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HomeMy WebLinkAbout0037 CARLETON LANE .. r ` , . q. i n .. O � ',. ,� �. j. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division Date Issued Conservation Division Application Fee fp no Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 3 7 C -re I�o4 6h Village C LA, I-e Owner G'��1.�`� reW Address Cc re-4-c ► (,e/Itza'yif�/I��. Telephone Permit Request Rern oye- Lam;k6jrx cabs ��'{Q.Sf,4/� �� . R�,/yLr7�� 1gA ;J Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater.Overlay Project ValuatiA J�� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) p Age of Existing Structure Historic House: ❑Yes ❑ No On Old King' H ghway: :G Yes -❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) T Number of Baths: Full: existing new Half: existing = new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name l Telephone Number Address 1" 6,� License # C S 0,0 S Z Home Improvement Contractor# ` 0 - Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I Z - I I FOR OFFICIAL USE ONLY I APPLICATION#_ DATE ISSUED r MAP 1 PARCEL NO. ADDRESS VILLAGE r OWNER F DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL '.� PLUMBING: ROUGH FINAL y GAS: ROUGH FINAL F FINAL BUILDING t DATECLOSED OUT ASSOCIATION PLAN NO. 140, a e t _ Deparhaeat qfIndks&id Accidents OK-We OfIrmesagadons 600 Waylyingtan&reet $ostazz,MA 02 wFt-mYnasngasa dirx Workere Compinzsatian Ium uce idavit:Builders/Coasts:cbn-, ectriciansfMumbers Applicald Information. Please Print Legibly Name;(g on/fidr�ai}: vl i , . e—ss: 0 �d �52 m Say ;& M(I OZ(0 2 City/Sta&Zip: "C Gx Phone 4: .?7 you an employer?Check the appropriate bow Type of o'ect (r L ] I am a employer with 4. ❑ I am a<geneal contractor and I � J (required): emP y � ❑New won t�employees{i`nll arkdlorpart-#ime}* tta�ehiredtl>e sasltois 6_ 2.❑ I am a sole proper or partner listed on the attached sheet - Remodeling❑ ship and hate no employees These suk►-contractors have g: ❑Demolitiaa wotldng for me in any capacity employees and have woskers' 9- ❑Building addition. No worlams' comp_insurance comp-insurance., . 5-❑ We are a corporation and its 10_0 Electoral repairs or additions required Of pace e e cised their 1 Plumbing airs or additions 3_❑ I am a homeowner doing all wtrr,� 1-❑ g�P , mysel€.[No worloers'tromp_ right.of e2wXqYtionper MOL 12-0 Roof repairs innance required_]T c.152,§1(4),and we lie a no mt employ-[No wogs` ! -❑tither . comp.msu ance requiresl:1 *Airy appb at that chedm box-91=A also 5R out the seciina below sbnwmg then wa�c�'cozmpensaLioa pnlicF ix�t�on Hnmeawaers Who submit toss sf 5davh umEcs&g they ate doing gH vm&and then hae outside coat=tars—st subs a nffw affidavit mclratan;scull tcoubmCIUM that check this box mast attached as additional sheet d Wwh3.-the name of the pis-ca ft3ctD s and state Whether ornot 5mse have employees Iftbe mb-ca t ctas bzm emgIayee%they tmtst Fuvide their workers'comp policy mmmber_ I rim an err pZojw that is pprfning workers'congmnstrrtton insurru ca for rti}'employees, Below is the po cy raid job srte information. Insurance Cbmpany-Name:' - Policy#or ,Self itzs Lim# Expiration.Date: Job Site Address: citylStawzlp: Attach a copy of the workers'camge$ga6m policy declaration gage(showing the policy nuarber and expiration date). Failure to secure coverage as required under Sectim 25A of MUL t:, 152 can lead to the imposition of criminal penalties of a fm up to$1,,500 OD and/or one-yearimpnv. o ,as weU as t nRl peuallies in the fiom of a STOP WORK ORDM and a fine of up to$250-00 a day against the violator. Be advised that copy of this statement may be forwarded to.the Office of hwestigations of the DIA for insurance coverage verifit°atioti I do hereby cmItfy upder thepruas and pen a es ofpedwy thatthe information provided a �e is unrr correct Sie ature: Date Phone#: (WE aI use anly. Da not write in ibis area,to bs completed by city or town offieiaL: City or Town:. PermidLiceuse# Issuing Authority{circle:one}: L Board of Health 2.Biding Department 3.CitvHown Clerk 4.Electrical bispector S.Plumbing Fnsgector 6.Other Contact Person: Phone#_ 6 Information and. Instructions Massachusetts General Laws chapter 152 requiresall employers to provide workers'compensation for their employees. Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract ofhire, 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 stales that"every state or Iocal 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 sit m.don and,if necessary,supply sub-contractors)name(s)'address(es)and phone number(s)along with their cer ifacatc-(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)wia 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 Dparbnent 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-insuraum 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 permitllicease number which will be used as a reference number. In addition,an applicant that must submit multiple pemiit(license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT requited 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 Commmweatth of Massachusetts Depaztment of Industrial.A.cckdmts Qffee of kvewg-4ticas 60o waste oil Sleet Bostwn MA G21 I l Tel:A 617 727-49 0 W 406 or 14 MASWE Fu#617-127-7149 _ Revised 4-24-07 . .maso�dza FdW� ' 7ER 11ODlYYYY)CERTIFICATE ®F LIABILITY INSURANCE14CERTIFICATE !S ISSUED AS A MATTER OF INFORMA7T10N ONLY AND CONFERS NO RIGHTS UPON THE CERPIFICER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,' 'EXTEND OR ALTERTHE COVERAGE AFFORDED POLICIESBELOW. THIS CERTIFICATE OF INSURANCEDOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURTHORIZEDREPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.ORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ieS) mustbe endorsed. If SUBROGATION ISubject tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does nothts to the certificate holder in lieu of such endorsement(s). NAME: PA SCHLEGEL__— _—_-_ PRODUCER - ---- - --TFAX SO8-7710663 .PHONE SCHLEGEL INSURANCE BROKERS INC (A/c,No,Exq_508-771-838i —_ (AIc_Nol. E-MAIL SCHLEGELZNANCE@GMAIL.COM 34 MAIN STREET ADDRESS: _ --;— INSURER(SORDING-0OVERAGE —� _NAIC 9- WEST YARMOUTH MA 02673 - J4788 INSURERA:NGM INSURANCE COMP . INSURER s:AMGUARD .INSURANCE COMPANY __---I}}}-----------._.-._--- ED Tecc Homes L1C iNSURERC:. PO BOX 87 - - INSURER D_ ---- .. INSURER E ----- Sandwich, MA 02563 INSURER F: REVISION,NUMBER: COVERAGES CERTIFICATE NUMBER: 'I-HIS IS TO CERTIFY. THAT THE,POLICIES OF INSURANCE LISTED BELOW .HAVE BEEN ISSUED TO THE INSURED .NAMED: ABOVE FOR THE POLICY PERIOD NDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION, OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 6E 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 -- 'POLICY EFF POLICY EXP LIMITS INSR I POLICY NUMBER (MMIDDIVYYYL J� (MMIDDIYYYYI - - LTR I TYPE OF INSURANCE 'INSR INV - 1 QQO,QOO A ,'GENERAL LneluTY i MPTS400P 9/2014j09/09/2015.EACH OCCURRENCE S -_ 09/0 I rrPR i'PREMISES(Eaoccurrence}- S 500 00O COMMERCIAL GENERAL LIABILITY ( -- - 5 10,000 X iJED EXP(Any one person) 1^--J CLAIMS-MADE I�OCCUR _ ., 1 O-000OO ` PERSONAL B ADV INJURY S r —L. GENERAL AGGREGATE S 2,000,000. PRODUCTS-COMPIOP AG S 2,000,000 --- GEN L AGGREGATE LIMIT APPLIES PER: � S ..I POLICY I 1. JECT LOC ( (Ea accident) S — FAUTOIAOBILE LIABILITY _ j _ I 'BODILY INJURY(Per person) S _--.