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1006 CRAIGVILLE BEACH ROAD (6)
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F ., .. � . .. � a ., y e A _ .. v o .. ., a ,. r. .,, ,. _e �- _ �t u .. .. ,. - � .. .. .` � - +s w .. � - ,. ., .. � ,. ... w e - „ 'R. o ,. ,�. i .. .. s o � e .. a. � � - T .. i v. c LL .A ,. ,, .: ., ,: _ .- 226-004-OOA 1006 CRAIGVILLE BEACH ROAD, Centerville ANAGNOS,JEFFREY S 0369 22600400A BLDG A UNIT 1 -1 226-004-OOB 1006 CRAIGVILLE BEACH ROAD, Centerville WILLIAMS,BRUCE C&KIMBERLY K 6369 22600400B Q BLDG B UNIT 2 226-004-OOC 1006 CRAIGVILLE BEACH ROAD,,Centerville FAHEY,STEVEN M 0369 22600400C BLDG B UNIT 3 ........._... .. __..._.. ... ._..._.. .._. - ....... --. 226-004 OOD 1006 CRAIGVILLE BEACH ROAD, Centerville PAULSON,NICOLE J 0369 22600400D BLDG C UNIT 4 226-004-OOE 1006 CRAIGVILLE BEACH ROAD, Centerville SPELLMAN,LAWRENCE J III TR 0369 22600400E BLDG D UNIT 5 226-004-OOF 1006 CRAIGVILLE BEACH ROAD, Centerville HOBE,STEVEN TR 0369 22600400F BLDG E UNIT 6 226-004-OOG 1006 CRAIGVILLE BEACH ROAD, Centerville HOBE,STEVEN TR 0369 22600400G BLDG E UNIT 7 226-004-OOH. 1006 CRAIGVILLE BEACH ROAD, Centerville GRAMMATICAS,ANDREW PETER&HEATHER LINNEA 0369 22600400H 01 BLDG F UNIT 8 v 3 Application number.....)da:s5 a Fee............�.3S...................................................... BUILDING-DEPT. s • Building Inspectors Initials.......q..................... T s Ak FEB 2 4.2020 ;-21-��..Date Issued.:... .......... ..... .... ...................... TOWN OF BARNSTABLE c3 c, � oe tI ® . Map/Parcel ........ ................................................. TOWN OF BARNSTABLE z SCANNED EXPEDITED PERMIT APPLICATION: . ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION MAR 012 2020 PROPERTY INFORMATION Address of Project: 00(a 0 J I/c &4r4 Ai i'/ . NUMBER STAEET VILLAGE Owner's Name: e 2h a 110 S Phone Number y )0&? 0 U Email Address: Cell Phone Number Sa M e Project costs 1 000 Check one Residential ,Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: 'TYPE OF WORK Siding 0 Windows (no header change)# F-1 Insulation/Weatherization 0 Doors(no header change) # Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will.be going to !i'f +►'t 1�1 QAf'GC;� CONTRACTOR'S INFORMATION Contractor's name T o Skil(4 Da:s`sz — Home Improvement Contractors Registration(if applicable)# ��3CO3`i (attach copy) Construction Supervisor's License# ,,� s—lf3,55'L (attach copy) Email of Contractor Phone number s03-3&0-f 1(o2_ 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..........................................P............... a *For Tents Only* Date Tent(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 TentX X X rlM1V1 ;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 A30 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: e f A (4 14 0S Telephone Number s 7d(v g,�'a 0 + Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the�Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. „ Signature Date APPLICANT'S SIGNATURE Signature R Date All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 j www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): v' -- Address: P. d : E0" !aC City/State/Zip: 9Vaj,at5gd (Y zu,4. Phone#: f'D�"36i 00 %LP�- Are you an employer?Check the a propreate box: Type of project(required): I.0 have hired the I am a employer with 4. 'fJ I am a general contractor and I ' 6. New construction employees(full and/or part-time).* f3 listed te a h d on&attached sheet. ? Reiitodeling 2.❑ I am a sole proprietor or partner- ship and have no employees „ These sub-contractors have g, 0 Demolition workingfor in an capacity. employees and haveYworkers' Y P ty. 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. tContractors 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. Insurance Company Name: . . Do At Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: f UD(O CuuIc,yi ffe Me-4 Ad . City/State/Zip: Ce4lV.r-0 ( l`e 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 under the pains andpenaldes ofperjury that the information provided above is true and correct Signature: Date: L z0 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/Licenie# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Elec_trical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r 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 pennit 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 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 :_ Fax#617-727-7749 www.mass.gov/dia .y Client#:36429 2BASSETTJO ACORM CERTIFICATE OF LIABILITY INSURANCE °"TE'M""°°"""' 01/13/2020 