HomeMy WebLinkAbout1006 CRAIGVILLE BEACH ROAD (2) ' Y7
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. Vie Town of BarnstableBuilding
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tThisCard SoThat rt s Visible,Fromthe`Street YA rouetl Plans?:Must besRetamed onlob andthis.Card Must be Kept, ,
* BARNSGBS.6, �'
MASS. O
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Permitosted Until Final Inspection Has Been Made � �
16 .�+R Permit hereaa Ce NO. B-18-1083 Applicant Name: THOMAS DALY Approvals
Date Issued: 04/13/2018 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 10/13/2018 Foundation:
Location: 1006 UNIT 4 CRAIGVILLE BEACH ROAD,CENTERVILLE Map/Lot 226 004 OOD Zoning District: CBDCB Sheathing:
Owner on Record: PAULSON, NICOLE J z Cootractor,Name � THOMAS DALY Framing: 1
Address: 199 SPRUCE STREET �', ContractorLcense CS 109941 2
ABINGTON, MA 02351 Est Project Cost: $40,100.00 Chimney:
Description: reside, replace 14 windows.30 uvalue Permit Fee: $204.51
I l u Insulation:
Project Review Req:
5 Fee Paid:' $204.51
4D�to 4/13/2018 Final:
Plumbing/Gas
a
a, Rough Plumbing:
�. s
,,, .Building Official
"' � Final Plumbing:
� onths after issuance. Rough Gas:�.
This permit shall be deemed abandoned and invalid unless the work authorizee.'d by this permit is commenced within six m
All work authorized by this permit shall conform to the approved application and the approved construction documents4or whit,hthis permit has been granted.
Q Final Gas:
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes.
. ',
This permit shall be displayed in a location clear) visible from access st kcir road and shall be maintained open for public inspection for the entire duration of the
All pY
work until the completion of the same. � Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service:
Minimum of Five Call Inspections Required for All Construction Work:
1.Foundation or Footing Rough:
2.Sheathing Inspection Final:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation
_ Low Voltage Final:
7.Final Inspection before Occupancy
Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department
Building plans are to be available on site Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
Town of Barnstable *Permit# �-���/D Y73
Building Department ires6monthsjromissue date /
y S-
• snaiasrwsi.E, • Brian Florence, B {�
9cb 116 9p- Building Commi '
iOjFo tom" 200 Main Street,Hyannis, 02601 Zo�B
www.town.barnstable.ma.us 011
Office: 508-862-4038
TOWN ®� ��RNS�A � 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint '
Map/parcel Number 4 609 j0o
Property Address 10()(o 1A)%T 14 Al&S I LLF -M44 f-0
[Residential Value of Work$ ZI6, J DO . 00 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address K) LF P+AuLSn t\j
'100(o U tj�T 14 (YAI LU I Lf t= 5i;-iACN C-0
Contractor's Name Telephone Number_
Home Improvement Contractor License#(if applicable) 12 Q $a Email:_-V"c)An►4SOAL`( L(@ yA goo- Cdr-%
Construction Supervisor's License#(if applicable) 1 U9�1 1 1
orkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name-Fi2 A\J ELF CE—S
Workman's Comp.Policy# t R 9 :3 4o l
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 fJ 13 OAS—
❑�e-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
�e-side
Replacement Windows/doors/sliders.U-Value_ Qj (maximum.32)#of windows
#of doors: .
*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 uired.
SIGNATURE: �--_
Q MPFILESTORMSTMESS2017
Yh.e Casnrai~omveatth afMassra�dlttrsetfs
Dep artmezlt crf grr trial Acciciw&
007ce a,fl�nvesir'gatiem
600 Washiggton&treet
-- Boston,MA 02 U1
fvrvIu masmgOvI ita
Workers' CaffipensatianInsasanceAfdavit Bt�dderslCnntractursMectdcians/Plumbers
AppEran#Infarmat ian Please Print
Name(Husinesw1mga�ti�a1
Address: rb 63 e 6 dTf Pr
City/Sta& &, 6r,1 i( o25 Phone S 6W C, 7 T 7 Q 7
Are pa employer?Checkthe appropriate born: ' T of ro ect(required):
I_ I am a era 1 u 4_ ❑I am a general contractor and I � F ]
P 6-* 1mvehimdthe sab6 contmctozs ❑ oons�mcfiiaa
employees(fall asrdfor part-time)-* i�
2�.❑I am a sole proprietor orpartatrr- listed on.the attached sheet` �- Remodeling
ship and have no.employeer. 1tese snb-cordractars have g-,❑Demolition
-woddng for me in arty capacity. employees and have wozkzrs' 9. El Builtimg addition
INN UP&E ' comp.h3SW. ,Ce comp-susuran�I
required] 5_ ❑ We are a-cosporafim and its 10-❑Electrcal repairs or addfions
3_❑ I am a homeo� ofncerrs have e=—ised er doing all wati€ 1 L❑Plumbing repairs ar additions
myself,[Na woilmm'c:omg- right of exemption per 1`irfGL 13.❑Roof repairs.
