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Home My WebLink About1052 CRAIGVILLE BEACH ROAD _ � _ � � �, . . �. . .. ,. ,. x r � ,, , � . . } ,., . Q a o.a n o o a �. ., TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 26 Parcel-' arcel Application Health Division Date Issued, Conservation Division Application Fee n ]� Planning Dept. Permit Fee+. O •U`v Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street d s L �mA�7 villag---- / CC41 r V� G< -Akl- - �4 �Owne-- b e Address 7� �p e l O LCIC P\k er_mit Request eNt. iC r' / mot. Il &e of e r Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District __ Flood Plain Groundwater Overlay Project Valuation 7 0,9& Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. 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 Number of Bedrooms: existing _new �G Total Room Count (not including baths): existing new , First-Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other �y �'� �Q Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wep, coal stove: ❑Yes .❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Bari ❑ existing ❑ new size_ 9 Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size Other.Z& Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION - (BUILDER OR HOMEOWNER) Narnem �D cJ�ly`'� Telephone umbeyr �O �� (-Address-•4j,_ \,� ense `O r'Home.lmpr-ovement.Contractor# ail Worker's Compensation # ALL-CONSTRUCTION:DEBRIS`RESULTING'F[3QM THIS�PROJECT WILL,BE TAKEN TO SIGNATURE CQ 1 r DATEWv "� : -`•�b FOR OFFICIAL USE ONLY tj APPLICATION # : S R DATE ISSUED r MAP/PARCEL NO. t - 't ADDRESS VILLAGE t` j OWNER DATE OF INSPECTION: / FOUNDATION >t FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL t ` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT s ASSOCIATION PLAN NO. Et°ti Town of Barnstable ° Regulatory Services 9MAS& $ Richard V.Scali,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �tO,ht\ `��!REU-P�M ,as Owner of the subject property hereby authorize :a ,J:'( to act on my behalf, in all matters relative to work authorized bythis building permit application for. j AUZ (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 performed and accepted. e of e Signature plicant Print a me . Print Name Date Q:FORMS:OWNERPERMLSSIONPOOLS ' ' f Town of Barnstable Regulatory Services of raiy,� Richard V.ScaIi,Director Building Division F Tom Perry,Building Commissioner XAM 200 Main Street; Hyannis,MA 02601 QED µPS� 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 phone# work phone# p CURRENT MAILING ADDRESS: cityHnwn 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. DEFINMON 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 B amstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Balding 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 he exempt from the provisions of this section(Section 109.11-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 Iack of awareness often results in serious particularly articularly when the homeowner hires unlicensed persons. In this case,our Board cannot P 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 Iast 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:1wPFILFSIFop,mMuflding permit formslMRESS.doc Revised 061313 . lie Comr ornveaIilt of-Hassadtrrsetts Deparhwent a,f rndks&W Acciderzts Orke afLrvesdgadow . 600 WashhW f on,�trreet -- Boston,MA 02HI iPYvmmass_gvr/din Wmimrs' CampensatinnInsurance Affidavit$•tUdexsdCaniradursM cians/Plum.hers Applicant Informatian. Please Print Le� v Name _ i� - Address �iigfStatelx �ne "\. Are :aemployerw n employer?Check a appropriate bow .. Type of project(req�ed): I I itb 4. ❑I am a general contractor and I employees.(fall an�xifar part-fine)* have hired.the sub-coabmctors 6. ❑New construction 2.❑ I am a sale propdetar or partner-' listed on the attached sheet ?_ ode7iug ship and have no emplayees These sob-canlractors.have g- Demolition wotizing for mein any capacity. enTloyees and have wo&ers' 9. ❑E,uikang addition WO Wadans' comp-:rasura„ce Camp.inererarxp 1 . required-] 5. We are a zorporati m and its 1�1 d❑Electrical repairs or ads 3.