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 have ADDITIONAL INSURED provisions or 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER I ME: The Hilb Group of N.E.dba P"DINE 508 775-1620 . FAX A/C No Ext: A/C Ne: 5087781218 Dowling&O'Neil Insurance Agy E-MAIL P.O.Box 1990 ADDRESS: - INSURE S)AFFORDING COVERAGE NAIC N Hyannis,MA 02601 INSURER A:NGM Insurance Company 14788 . INSURED Joshua Bassett Inc. INSURER B:Associated Employers Insurance Company 11104 P.O.Box 128 INSURER C: West Hyannisport,MA 02672 l"suRERD: ` INSURER E: 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 CONTRACTOR 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. INSR ADDL SUB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I POLICY NUMBER MMIDD MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY MPJ2966M 3/11/2019 03/11/2020 pEACH p�OECTCURRE�ENCE $1 OOO OOO R� CLAIMS MADE OCCUR PREMISES Ea oa rrence $500 OOO MEDEXP(Any oneperson) $10 000 PERSONAL&ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 . POLICY n ECT LOC PRODUCTS-COMP/OP AGG s2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accidant ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA UAB OCCUR EACH OCCURRENCE - $. EXCESS LI►B CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B AND KERS EMPLOYERT LIABILITY COMPENSATION WCC50050078582020A 1/04/2020 01/04/2021 X PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN - E.L.EACH ACCIDENT $5OO OOO OFFICERIMEMBER EXCLUDED? � N/A (Mandatory In NN) E.L.DISEASE-EA EMPLOYEE $500 OOO If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) Certificate holder is named additional insured for general liability when required by written contract Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. 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 REPRESENTATIVE O ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S251887/M251886 LS1 i.a2'J apuh - _ 2:t9210*vW.idbdsm.iVXH r-, SZt X090d 1135S d9 9 t/f11iS. f` OZOZ/tZlLO — 56E9Et' i; of jl x3 u i}ealsl !i. IenRlnlFUI liOlOVlf1C.OD IN3GV3AOFldWI 3Jlt�?H uolteln6ay ssaulsng v saleUV iawnsuoD fo-4r14;j. - _ v"�rnpp�ic7�a�y�srivazccz�ca• � - Commonwealth of Massachusetts ®� Division of Professional licensure Board of Building Regulations and Standards f I Const`4 sk ct&Upgrvisor CS-113552 �ires' 05/25/2023 JOSHUA B BPS r W HYANNISO� 4A .� 10 i Commissioner Page# of pages �ostioa �aSs,�►J' 02to?Z PROPOSAL SUBMITTED TO: A/� JOB NAME JOB# G ADDRESS JOB LOCATION l©UlP r l vi elt aea 4 Rd, DATE DATE OF PLANS f PHONE# /�� � Say FAX# ARCHITECT V e hereby submit specifications and estimates for: f -- --- j 3 - eke (00 1. 0001. chded fee 6n Toh Dumb Pr►"c.e -- — ------- ---—= PC r r i e propose hereby to furnish material.and labor—complete in accordance with the above specifications for the sum of: $ All 4.6o r ? Dollars with payments to be made as follows: /'"r dQ r ess Pay M iPn k—s 0-4 Ff i dA YS Any alteration or deviation from above specifications involving extra costs Respectfully will be executed only upon written order,and will become an extra charge submitted Alz � over and above the estimate. All agreements contingent upon strikes, accidents,or delays beyond our control. Note this proposal may be withdrawn by us if not accepted within days. 0(cceptance of VropofW The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. -V Payments will be made as outlined above.) Signature Date of Acceptance 2/" 3 L Z�Z Signature A-NC3819/T-3850 09-11 - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Q dl 66'4MA Parcel b ti tY -T LD Q Application# Le Health Division Conservation Division Dip, " 01 Ui3 Permit# Tax Collector Date Issued Treasurer Application Fe ' a Planning Dept. Permit Fee ��/ • Gb Date Definitive Plan Approved by Planning Board �91261 Historic-OKH Preservation/Hyannis Project Street Address.;. ()A) IT 14 C 0 It', U'I L le-f R E-Ach I&J Village C E hiE.ie-v t LA-E Owner CO % LL. uA vvN ' a S t Address Telephone f _ci v S/ C9 4 y f Permit Request y tv n?Tuck E Q D ec% �s Square feet: l st floor:existing proposed 2nd floor:existing proposed ) Total newer Zoning District Flood Plain Groundwater Overlay -Project Valuation-1 )oU Construction Type ' Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting d cumentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: "❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new h 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: Y Zoning Board of Appeals-Adthorization- 0=-Appeal-# =r - Recorded-❑-- Commercial ❑Yes o if yes, site plan review# Current Use Proposed Use �'C�f��2 01 FAR C h 4 R_,S BUILDER INFORMATION 3G i(^ t/(o'� Name 9 R Aek V#�_Oda a l Telephone Number S Q� Address a 9 DE b.b &J Lu ktC License# f$_ y� b�f(� fat W P,S t•0-1U Q-N f LLS .