insure required.]i a 152,§1(4k and we have no
emplayees-[Nowor}-.err' 13_❑Other
comp.insurance required.]
•Any appiii�ihst cltec�boa rl toast aLsa ffioofthv:sectEoabeTawsb�asdag s'heirivodse�'eompeasatiaapoTicy i.�aob .
Hamwwnerswbo submit this.af8dw9inr�icz , theyaredamgzHwv&=4dben hire autd&coot=t3mmnStsultmitanemaffidaeFtmdiamnornrh
ICaatt9ctoC5fE121e'heckiW b=nFasta=ched ffiadditi—1 Shia sbeuIngthaTimneofttesdb�-ccn=ctom sad stafe whether ornottthoseeetitiesbsve
emphWees.Ifthemb-c=txctmbaseemploye2%dieymnLstgiwidetbek wcrkm'romp.pGrmjn»Uer.
I am an esnplayer the is prai idirg warkers'couTensidian inmarance for m;y*employees $aloe`is 1114 policy and job sfte
hz formation.
Insuiance Company l =m:
-Pflficy 4 cr Self--ins-JUc-4 U R 013 CP AT-7 FxpirationDate:
Job Sife Address_ 10 0G i IN 1T A CQ.•Ai(-,Ut Lfj!E VY1104 09 City/Stat Ew-CrIVF2U ju-(=i^'l P�
Attach a copy of the workers'compensationgolicy-declarationgage(shag the policy number and expiration date).
Failure to secure coverage as requiredunder Section 75A of MGL a 157—can lead to the imposition.of criminal penalties of a
fim up to,$UOa Da an&br axle yeariutprismunenf,as we11 as dvil penalties.in.the form of a STOP WORK 01=and a hate
of up to$259-DO a day against the violator. Be adzdsed that a copy of this statement maybe forwarded to the Office of
1mvestigations ofthe DIA for insurance coverage verif ration
Fdo Hereby eerlr;f5?rurder tltepains atrdps udgzs ofpedur}'f latifis ia,forrrur Ywjprati&ff a ,s rs bars wid earrect
Si>artature_ , Date- L1bl by-
Phone ik 5 a X:—?,(`1 —'K7Q�
Of Tchd use only. Do scot wrke in dds area,to be cainpietad by sit arto n official
City or Town: Permiff-iceuse 9
Lnuing Authority(circle one):
L Board of Health 2.RuticTmg D ra,tmeat 3.CitpTovm Clerk 4.Electrical Iuspector S.Mambing LLVector
6.Other
Contact Person: Phone ik
laformation and Instructions
Massachuse#fs C,==al Laws chapter 152 regones aIl emploYess'in ProvideWDITM&compensation fir their employees.
p��this sty,an ear�airryr�is defined as.¢_-every personin$e Service of another nosier any cont-ad ofliIIe,
express or aaplied,oral or written.."
An an
player is defined as"an mdx4idnal,Paz�ersh�,asso�fron,corparaiion or other Legal 9,or any f�O or mole
of the fizregoing=pged is a Joint enterprise,andin_hzdmg the legal aepresenfaiives of a deceased employer,or the
receim or tastee of an huHTidual,partnership, on associati or other legal entitY,employing employees. However the
owner of a dw cUjng house having not more thin- iree apartments and who resides therein,or the occupant ofthe-
dwelIin.g house of another who employs persons to do make,raustract on or repay wank on such dweIling home
not of employment be deemed to be an employer."
urtenanttherefo shall �P
or on the-moods or bm�app
MG e "every chapter 15Z,§25C(6�also sizs that every sfala or local T'r�agency shale withhold the issuance or
anwealth for
to operate a husuress or to construct b�dings is the cumin any,
renewal of a licetLse or permit p „
applicant who has not produced acceptable evidence ofcompl-r=mwiththems rance.coverageregnired.