---- ANY A'JTD ) I - BODILY INJURY(Per accident S -i 4.LL OV¢r-IED ----I SCHEDULED I - - I I — AUTOS t I I_ PROPERTY DAMAGE S d1i05 1— NON-OWNED I - I .I '(Per accident ,----- HIRED AUTOS II—y AUTOS I - - I - S r EACH OCCURRENCE 5 UMBRELLA LIAR 1 OCCUR - 11- _-- -- AGGREGATE S_ _ I EXCESS LIAR - j CLAIMS-MADE - _ 5 I D_LI , T H- _RE7 RETENTION S WC STATU- I OT I WORKERS COMPENSATION - I. WCT-1066672 B 11O/01/2014hO/O1/2015� ACH ACCIDENT 100 0001TORY LIMITS i ER -- - I E.L E S AND ECIPLOVERS'LIA BILITV YIN I �ANY PROPRIEI'OR'PARTNERIEXECUTIVE N I A OYFICERMEI.ABER EXCLUDED' I, - - EL.DISEASE-EA EMPLCVEE `' $ 100 OOO. (Mandatory in NH) II yes.describe under - I, _I E.L.DISEASE-POI ICV LIMIT S 500,000 DESCRIPTION Of OPERATIONS below j required). DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space IS CANCELLATION CERTIFICATE HOLDER JOHN MCKENZI - - - SHOULD ANY .OF THE.ABOVE DESCRIBED 'POLICIES BE CAN BEFORE 37 CARELTON ROAD THE EXPIRATION DATE THEREOF, NOTICE _WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CENTERVILLE MA 02632 AUTHORIZED REPRESENTATIVE - - - DIJON55@HOTMAIL.COM ( ©198 -2010 ACORD CORPORATION. All rights reserved.. ACORD 25(2010105) The ACORD name and logo are registered marks of{A ORD r Page I of 1 0000, m . M , a ADemogra luc Information t a FuIIN"".arne5,�` CHRISTOPHER A BEASLEY Gender ""elj License'Ad'dress Information ressm ro aT � Harwich � f slip odek :02645 Count United States :. License Information *{ L""license No CS-103589 License Type: Construction Supervisor . Profession Building Licenses Date of Last Renewal: 3/21/2013 " Issue;.Date-. Expiration Date: 3/14/2015 License.Status: Active Today's Dater 10/30/2014 Secondary License: Doing Business As: Status Chan e: License Renewal Prere uisite Information No Prerequisite Information . Disci line No Discipline Information Documentum http:Helicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license id=29251... 10/30/2014 f ,,,ofConsumerAffairs &Business regulation- Mass.Gov Page 1 of 1 The Official Website of the Office of Consum er Aff airs.&Busine ss Regulation OCABR Consumer Affairs and Business RejluiaUon, Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Compiaints Registration# 180259 Home Improvement Contractor Registrant TECC HIMES LLC. Registration Home Page Name CHRISTOPHER BEASLEY Address P.O. BOX 87 City, State Zip SANDWICH, MA 02657 Expiration Date 10/28/2016 Complaints-Details No complaints.found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search http://se'rvices.oca.state.ma.us/hic/liedetaiIs.aspx?txtScarchLN=82200 10/30/2014 L IHE Town of Barnstable Regulatory Services wsa� Richard V.Scali,Director i639- 6 is Building Division . Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder �fi-4 , as.Owner of the subject property hereby authorized Cam- 77T. (!!—S to'act on mybehalf, in all matters relative to work authorized by this building permit application for. 3 C � �/ (Address of Job) " ''Pool.fences and alarms are the.responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are.perfo ed and accepted. , Signat�}i�e of Owner , Signature of t. I Print Name Print Name. , 6? Date Q:FORMS:OWNERPERMISSIONPOOIS " _ i Regulatory Services Prof1HE roxyy Richard V.ScaIi,Director Building Division i Ra� eR Tom Perry,Building Commissioner MASS. r� i639. ��� 200 Main Street, Hyannis,MA 02601 QED www.town_barnstable.ma us Office: 509-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone 9 CURRENT MAMING ADDRESS: city/town state rip 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 minimrnn inspection . .. .....:.: ... ... procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homcowner 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 persou(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,RuIes &Regulations for Licensing Construction Supervisors,Section 2.15) 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 Iicensed 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 0613.13 -- � �;► �/w - '01p 1111 ����� o - I � 0 :: �_ _- _ ,' . �« ._. � • ,L ! I , . ,,, - u . L. L y � f Lt '' _ _ , i 4 L .+ _ - .