�1A • Home Improvement Contractor# ( q t 7 Worker's Compensation# 4U16 16119 3 qO V ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO F3tl_ L,1Ajj FI LL J` SIGNATURE DATE <J- 19'O'l - I 3 # ` FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED ip 1 MAP/PARCEL NO. ADDRESS VILLAGE t " s r OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL } PLUMBING: ROUGH FINAL Y. s GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. . 4 f The Commonwealth of Massachusetts Department of In du stria lAccidents _ Office of Investigations R � - ? ' a 600 Washington Street Boston,MA 02111' www.mass.govldia ' Workers - Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): . 8k Mn rfi f.7oock. Ad6ress: d l V E S 6 to c- LA ki f- City/State/Zip: ►"► I P-Stb iiS' MZ LLS ,�A Phone.#: 56k- k/ y0S"�' Are you an employer?Check the appropriate box: :Type of pioject(required):. 1:[� I am a employer with / 4• ❑ I am a general contractor and I employees (full and/or part-time),* , have hired the sub-contractors 6, ❑New construction . 2.❑ I am a'sole proprietor or partner- listed on lhe-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition 'working for me in any capacity, employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp, insurance•$' • required.] 5. ❑ We are a corporation and its , 10.❑•Blectricalrepairs or additions officers have exercised their 3.❑ I am a homeowner doing ill-work . 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 boa#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, lContractors that check this box must attached an additional sheet shoving the name of the dub-contractors and state whether 6r not those.entities have employees, If the sub-contractors have employees,they must provide their workers'comp•policy number. .Taman employer that is providing workers'compensation insurance for my employees. Below is.the'policy and job site information. Insurance Company Name: (1i YY,% M ,-tru lA (,_ 1 4 J S U CC 0 W CC Policy#or Self-ins.Lic•#: A4)C "l o p at) Expiration Date: /7—o-7 lob Site Address:._i 0 (n C. C fZ 611(, 0 L L i,E 13, E iA C v, City/State/Zip: CIE lk i tE t-0 (L L l Attach a copy of the workers' compensation policy.declaration gage'(showing the policy number and expiration date). Failure to secure coverage as reQaired under Section 25A of 1vIGL e, 152 can lead to the imposition of eriurinal penaires of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP 7rORK,ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statemerit maybe forwarded to the.Office of Lvesti�:ations of the bLk for imtnance coverage verification. Ido hereby certijy under thepalins,afndpenalties of perjury that the inf onnation provided above zv true and correct. Siznature: ar'1' �.� . Qa-eX Ij24 Date Ofzcial use only. Do not write in this area, tb.be completed by.ci y or town official City or Town: Permt/License-L Issuing Authority(circle one}: .,1,Board ofEealth 2.BuildingDepartment 3, City/Town Clerk 4.Electrical Inspector 5•Plumbing T spector '1 6.Other i( Contact Person: Phone rr: 1 information a -i i e-cline Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees• Pursuant to t�statute, an employee is defined as"...every person in the service of another under any contract of hue, 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 d. elino,house'naving 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." AdditionaIly,MGL ehapter-152,§25C(7)states'Neither the commonweal`di nor any of its political subdivisions shall enter into any contract for.the performance of public-workuntii acceptable evidence-of arzce +ith tile instance' 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,i� necessary, supply sub-conti:actor(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 instance 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 appropriateline. 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 tc give us a call. The Deputment's address,telephone-and fax number:. °�h�Co.mmozw th ofMasaxhtmsr,.S Dtpartmz�mt of Industrial A.cozd1lits . Qffiee of layest ga ons B.o to-,.MA 021 H • Tel. 617.727-00.0 ext 406 or 1-377-MASSAFE Fax#617-727M770 Revised 11-22-06 WWW.ma,SS 8ov/dia I RESIDENTIAL: SHEDS -POOLS—DECKS-OPEN PORCHES-GAZEBOS FEE VALUE WO HEET APPLICATION FEE: $50.00 BuaMVGPERMIT FEES: ACCESSORY STRUCTURES >120 sq.ft.