Addhiona ly,MGL chapter 152,§25CC7)staffs-Neifher the commonwealth nor any of is political subdivisions shall
ear into any contract for the pab aaceofpublicworkuntilacceptableevidenceofcompliancev�iihther,s,„-a Ce.
rmrair limdf of this chapter have been presented.to the contracting aufhozity.r
Applicants
Please fill obit the worlors'compensation affidavit completely;by checking the boxes that apply to your situation and,if
necessary,supply sub-cont r(S)name(s). addresses)andphmt-- nmmber(s)along wiLthe3r certIfIcaiE(s)of
,,c=dT,ce. L�dLiability Companies(LLC)orLjna e LiabUity-pmt=shTs(LU)withno employees other.than the
members or partners,are not regoaed to carry workers'campeasafion insr raam U an 1LC or LLP does have
employees,a policy is repaired. D e advised that this affidavit may be snbmif t d to the Depa--aent of BAUs dial
Acc fsideu far confirmation o a c
f overage Also be sure to sign and dafe-the of idavit The affidavit should
bez-etrnned to the city or town that the application for the peanit or license is being requesbA not the Department of
LnrTnctrial.,_cci Tr�fs- Should-you have any questions regaldmg the law or ifyou are=gaffed to obtani a workers'
compensation policy,Please call fhz Departm e±at the number listed below: Self-mso ed companies should enter their
self-fi sarance Hcemse number on the approgaate line.
City ar Town Officials
Please be sm-e that thJu affidavit is complete and pried legibly. The Deparhnenthas provided a space at the bottom
of the.affidavit for you to fill out in the event the Office oflnvesfiga-6Ons has to contact you regarding the applicant
Please be sure to fillinthepenziUlicensenumberwhichwz�beusedasall =encenumber. Inaddition, applicant
That must Submit,multiple p=-i,t(license applications in any given year,need only submit one affidavit indicating cent
Policy inafb=m.atioa Cif necessary)and mzder"lob Site Address"the applicant should write"all locations is (CiiY or
town):'A copy of the.affidavit that has been officially s mTed or marked by the cry or ffidadavitmust be filled out earl
v may be provided to the .
applicant as proof that a valid affidavit is on file for fntzse'pezmi s or licenses Anew
a
year.-Where a home owner or citizen is obtaining a license or pemxit not related.in any business or commercial vent u e
(Le. a dog license or permit to burn leaves etc.)said person is NOT required to complete Isis affidavit
The Office of Invesdg�ons wouldli tD thank you m adv�-e fur your coopedion and should you have any questions,
please do nothesifate to give trs a call
The Department's address,telephone andfaXz�lanber:
. Dega�m��Iudk Aacxden.�.� .
�a�n=�fA E�I1F
TgL4 f 17-727-4 QD t 4-06 Qr 1-977 MA GAF
Fax 9 617 727 7749
Revised4-24D7 w w ma gpgfdiEL
V111/2Ulb 14:4b t)UbbbbU!DnU ALMt1UH AND UAKLSUN rHUt ui/t71
'1 THOMDAL-02 MANDERSON
RIa'' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
04/11/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AFTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION 1S 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 endomemen s).