�� � L f � L, �'�... YJ„ ,.. i,w � ^! '�� � � t 9 e ( 1 . ow 1113 Ire t Town Of Barnstable *Permit# ��j �C17 S Expires 6 months from issue date Regulatory Services, Fee MASS. PERMIT Richard V.Scali, Director p 1639 3 0 lFt, 0 2014 Building ]Division om Perry,CBO,Building Commissioner TOWN OF BARNSTARLET 200 Main Street,Hyannis,MA 02601 w_ww.town.bamstable.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 4Residential Value of Work$� 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address � � A4-- V S Tele hone Number 2 Contractor's Name �il f / p ^� J10— . Home Improvement Contractor License#(if applicable) X6�e Email' r Construction Supervisor's License#(if applicable) " U / ❑Workman's Compensation Insurance { Check one: ❑ I am a sole proprietor ❑❑ the Homeowner have Worker's Compensation Insurance Insurance Company Name i'� � ��' C� ZI Workman's Comp:Policy Copy of Insurance Compliance Certificate must accompany each permit* Permit Re est(check box) Re-roof(hurricane nailed)(stripping old shingles)All construction debris will be taken to �✓n�ps�� J�ero�_s f urricane nailed)(not stripping. Going over existing layers of roof)i de de Window doors/sliders U-Value (maximum.35)#of windows #of doors: • ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with-red Sand 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 requi d. SIGNATURE: -Q:\WPFILES\FORMS\building permit o XPRESS.doc Revised 061313 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: , %G!� G" Phone#: Are ou an employer?Check the appropriate box: Type of project(required): 1. am a with employer 4. I am a general contractor and I � ❑ 6. ❑N construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' t 9. ❑Building addition [No workers' comp.insurance comp. insurance. Electrical repairs or additions required.] 5. ❑ We are a corporation and its 10.❑ P 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#I 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 thepolicy and job site information. ��JJ Insurance Company Name: Policy#or Self-ins.Lic. 161" Expiration Date: 6 Dz Z/-> Job Site Address: 72 City/State/Zip: ` - Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u der the pains and penalties of perjury that the information provided above is true and correct Si ature: Date: IL f Phone#: --7 d Official use only. Do not write in this area,to be completed by city or town official Permit/License# Issuing Authority(circle one): -11 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 5 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-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-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 0211.1 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.gov/dia 4)e t Office of Consumer Affairs & Business Regulation- Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints -i1 Registration# 180259 Home Improvement Contractor Registrant TECC HIMES LLC. € Registration Home Page Name CHRISTOPHER BEASLEY Address P.O. BOX 87 City, State Zip SANDWICH, MA 02657 Expiration Date 10/28/2016 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search http://services.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=82200 10/30/2014 Details Page 1 of 1 Licensee Details Demographic Information Full Name: CHRISTOPHER A BEASLEY Gender: Owner Name: License Address Information Address: Address 2: City: Harwich State: MA Zipcode: 02645 Country: United States License Information License No: CS-103589 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 3/21/2013 Issue Date: Expiration Date: 3/14/2015 License Status: Active Today's Date: 10/30/2014 Secondary License: Doing Business As: Status Change: License Renewal Prerequisite Information No Prerequisite Information Discipline No Discipline Information Documentum p . v http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id=29251... 10/30/2014 s Massachusetts -Department of Publie Safe#y Board of.Building Reguiations and Standards I: License: CS 1035P s - CI MSTOPHER A-BEASLEY 4 Partridge Lane.