(Sheds,gazebos,etc.) >120 sf-500 sf $35.00 $ >500 of-750 sf 50.00 >750 of-1000 sf 75.00 $ >1000 sf-1500 sf 100.00 $ >1500 sf USE NEW BUMDING PERMIT APPLICATION DECKS x$30.00— $ (Number) TORCgES x$30.00= $ _._ (Number) ' YN GROUND SW711?MiNG POOL S60.00 $ ] GROUND SyynDOIG POOL $25.00 $ RELOCA'TION/MOYING $150.00 $ (plus above fee if applicable) _ $ERMIT FEE' $ �d Q:farms:dkcost • nV:063004 tc SS' �pFTMF'ois. Town of Barnstable yP tips - Regulatory Services � r3' + AB 9BA MASSY Thomas F.Geiler,Director �jDyf 6.19, �0 Buildizu Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax; 508-790-6230 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: Estimated Cost Y,Ito t Address of Work: /6 ft C-9 A 1(a k9,J ,.CF_�JTt--.P_V y L AT t 011 a Owner's Name: .- e L L( 1 W1 tZ b Date of Application: -J -b`7 I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under S 1,000 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 WORD DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name Q:fomu:homeau,dav �� ZHE•�p�yo . : Town of Barnstable h Regulatory Services 8 � Thomas F.Geller,Director i639• '°lFD►, Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,NIA 02601 www.town.b arnstabi e.ma.us Office: 508-862-4038 Fax: 50$-790-62 30 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property he authorize AD " to act on my behalf, in all matters relative to work authorized by this building permit application for: , a (Address of Job) Signature of Owner Date I I I tLi M M2 r S Pent Name QF0RvfS:0a1?QER'ERMISS ON - . ... ... .._..__;-I1.!, -,' --! '. .._ F,-�r'•In lt. . . IU;I J. .tr., .. .. ..._. I tl:�• . . . to . a .�•t. .. i t rulnn;wlNlu�l rt.nu UI" 1•Allll JII nnllg3rnitl.0. 18162 , AVael.•,.t• AIW NJ9,. :Arlo., 9ut•veyot••, - UPt a�nituA• T 1, 190p ��o e. - - I W 6 I16.N � X Jlv"� •, of ,��� r • Juan• " ,y „ • XIi'y _ � U \`eye ��er•�nio•F �. ► ; ,t t 1 i r 17 77•'� �y ��� �,�� I, r��' ter•Wen"� ,� Fr ��•{ � 6�L9 I Y.. IF�1 • Ihfrl' f� (� �• rr AJ [2 J Is0•cw 11 r �f, I rr rn• e•' a �U Al ` 1k • rlp�lt� ��►�es`�`"► �' a nrre tip. rerni o e �S ! 1' I 1 t N .O• ,.• 1l' Cj7AlGVII.L� aCACH !laht11vIIIJnit nr I.rllt A510, z end 11 ,.,,.�t, o'l•rn1 ROAD shown on 101W. MOP WIWI •inl 1011;:.1 1 ' I.11t•4 ullh !•ert. ur Title llon. luT7', 11127, 16701 end 250, iAeltlal.l'y U!.alrlol nl' Itnrlt�t�hle Cnunl•y �\�. Srgtnreln A nrlulcel�ta u1 HUn stay b1l IsiueJlur innJ A,lif c,rl tin lOtN7'ed At'!'. 't.. _ .... (; f .. CN•1•e�pl lbr rta,i •< - nl•ilia Gulf. . .�U' i f/ r�'I LIiNI►ItlOr51hA11nNVr'1'It:E JUti/ �',19BA nSCOt ( leuuA �na•,lneln,,.IvaCc"rl . .. Act (/ . ,a ii,•.r '. ._.« r. A. a;.�.,..__».-...:xw.....w.+..•-.w`....:._:•...........,... ...:.i-ci�nc+�=^:.•...-.r-..--.cam-<-aec•-c—^.• SSUE DATE 07/31/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A\MATTER OF INFOR\1AT[O\1 ONLY,AND \4iller\%IcCaltin CONFERS.NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE At DOES'NIOT.AMEND.EXTEND OR ALTER THE COVERAGE.AFFORDED BY THE v dba Dov in �C 0\eil In:A�cv POLICIES BELOW.. 122\Vest\fain Street t a. Hyannis..MA 02601 COMPANIES AFFORDING COVERAGE F [INSURED " Bradley A Paddock dba Paddock Home Improvement COA9PAN1'A A.LN4.\1 4LItUal Insurance Co 34 Debbie' Lane LETTER Lane _ Marstons Mills,MA 02648 �`u -1�.�. •., ara°� ,- �# .!ic/' a� THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. \OT\\'ITHSTA\DI1G ANY REQI•IRE\SENT.TERI\1 OR CONDITION OF ANNY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR\S.AY PERTAIN.TH.E INSURANCE.AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 'fU ALL THE OF SUCH POLICIES.UIMITS SHONVO-lAY HAVE BEEN REDUCED BY PAID CLAIMS. Cti l'Y I'EOF IN PRANCE POLICY NUMBERPOLICY EFFECTWE POLICY ECPIHATION - LTR DATE INI\IUD+YY9 DATE INIMIDD.VO LINWIS - GENER.\L LI:\BI LI71 !ENEP-.L AGGREGATE S . PRnUL;CTS.CO,.iPinP AEG. . �•:•.-.'d'%ERi.I.=.L vENEt.P.L LIL-ALIT"i PERSONAL,:AU:'.IN)URl' - ErJ;li+?CCiiRRENCE FIRE UAS.IAGE�-.m:.nr ei _ P- �L 10N10 BILE LI.\BILI II '.iBI EU Z. .'.... - Ll..fh •B UIL IN1!-.Y'i , ODIL) IN!UR) I':'.:?.'.•GE LI.>.BILIT-i` f'::-ccdcnu PROPERT) U.-.7.i-<GE ENCCS�LIAB.ILIf\ F-A�'ii GCO.RF.ENCIL UMBRELLA FORM AGGREGATE OTIIERTIIAN UMBRELLA FORM WORKERS COMPENSATION AND STATUTORY LI\IITS OTHER EMPLOYERS LIABILITY S E::'.;.•-';at-... EL EACH ACCIDENT S I00,000 021-1901 2007 06/06/2007 06/06/2008 EL DISEASE--POLICY LIMIT 500,000 INCL �E'CCL EL DISEASE--EACH 1 GU,000 EMPLOYEE COMMENNTSi DESCRIPTION OF OPERATIONS OR LOCATIONS: BRADLEY A PADDOCK IS NOT COVERED BY THE NVORKERS'CO'MP.ENSATION POLICY. I ,..,..,.., ..,,, ,•:u.r,.. .. :. .M��x�� .p��I€�..a 3r a,..,,_., _��.. ��..