBER P y LIMITS
GENERAL LIABILITY EACH OCCU6RE'4CE I
COMNEROAL GENERAL UAEILI`1 AGE TO RENTEU
1 PR AI Eea curt
CLAMS-MADE OC;UR a i MEO EA'(.Any one Psrsor) 4
PERSONAL&AD'JINJURY S
GENERAL AGGREGATE I
ENL AGGREGATE LIMIT APPLIES DER: PRODUCTS-COMPtOP AGO t
L CY RO-LEC OC
COMB NEC SINGX A"T_
AUTOMOBILE LIABILITY i _ g
ANY AUTO BODILY!NJLRY(Per Ge ON 1
ALL OWNED SCHEDLLEO BODILY INJLRY(P8r EC:ideni)
AUTOS AUTCS
NON-OWNED PROPERTY DAMAGE �
iIFEDAUTCS AUTCS
UMOWLLA LIAR OCCUR EACH OCCURRENCE
EXCESS UAa CLAIMS MADE G»REGATE g
JED RETENTIONS 4
ANDF3iPL0YERe`LIABILIIY Y X ?� a`L`i�Tl�s 3b
A YIPR& bo&P&TH�PE/�cECUTIYEr-� w1a AWE-A00-T020385.2013A 11/27/2013 12/2712014 EL.EACH ACCIDENT 1 100,000.00
(Mandatory In NH) lyl E L.DISEASE-EA EM3LOvEE 4 100,000A0
��ff ��,,1sgg33iCff��ppa�undar EL.DISEASE-POUCYLIMI- 1 500,000.00
D�SCfzIP710N OFOPERA710N5 belrn
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule.Irmore spats Is required)
The workers compensation policy does not provide coverage for Steven L Mellor
CERTIFICATE HOLDER CANCELLATION
Town of Barnstable
367 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Hyannis,MA 02601 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DBLIYERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORQED REPRESENTATIVE
8.2rights reserve .
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
7303
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-049879
STEVEN L MELLOR
199 PERCIVAL DR
W BARNSTABLE MA, 026a68
Expiration
-
Commissioner 05/22/2016
l .
22 ✓(�l,G•dd au,1��aPf .
ze O I�7/IYI,O I LI�/P�GL/
ind►vidtil use on
cons
umer Affairs&Bdsiness Regulation.
License or registration valid for y
Office of C
- and return to:
_ expiration date. If found.before the ex
HOME IMPROVEMENT CONTRACTOR
P
Registration: ,>117610 Type: Office of Consumer Affairs and Business Regulation
Expiration: 10/25/.2016 Individual 10 Park Plaza-Suite 5170.
.-.Boston,MA 02116
ST EN L. MELLOR _ fi
F _s
STEVEN MELLOR. t - pp
=
199 PERCIVAL DR
W BARNSTABLE, mA.02668 Undersecretary Not valid without signature
719xj '6a.
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