• t ; Harwich MA 02645 X=- I: t'elx+era# 0311.. Commisslener �T • 1ARIMA3314 • Town of Barnstable Regulatory Services Richard Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,'MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section , If Using A Builder as Owner of the subject property, hereby authorize i2/�S- /��.?r� to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature f Owner Date Print Name . If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMS\building permit forms\smokecarbondetectors.doc. Revised 050412 Town of Barnstable Regulatory Services r pF "� Richard V.Scali, Director ' Building Division sARN81ASIE « Tom.Perry,Building Commissioner KAM a639. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us I 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. i CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/VYYY) 10/17/2014 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 endorsement(s). PRODUCER CONTAGI NAME: PAUL SCHLEGEL SCHLEGEL INSURANCE BROKERS INC PHONE 508-771-8381 FAX (A/C,No,ExU. _ (A/C.N0)508 7710663 34 MAIN STREET AIL ADDRESS: SCHLEGELINSURANCE@GMAIL.COM WEST YARMOUTH MA 02673 INSURERS)AFFORDING COVERAGE NAICA INSURERA:NGM INSURANCE COMPNAY 14788 INSURED v�W INSURERB:AMGUARD INSURANCE COMPANY - Tecc Homes Llc — INSURER C: Po Box 87 INSURER 0: INSURER E: Sandwich, MA 02563 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. irJSR DD SO _ ---- LTR �� TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP L (MMlODIYYYV) (MM/DD/VVW) LIMITS A GENERAL LIABILITY MPTS400P 09/09/201409/09/2015 EACH OCCURRENCE S 1,000,000 X I COMMERCIAL GENERAL DX PREMISES(Eaoccurrence) —_ S 500,000 CLAIMS-MADE t_X l OCCUR MED EXP(Any one person) S 10,000 PERSONAL S ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PRO- I JECT LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ) BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS BODILY INJURY(Per accident) S AUTOS NON-OWNED RO M TYDAA E HIRED AU —!tt AUTOS (Per accident) S I S UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S ^ DED RETENTION S -S B WORKERS COMPENSATION WCT-1068672 10/01/201410/01/2015 TORYLMITS OTH ER AND EMPLOYERS'LIABILITY YIN — ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? a NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 100,000 It yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION JOHN MCKENZI 37 CARELTON ROAD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CENTERVILLE MA 02632 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DIJON55@HOTMAIL.COM ©198 -2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ORD 77 Assessor's map and lot .number -rY1 q!1. r 77,f ... ..... 47' 1 S Sewage.Permit number .......................................................... TOWN OF BARNSTABLE TH E TOr SARIMBLE, i 0 "b 9 \ BUILDING INSPECTOR APPLICATION FOR PERMIT TO f8MI...V...—OTe................................................. TYPEOF CONSTRUCTION .ur.,.,,a... . ......................................................................................................... .. ............................... ......19. ..... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .r.:^i'-1� f"arl csi-nn T anp i n C"Pnt�arvi 1 1 aq Ma .........:.................................................................. �i»crl o ft�m9 i�r uc+x�r rnt7►�ri hmm� Proposed Use ...... . .. ._... ......... ...v,..a..... ...... ..,.....,. ...: ................................................................................................ Zoning District Fire District ...Cf' ' T 8l hQr+ Raca�i-F T tMpn TArkpP ;m t'h y..o � Name of Owner .. . ..........,... ._........................Address ....._,,. ........b ......... Nameof Builder ....ramc......................................JI...............Address .................................................................................... Name of Architect ..