--,��„su,. .,,,_�� H,;::- -.HM�.,_.._. _,v . SHOULD ANY OF THE ABOVE DENCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TOW N.Or QARNSTABLG riIEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 14 WRITTEN NOTICE TO THE CERTIFICATE EIOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION - ,LI:\BILITI'C-F A\`}'RI\D GPi+N THECUN�IPA\}'_ITS AGE.N"'TS OR REPP.ESENTATI.VES. ....... tun�9A1\ sT _ HYANNIS. CIA 02601 AUTHORIZED REPRESENTATIVE ,l �0" r� Al 1 . ors o �N1 �Q6 O� F �pO Out DARD CDC, r CIcenSe CONS O N OF gUl 4 is NumbeY .;CS STRUCTICN SUPERV T�� � l gIrtbdate `' 048086 SCR �x Px � ��03/28/jg5g per ..,8 g 24 gCLEY pR l ��tea 00 r Tr.no. MgRS�BIES L� 25682! CNS M1ICS��Mq 0266a . C- -� Com miss' Oner I� , �-^ - f fFH P1 3'°.� -_t ...4__..._—. ._ .���,�'�'�— i� �.,: .,�P` F' ��M•.�,��J I.� ! I ! ` � i I ` K I •+-�,� ic' w_�r eF +'.j R."�r�(��� I ` I 12 {V `- !-� !- I ! - I —1 j � �•�,... �. ice'� ' �p �, t j I i i i I j�---i----�--�- -r � � -� i•' _.�-•----� # --- -�-_ ��.- fir. --f-"--t---"----;--- -�-- Results Page 1 of 1 Home Improvement Contractor Look Up Enter Search terms separated by spaces. Search terms can be Town/City, Name, or License number Select Search type: cr AND r OR ZSearcl Search Results Reg. N I Applicant Street City State Zip Lame Title Expiration BRADLEY 24 MARSTONS PADDOCK, SOLE A 121967 A. DEBBIES MILLS M 02648 BRADLEY PROPRIETOR 7/3/2008 PADDOCK LANE Total of 1 Records matched. Back to Home Page BBRS Privacy Statement http://db.state.rria.us/bbrs/hic.pl 9/5/2007 011111111111111P4 1 Massachusetts Department of Environmental Protection ,Bureau of Resource Protection - Wetlands -WPA Form 2 - Determination of Applicability �,STABM i639'Massachusetts Wetlands.Protection Act M.G.L. c. 131, §40 rFD�A and Chapter 237 of the Code of the Town of Barnstable DA- 07043 A. General Information Important: When filling out From: forms on the Barnstable computer, use Conservation Commission only the tab key to move To: Applicant Property Owner (if different from applicant): your cursor- do not use the William I. Ross return key. Name Name 102 The Valley Road Mailing Address Mailing Address Concord MA 01742 City/Town State Zip Code City/Town State Zip Code 1. Title and Date (or Revised Date if applicable) of Final Plans and Other Documents: Sketch of Deck 5/25/07 Title Date Title.. : . . Date Title _ _ . . _. ,., _ .._.� _ ._ _Date...- ._ 2. Date Request Filed:May 30, 2007 B. Determination Pursuant to the authority of M.G.L. c. 131, §40,the Conservation Commission considered your Request for Determination of Applicability, with its supporting documentation, and made the following Determination. Project Description (if applicable): Construct 12' x 16' platform (unattached deck) • z Project Location: 1006 Craigville Beach Road, Unit 1 Barnstable Street Address Village 226 004 CND Assessors Map Number Assessors Parcel Number wpaform2.doc•Determination of Applicability•rev.10/5/05 Page 1 of 5 A �4 -Massachusetts Department of Environmental Protection 'THE Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability _ EL4JtNffrMM Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 9`�A,M%639.s`e� ED MA'f and Chapter 237 of the Code of the Town of Barnstable DA- 07043 B: Determination (cont.) The following Determination(s) is/are applicable to the proposed site and/or project relative to the Wetlands Protection Act and regulations: Positive Determination Note: No work within the jurisdiction of the Wetlands Protection Act may proceed until a final Order of Conditions(issued following submittal of a Notice of Intent or Abbreviated Notice of Intent)or Order of Resource Area Delineation (issued following submittal of Simplified Review ANRAD) has been received from the issuing authority(i.e., Conservation Commission or the Department of Environmental Protection). ❑ 1. The area described on the referenced plan(s)is an area subject to protection under the Act. Removing,filling,dredging, or altering of the area requires the filing of a Notice of Intent. ❑ 2a.The boundary delineations of the following resource areas described on the referenced plan(s)are confirmed as accurate.Therefore,the resource area boundaries confirmed in this Determination are binding as to all decisions rendered pursuant to the Wetlands Protection Act and its regulations regarding such boundaries for as long as this Determination is valid. ❑ 2b. The boundaries of resource areas listed below are not confirmed by this Determination, regardless of whether such boundaries are contained on the plans attached to this Determination or to the Request for Determination. ❑ 3. The work described on referenced plan(s) and document(s) is within an area subject to protection under the Act and will remove, fill, dredge, or