PRODUCER 1 2A�cT Marylo Anderson
4lmefda&Carlson Insurance Agency,Inc ➢NONE FAX
�0 Box 719 (Arc,No,EXQ:(508)888-0207 �Nc,No►.(508)888-0550
sandwich,MA 02663 E�
_ — INSURERS)AFFORDING COVERAGI — -- NAIL 11
INSURER A:Travelers Casualty Insurance Company of America 19046
INSURED INSURER 0:Travels rs Indem_ nity Company Of Connecticut 25682 -
Thomas Daly INSURER c:
503 Route 6A `IN9uRER D___,
East Sandwich,MA 02537 ---- ---—
INSURER E-
IN,
INSURER .-- - - •— -•-- •- ---•---
COVERAGE$ 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. _
- _—
VSR` TYPE OF INSURANCE ADDL$UCR� POLICY NUMBER - POLICY FFF • POLICY EXPIMMIDD LIMIT$
A - COMMERCIAL GENERAL LIABILITY vivo IEACH OCCURRENCE $ 1,000,000
CLAIMS MADE OCCUR 6803A61$046 06130l2017 06130/201 B DAMAGE TO RENTED -
PREMISES,(Ea ocyurmnce) a- _
-• -•• MGD EXP(Any_—person _-,S 5,000
— PERSONAL&ADV INJURY $ - 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER; 2,000 000
GENERAL AGGREGA PROD ATE $
POLICY ,j�r I__ I LOC PRODUCTS-COMPIOP AGO S 2,000,000
AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT
ANY AUTO _ BODILY INJURY Per arson••• $
OAU7 WNt�ONLY SCHEDULED —
AUTTOSyy�NEp BODILY INJURY(Par eeeidQr);R
ABA ONI-Y A�TO�ONLY (PPOaCCIde^I?AMAGE - $ --- —
UMBRELLA LIAR OCCUR �Aq'GRE
H OQCl1RRQNCE
EXCESS LIAR CLAIMSIdADE GATF, _ $
DEC RETENTION 3 $
S WORKERS COMPENSATION PER
TATUTE RH
AND EMPLOYERS'LIABILITY S ANY PROPRIE U59HS3628T 06/30/2017 06130/201 B TOR/PARTNERJEXC-CUTIVE YIN 100,000
lan
F'Cant WrM )
EXCLUDED? NIA L,EACH ACCIDENT $ 100,000
e
pry n E,L DISEASE_•FA E-MPLOYEE 5•• _
It yPs deeerlb under
IZE$f RIPTION OF 0 ERATIONS bolo w E.L.DI_F, $E-POLICY LIMB SOO$ i000
-ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addi lun■I Remarks Schedule,may be attarhoo if more apace Is required)
:ERTIFICATE HOLDER CANCELLATIQN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIE$BE CANCELLED BEFORE
Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
24 Perry Avenue ACCORDANCE WITH THE POLICY PROVISIONS.
Hyannis,MA 02601
AUTHORIZED REPRESENTATIVE
• r r I
CORD 25(2016103) ®1988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
1 '
J
f6
C
o
trt "Wpaw?49aaruaect.l6L.�lbGl-dacleelect w
Office of Consumer Affairs&Business Regulotion Fr License or registration valid for individual use only o
HOME IMPROVEMENT CONTRACTOt before the expiration date. If found return to; c 0
Registration 171782 Typ& � Office of Consumer Affairs and Business Regulation E m
Expiration 4!24/�'01,8 `DBA. 10'Park Plaza-Suite 5170 N
IVYc Boston 1VIA 62116 a v > o
t "i HOMAS."bALY CARI?I=NTRY- o rn rn Q c
N1� ur c o v
��'�. '' i •! i s In = '0
ut
THOMAS DALY K r � E > > U o >- Q v w
I
i 503 ROUTE 6A .•. .
�. ti ✓Ire V v- �n u p w Z
r^ EASE:'SANDWICH, MA 02537"` — -- `° o c y Q. 0
Undersecretary Not valid without signature ' I= .400
�U
AlA O J c ON
1 a
r1FJE..1D)A,-1L Y Invoice
CA, IMPIEW IF , Y
4�:,671-8 1971
BiIITo ,
Nicole Paulson
1006 Crai.gville Beach Rd
Unit 4
Centerville, MA
Date:.. = Invoice No PO Number Terms Project
03/01/18 20
Item:': Description. Quantity;, Rafe' Amount
$10,000 DUE UPON COMPLETION OF SIDING
$10,100 DUE UPON TOTAL COMPLETION OF
DECKS/PROJECT
-------------------------------------------------------
$40,100 TOTAL
HOMEOWNERS SIGNATURE
general Construction of new shower, includes: 650.00 650.00
-demo and disposal of existing
-construction of 4x4 shower using pressure treated
framing, mahogany decking, and cedar fencing for
the inclosure
- = woAd I i Ice fv see
4-J e- Shiriqles first �S
Tha/7kS
Subtotal $40,100.00
Sales Tax $0.00
Total $40,100.00
Page 4
F�ri Town of Barnstable *Permit#
Regulatory Services Expires 6 raan:�
Fee
M6 q, " Thomas F. Geiler,Director
l
Building Division 011 yin
Tom Perry, CBO, Building Commissioner
200 Main Street,Hyannis,,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038
EXPRESS PERT APPLICATION - RESIDENTIAL ONLY 508-790-6230
MI
Not Valid without Red X-Press Imprint
Map/parcel Number 266 —D pj- _ Vol
Property Address 00io 1 ' 1I.a-.c— 'EACH OP L.L}gzQVILL eennA ill!
residential Value of Work 1 15-6 5 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address a)& 14 110 O
ORBRl MA-9;.