— me......................................................Address .................................................................................... . Number of Rooms ..;f.�?':'.?' Foundation .....x?i ? ?S'' ... ? r-e �' ............................................ Exlerior ...t , a t o fg a Floors harri i rnn�1/i n1 ai in kit R. ir+atl� Interior d"r w +l 1 Heating ?nr..•,ri i,f,+ vrs�i-e�r },ts aac ........Plumbing .�'!?a E':,11 l,fl•t li Er,'i tiRtI f. -n i nP Fireplace i,�, 'I i Sri n.!t...'^^.+•A rAd y`? .''.�' ..............Approximate Cost ... C1�►.................................................... Definitive Plan Approved by Planning Board _________________________ -------19--------. Area - �i ,....j. '7.U...S.� QQ 0a Diagram of Lot and Building with Dimensions see attached plans U P Fee ...................... .. ................... SUBJECT TO APPROVAL OF BOARD OF HEALTH I Ilk— .a' "op— I hereby agree to 'conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... :f .............I......................................... i t Bassett, J. Albert A=180-234 a 19442 one story, No ...1............. Permit for ......................t............ single family dwelling ...... : ..................................................................... Location 51 Carleton Lane Centerville ............................................................................... Owner J. Bassett .............................. Type of Construction/ frame .............................. ............................... .................................... #12 Plot .................. . ... .. Lot .......... 77 Permit Granted ..................................:.....19 Date of Inspection ................... ................19 Date Completed ......................................19 PERMIT REFUSED ........./.,***********'**"***""""****"* 19............% � .. ............. ................ f�................ Approved ........................................... 19 ............................................................................... c. /y ,/� MU - -' Assessor' map and lot number ..M..1.90.,L-2 4..:. SEPTIC S S E COmPLIANCL - KS INSTALLED IN "`` !% CLE STAT� II TOWN ' 4 S`e"tnra e5 Permit number ' WITH ARTI CODE AND 9 ......................... .................. ...... ,. .. SANITA REGULATIONS. TOWN` OF BARNSTABLE pETHE TO I STOItLE, i T ;� 3IL 9 c 'BUILDING INSPECTOR -';NPY a' v, N APPLICATION FOR PERMIT TO .C011S tY' 1C t,,,Sl2lgle„ 9 ily-home................ ................................. TYPE OF CONSTRUCTION Mood...fr.ame......................................................................................................... r ........... ... ..........................19... TO THE INSPECTOR OF BUILDINGS:` The undersigned hereby applies for a permit according to the following information: Location .Lot...12...Carleton...Lane...in...Centerville.,...Na.............................................................................. Proposed Use .....Single...family...year..rouna-home.............:.............................................................................. Zoning District ........................................................................Fire District ................. Name of Owner ...J....Albart...BaS.S.ett......................Address ...Lymran..Lanet.,,...$auth..Yarmouth,...X.A.• Nameof Builder ....Same......................................................Address .................................................................................... Nameof Architect ..S.ame............................................. Address' .................................................................................... Number of Rooms :.follr......................................................Foundation .....PQ.Ure.d,..0.Qn0r.e.t.e................................. Exierior ....white...ceder...shingles...........................Roofing .asphalt....s.erg.l..tab5...... ............................... Floors ...hard..wood/inlaid..in..kit.....