alter that area. Therefore, said work requires the filing of a Notice of Intent. ❑ 4. The work described on referenced plan(s) and document(s) is within the Buffer Zone and will alter an Area subject to protection under the Act.Therefore, said work requires the filing of a Notice of Intent or ANRAD Simplified Review (if work is limited to the Buffer Zone). ❑ 5. The area and/or work described on referenced plan(s) and document(s) is subject to review and approval by: Name of Municipality Pursuant to the following municipal wetland ordinance or bylaw: Name Ordinance or Bylaw Citation wpaform2.doc•Determination of Applicability•rev.10/5/05 Page 2 of 5 L Massachusetts Department of Environmental Protection mot„E, Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability BAMSTABM Massachusetts Wetlands Protection Act M.G.L. c. 131, §40AA�O� and Chapter 237 of the Code of the Town of Barnstable DA- 07043 B. Determination (cont.) ❑ 6. The following area and/or work, if any, is subject to a municipal ordinance or bylaw but not subject to the Massachusetts Wetlands Protection Act: ❑ 7. If a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s) and document(s), which includes all or part of the work described in the Request,the applicant must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c. for more information about the scope of alternatives requirements): ❑ Alternatives limited to the lot on which the project is located. ❑ Alternatives limited to the lot on which the project is located, the subdivided lots, and any adjacent lots formerly or presently owned by the same owner. ❑ Alternatives limited to the original parcel on which the project is located, the subdivided parcels, any adjacent parcels, and any other land which can reasonably be obtained within the municipality. ❑ Alternatives extend to any sites which can reasonably be obtained within the appropriate region of the state. Negative Determination Note: No further action under the Wetlands Protection Act is required by the applicant. However, if the Department is requested to issue a Superseding Determination of Applicability, work may not proceed on this project unless the Department fails to act on such request within 35 days of the date the request is post-marked for certified mail or hand delivered to the Department. Work may then proceed at the owner's risk only upon notice to the Department and to the Conservation Commission. Requirements for requests for Superseding Determinations are listed at the end of this document. ❑ 1. The area described in the Request is not an area subject to protection under the Act or the Buffer Zone. 2.The work described in the Request is within an area subject to protection under the Act, but will not remove, fill,dredge, or alter that area. Therefore, said work does not require the filing of a Notice of Intent. ❑ 3. The work described in the Request is within the Buffer Zone, as defined in the regulations, but will not alter an Area subject to protection under the Act.Therefore, said work does not require the filing of a Notice of Intent, subject to the following conditions (if any). ❑ 4. The work described in the Request is not within an Area subject to protection under the Act (including the Buffer Zone).Therefore, said work does not require the filing of a Notice of Intent, unless and until said work alters an Area subject to protection under the Act. wpaform2.doc•Determination of Applicability•rev.10/5/05 Page 3 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability _ BARN MAW Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 9`�,1639. and Chapter 237 of the Code of the Town of Barnstable DA- 07043 B. Determination (cont.) ❑ 5. The area described in the Request is subject to protection under the Act. Since the work described therein meets the requirements for the following exemption, as specified in the Act and L I LI the regulations, no Notice of Intent is required: Exempt Activity(site applicable statuatory/regulatory provisions) 6.The area and/or work r'❑ described In the Request Is not subject to review and approval by: Name of Municipality Pursuant to a municipal wetlands ordinance or bylaw. Name Ordinance or Bylaw Citation C. Authorization This Determination is issued to the applicant and delivered as follows: ❑ by hand delivery on Date: by certified mail, return receipt requested on JI►L 02 2007 Print Name Signature Date This Determination is valid for three years from the date of issuance (except Determinations for Vegetation Management Plans which are valid for the duration of the Plan). This Determination