Contractor's Name_ ®. Y M, ��®�CAc�1 Telephone Number's
Home Improvement Contractor License#(if applicable) I �-
Construction Supervisor's License#(if applicable) Z
❑Workman's Compensation Insurance
0Check one:
I am a sole proprietor PERMIT
❑ I am the Homeowner OCT 11 2011
❑ I have Worker's Compensation Insurance
r:.TO04 i' =B/ARtY'sTAB
Insurance Company Name A ) � �.�uA�— �
Workman's Comp. Policy# 70zzo o 1 1
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
/Re-roof(stripping old shingles) All construction debris will be taken to £
❑ Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
' #❑ Replacement Windows/doors/sliders. U-Value of doors
(maximum .44)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
Q:IWPFILES\FORMSIbuilding permit forms\EXPRESS.doc
Revised 070110
r- 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/IndividuaI 0 J1,r Q'UA
Address: 170 �FUWLAM�
City/State/Zip: tR6t%S1UZ kAA-SS 0 Z631 Phone #:
re you an employer? Check the appropriate box:
F'.
Type of project(required):
.❑.I am a employer with 4. ❑ I am a general contractor and I
mployees(full and/or part-time).* have hired the sub-contractors [7.
6• ❑New'construction
2. I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling
ship and have no employees These sub-contractors have g. D Demolition
working for me in any capacity, employees and have workers'
[No workers' comp. insurance comp.insurance.$ 9. []Building addition
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their `
11.❑P umbing 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. °p
Insurance Company Name:- A iN\1+ J�A
Policy#or Self-ins,Lic. #: ®2?�$�QQ1 ��`� Expiration Date: 12. -24 i 1
Job Site Address: 10 06 V 1 k1B1'%Jk Ro City/State/Zip: M
Attach a copy of the workers'c mpensation 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
Investigati s of the DIA for insurance coverage verification.
I do here erdfy under the pains an penalties of perjury that the information provided above-is true and correct.
Si ature: Z�
Date: ZQ/
Phone#: JV�� 9 ),—aj3
L
only. Do not write in this area, to be completed by city or town official
n: Permit/License#
hority(circle one):
Health 2. Building Department 3. City/Town Clerk "4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
TOR'll of Barnstable
Regulatory Services
s Thomas F. Geiler,Director
Fo ,r► Building Division.
Tom Perry,Building Commissioner,
200 Main Street,Hyannis,Na 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 E
13
' AOU0 as Owner of the subject ro
� p .petty
hereby authorize D to act on my behalf,
in all'matters relative to work authorized by this building permit
i006 QWCIVILLE Ar'N TIAID
(Address of Job)
**Pool fences�and-alarms.are the responsibility of the applicant. Pools
are not to be filled before fence is installed and pools are not to be
utilized until all final inspections are performed and accepted.
rC_ f��►-l�-�
Signature of Owner e f pplicant
Print Naive Print Name
-
Date
Q:FORM&OWNERPERMISSIONPOOLS
�TME r, Town of Barnstable
�* Regulatory Services
HAexsTasLE, ► Thomas F. Geiler,Director
y MA99.
�p 1639• �•�'A Building Division
TFp NIA'I
Tom Perry,Building Commissioner
Z00 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street
village
"HOMEOWNER":
name home hone#
p 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.)
if
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1•-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:forms:homeexempt
N-lassachusetts- Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 682
Restricted to: 00 Y'p
GREGORY M BOOKACH
170 GREENLAND PND RD
BREWSTER, MA 02631
Expiration: 5/8/2012
conmrissioner .Tr#: 26164
'a0M-04/04-Ca`iv,�.
�'le-��,vnea9w�eald a�✓�aaeac>Luraelta -- _
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date." If found return to: r.
Office of Consumer Affairs and Business Regulation
:'Reg'stratlog 111458 10 Park Plaza-Suite 5170
ExpiraWh 1ZW- /2011 Tr# 290167 Boston,MA 02116
Type;,:.:individual:'.;, ;
GREGORY M BOOKACH
GREGORY BOQKACH..'.
170 GREENLAND POND RD .
=T
BREWSTER,MA&2 1._ Undersecretary wak v without signature