&-hathinterior .dry...wall.............................................................. Heating forced...hot..water-by-gas......................Plumbing .one...full-hath...(plastia-pipe)....... Fireplace in-living...room...(red-br'i.Ck)..............Approximate Cost ...2O.rQOQ................................................. Definitive Plan Approved by. Planning Board ________________________________10________ . Area ....a ..l..!�...S: Diagram of Lot and Building with Dimensions see attached plans Fee iv...... ................. SUBJECT TO APPROVAL OF BOARD OF HEALTH Ilk— LL I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... . .. ..... Bassett, J. Albert X &'- -- 19442 one s ory Nti-'!A Permit for .................................... single family dwelling ......................................................................... M1 4 Locationj.1...Carleton Lane...................................................... Centerville ............................................................................... Owner .............J.......Albert Bassett............................................... • Type of Construction .........f.ram.e....................... ............................................................................... Plot .............................. Lot ............f12....... n............. �4 July 28 77 P6rmit Granted .......................................19 COO, Date of Ins pection .... .......119 Date Completed ..............19 4 PERMIT REFUSED ......................................................... 19 ............................................................................... ............................................................................... ;> . ........................................ ...................................... . ............................................................................... Approved ................................................ 19 . ............................................................................... ................ ............................................................. • COIL L0.0 -{ �XN idkii,mynwr..UM J Al2;yu�r, /o%.L ' Y PEASTONE —LOAM S. FILL—"" IY MAX. Mr 1 " . T;j j • 0 0 4 C.I, Dlst ! BOX �•'•° po °• 124°MIN• :5 w 1000 I, 11, 1000— GAL. GAL. ° PRECAST OR ° ° ° SEPTIC 6 � o�d�. BLOCK '0 °°0l M TANK 1�'. , o . SEEPAGE PIT 0 S� I�• ° o. Oo os 20' MINIMUM -��oo"• �o 0 01 FOUNDATION 1 1 I %z" WASHED STONE ,a • SCALE: �' IWIVATIORI SKETCH ir; 10 —� PQCJC. RATa1,ee^10 � +,,T SCALE: 1"= 4' t TEST BY: �'�•Cr.�.�/"ro,eC /l?.y/S*-r- TOWN INSPECTOR. ,P�,` eea;ee ss✓ BACKHOE OPERATOR J•,44;A9e1a> • 1j1ser'r'r_1zZ /F_,e ,6>, cp;,z•',I=y �`j�T7�IG£' `r TEST MADE ON �.� � G iZ, 191-7 STK�Tu R.e. S�E��,..1 y F�oiar c.ca�S �cscraTsxS - 3y o9ja ACTu a L. F"F_l d, S,4aut, px� 1,4r 2s" 1577 �4ml> co"vx;Rms � 7~4e A i3�n:ru a b!•e , fl�asS. �, � • � � �!� , � - -ole off 1 r� �E$. Wti;ELL ' ',ces ,.> too �;� . o ' -~ -,.. su 01 3PROP 31 Oe J, 3 to$- ,� "�',:..-1.,_ " . ✓ "' "', - ah t RENWICK yN _ cs CHAPMAN � APPROVED BY BOARD OF HEALTH s - + IVu."27654 DATE 19_ _ "r r •off 9E c> IVAl. ��'\ J. - -'tat—_ �msntoco, C;�EVA� ticyiV • ELEVATION- SCHEDULE PROP08G�® 0!Y-G�, PLAC,9 .• • , I. INV. 'AT FOUNDATI _ �a•16O Q QN . . . aC�CyAOG �3vaYCE� �C�#Qp . 2. 1 NV, I NTO 'SEPTIC TANK IN 3. 1 NV. OUT OF SEPTIC TANK a �� LoT /2, .�.1�Gr::i►a..i �• •�• " 4. INV. INTO DISTRIBUTION BOX _ _ .aS a �������° q SCALE: I °41�" � , , C. 19'"►'7' 6. 1 NV, OUT OF DISTRIBUTIQN BOX +�: � C-3, 6. INV INTO 'SEEPAGE PIT a 1�I�1S CAPE COD SURVEY CONSULTANTS ROUTE 132 7. aOTTOM OF PIT- - o 01 HYANNIS,MASS. w . a� A DIVISION BOSTON SURVEY CONSULTANTS" INC. 8. 13OTTOM OF STONE LAYER = -12' r