does not relieve the applicant from complying with all other applicable federal, state, or local statutes, ordinances, bylaws, or regulations. This Determination must be signed by a majority of the Conservation Commission. A copy must be sent to the appropriate DEP Regional Office (see Attachment)-and the property owner(if different from the applicant). Signa res AW On this day 200 ,before me personally appeared o me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/h a act and deed � Notary Public CLAUDETTE BOOKBINDER My commission COMMONWEALTH OF MASSACHUSEI-tS MY COMMISSION EXPIRES 11/21/08 wpaform2.doc•Determination of Applicability•rev.10/5/05 Page 4 of 5 L� Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands LI WPA Form 2 — Determination of Applicability = BARNSPABM MARIR Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 and Chapter 237 of the Code of the Town of Barnstable DA- 07043 D. Appeals The applicant, owner, any person aggrieved by this Determination, any owner of land abutting the land upon which the proposed work is to be done, or any ten residents of the city or town in which such land is located, are hereby notified of their right to request the appropriate Department of Environmental Protection Regional Office (see Attachment)to issue a Superseding Determination of Applicability. The request must be made by certified mail or hand delivery to the Department, with the appropriate filing fee and Fee Transmittal Form (see Request for Departmental Action Fee Transmittal Form) as provided in 310 CMR 10.03(7)within ten business days from the date of issuance of this Determination. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant if he/she is not the appellant. The request shall state clearly and concisely the objections to the Determination which is being appealed. To the extent that the Determination is based on a municipal:ordinance or bylaw and not on.the Massachusetts Wetlands,Protection Act or regulations,the Department of Environmental Protection has no appellate jurisdiction. wpaform2.doc•Determination of Applicability•rev.10/5/05 Page 5 of 5 CORAL VILLAGE ASSOCIATION, T Sept.211,2007 Barnstable Building Dept. Bill Ross has the approval of the Coral Village Assoc. to Build a deck addition to his house o 10 ill Beach Rd. Wayne Paddock,President CIO • . .fit '� . ,, Z�- G C - i �IKETp� Town of Barnstable *Permit#. Expires 6 montks from issue date Regulatory Services Fee ?"S • a,►ruvsr.+st.e, MASS. Thomas F. Geiler,Director r3r,¢a�° Building Division . -' aESS PEA 1IT Tom Perry,CBO, Building Commissioner 0 2011. APR �. � 200 Main Street,Hyannis,MA 02601 _ www.town.barnstable,ma.us A' r(1 N OF BAR Office: 508-862-403 8 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY r y p Not Y,pa®�lid without Red X-Press Imprint Map/parcel Number Property Address- G b�o `X V1 1�C� -6 eaAQ,D [Residential Value of Work 5O-5®. Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address M U 'm " DO ZA,0280 C0Vf1 D oR I Contractor's Name G- Q r_,4D_PY `q , -N2-k0 V;,(kj�; . Telephone Number 50 9`" qqh Home Improvement Contractor License#(if applicable) 0 14513 Construction Supervisor's License#(if applicable) - E40rkrnan's Compensation Insurance SC • Ch k one: LJ i am a sole proprietor �PR z01� ❑ 1 am the Homeowner ❑ I have Worker's Compensation Insurance ABLE To\fgW OF BARNS Insurance Company NameA i Ut—SkApa- :F4j SU1'?A EJ Workman's Comp.Policy# 7D C)I 2. C90 Copy of Insurance Compliance Certificate musi accompany each permit. Permit el�quest(c tfeck box) 5/Re-roof(stripping old shingles) All construction debris will be taken to ::T• E a ❑Re-roof(not stripping. Going over existing layers of roof) � � ❑ Re-s ide _ #of doors ❑ Replacement Windows/doors/sliders. U-Value (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:IWPFILESIFORM \building ermit nnskEXPRESS.doc RevicPri n7oi I n �s The Co' mmonwealthPoflVl ss aachusetts XN I Department,of Industrial Accidents Office of Investigations # ' w • 4 it 600 Washington Street os '' • ' f _ B ton MA•i7Z1�l 1* ,. www:mdss.gov/dia-w'- Workers Compensation Insurance Affidavi t: Builders/Contractors/Electricians/Plumbers - Applicant Information Please Print Lezibly Name (Business/Organization/Individual): �f C-y� , - e ®'OCi� `, Address: 171D Z1Mh G � �?,_OA' ' City/State/Zip: �'jW�-► - 1� Phone #: Are you an employer?Check the-appropriate box:, Type of project(required): 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and I 6• e have hired the sub-contractors ❑New construction': mployees(full and/or part-time).* ' 2. I am a sole proprietor or partner- listed on the attached sheet. # - ? ❑Remodeling These sub-contractors have 8: Demolition . ship and have no employees _ P working for me in any capacity. workers' comp. insurance. 9-❑ Building addition [No workers' comp. insurance 5, ❑ We are a corporation and its required.] officers have exercised their 10 ❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MU l LE-] Plumbing repairs or,additions myself. [No.workers' comp. ', c. 152, §1(4),and we,have no 12.❑ Roof repairs insurance re uiied 't ,kt` A employees. [No workers' q ] comp'. insurance required.) 13.❑ 'OtheriS t �,' p *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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance'for my employees. Below is thepolicy and job site:'',., + information. , Insurance Company Name: Policy#or Self-ins.,Lie.#: '. Expiration Date: x Job Site Address: 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 ify unde;Ihefains and penalties of erjury that the information provided above is true and correct Signature: r s Date P.1(- Phone 4: l7® r- �Q , 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#: II 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 cant'workers' compensation insurance. If an LLC or LLP does have employees,a policy-is-Tequired. Be advised that this affidavit may be submitted to the Department of lndustrial 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: ThetCoin onwealth 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 5-26-05 Fax,,# 617-727-7749 www.mass.gov/dia Massachusetts-Department of Public SafetN- Board of Building Regulations and Standards Construction Supervisor License License: CS 682 Restricted to: 00 4 Y GREGORY M BOOKACH 170 GREENLAND PND RD 4 -- BREWSTER,-MA 02631 Expiration:"i5/8/2012 L ('ummixsiuner Tr#: "26164 + � �'"lee-�omneaneuieall�a�./�aaa�euaP,l� . Office of Consumer Affairs&Business Regulation License or registration valid for indmdul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:,_-11 1458 Office of COnsumer-Affairs-and Business-Regulation- - Expiration =12f2912011 Tr/1 290167 10 Park Plaza-Suite 5170 . Boston;MA 02116 Type; Individual GREGORY M BOOKACH`; .-.:;:' GREGORY BOOKACH: _._:. 170 GREENLAND POND RD BREWSTER,MA-0:601 .,..:'" Undersecretary v without-signature T ti Town of Barn-stable ` i. Regulatory Services �xxsrAsc.� t _ u�sa Thornas F. Geiler,Director 163D- �E1) Building Division Tom Perry,Building,Coinmissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us +` Office: 508-862-4038 Fax: 508-790-6230 Property Owner Mus t Complete and Sign This Section If Using A Builder T, V(�1 l'� �' ►'�Btti as Owner of the subject ro e . . _ .P Pam. - hereby authorize �S C�o�Y ��t. �O kAZ 1A to act on my behalf, M all matters relative to work authorized by this building permit application for. v ( dress bf/ ob) Q S' ture^ o4 Owner Date Ant Name oti L deo 5s- If Property Owner is applying for pem-lit please complete. the Homeowners License Exemption Form on .the reverse side. Town of Barnstable Regulatory Services Thomas F. Geiler,Director hUSM Building Division PrEO '�� Tom Perry,Building Commissioner 200 Mairi.Street,_Hyannis,MA 02601 Rr".to wn.b arnstab l e.ma.us 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# CURIZ NT MAILING ADDRESS: eityhown 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. DEF711ITION 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 cons"cts 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 5 rrennncrble 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"ccrtifies that,be/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 Hameowncr Approval of Building,Official Note: Three-family dwellings containing 35,000 cubic fact or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXETr m6N The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this sec On.(Section I D9.1.1 -Liccnsing of construction Supervisors);provided that if the homoowncr engages a peson(s)for hire to do such work,that such Homeowner shall set as supervisor" Many homeowners who use this cxenpticm are unaware that they arc assurting the responstbilitirs of a supervisor(set Appendix Q, Rulcs&Rcgbladons 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 Superrisar. The horrrcowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responnbilitics,many communities require,as part of the pa-mit application, that the homeowner certify that hrJshe understands the responstbilitia of a Superrisor. On the]ast page of this issue is a,form currently used by several towns. You may care t amend and adopt such a forrn/ccrtification for use in your cormiunity.