❑ I am homeowner doing all wak officers have exercised their 11-0 Pluuibsagrepaiss or additions. myself[No y=l=•comp- of exemption per MGL lry❑Roafrepairs insurance retpied-]i c_152,§lM andwe have no w employem[No workers' 13_❑other comp-in.smmam required.j 'Amy apg5cstfut cherstws R amst also McW the mctianberawshavdng Omkwo$cere campenM&npeayiuffirmsaaa.. #F3 omeaaas6�rh0 sabu>Ft rT77S af5daeu]4diCabm�they am dam-O waml snit dean him autsi&contmcM=—rt submit anew afdavk indicirfin;rnrt;• fCamtmctm fast ebeclr t ds bcxx mast attached as addilinnal sheer sbouing the nne<of the sab-cam=t3s snd stye whaffiec or not Ib se edifies ham emplayees.Mhesmt-cantsams bare emplcyers,9heymustpi0 ide&eir srorkexs't—p.galuYnumb - I am aiz elrtpIr f7ifftis prautducg�t�rrkets'caarpertsriftart utsziraitca€or my enrplay�ecx Setoev is cite policy ami jai site iurf ormatfon Insurance Company Name: Policy,4 or pelf-isss.Tic_ Expiratio—nDate- - Job Site Addre= cityl5tafe12ip: 'Attach a cagy of the workers'eompensationpolicy dedaration page(showing the policy,number and expiration date}. Failure to secure coverage as required.under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$UOD 00 andror one yearimpLisonment,as well as civil penalties m the fa=of a STOP WORK ORDERand a fine ` of up to$250_00 a day against#fie violatar. Be wlsdsed that a copy of this statement maybe forwarded to the Office of , Investigations of tine DIA,for ihsmance coverage vecifisa#ion 1�do hera&y canfb5T rea a is aadpsrraIttes of petfrcry that t*g informa€iort proud'aahm,a is true and�carrm t Sitmafiner t Date: V. ► ��'O Phone ik _l V tl�A Ojft d use unary: Do not wrke in this area,to 5e crrr4Wed by city ortonn o fJx at City or TG-"U: Permitilkense ii Issuing Autlwr€ty(circle One): L Board of Hzdth :.Building Department 3.Mp Tossn Clerk 4:Electrical Inspector 5.Plumbing Inspector . 6.Other Contact Person: Phone#: ' r Laformation and lns c-iolas Ma�sar?�se tfs Ge�Laws cb.ajY=152 regai es all einpIoyers is provide w013eas'compensation for tl eir`"`TIoYe`es- FMCM1MttD fhis sia e,an ernpLUyee is defned as-"_.every person in the sedvice of another ffider any contract ofhire, express or implierL oral or wzit tf . An=Ipkyl•is defined as"an individmaL partnership,association,corporation or other Iegal eddy,or any two or more of the foregoing=gam is a Joint eotmpi s ,and.inclndmmg the legal rcprwentafives of a deceased employer,or the receiver or trustee of an individual,parti=sbip,association.or other Iegal emfiy,employing emploYees_ However the owner of a.dwelling house having-not more than three apartment and Who resides therein,or the oast of the- dwelling house of another who employs persons to do maiteoance,construction or repair wo&on such dwelling house or on the grounds or bulVing appurtenant tTa=b shall not bmame of such employin ut be deemed t o be an eurployex." MCrL chapter 152,§25C(6)also sfafes that every sty or local ficensdng agency shallwifhhoId ffie iwna.,ce or renewal of a Hce r—or permit to operate a bnshne,�s or to constract buildings in the commouvPealth for=y applicant:-who has not produced acceptable evidence of ceimpliznce:with the hmmrance coverage required-- Additionally,MCrL chapter 152,§25C(7)stags=Naifherthe c=n=7e;ahh nor inyy ofits political subdivisions shall FM ter inin any contract for the perf=mncz ofpubhc w0ik uifI acceptable evidence of compliance vdith the fism�% reqairements of this chapter have beaupresenisdto the cn_ntradingaxdhozity_" Applican-t s Please fill,out file won3s'compensation affidavit completely,by che6 me boxes brat apply to your sitnation and,if necessary,supply sob-cantactor(s)name(s). ad&ess(es)and phonem mber(s) along with theircertificat*) of i mn=ce. Limited LiabB4 Companies(LLC)or Limited Liab1ELY_Paraeasbips(LLP)withno employees other than the merhbers or partners,are not regLm.-ed to cagy wc�eas'campesatidm iusrmmce If an LLC or LLP does have employes,a policy is required- Pe.advisedthat this aff dayft maybe submitted to,the Depaitinent of Industrial Accidents for con{nmati m of i astnance coverage- Also he sure to sign and date the of davit. The affidavit should be retuned to the city or town that the applicatirm for the pe iidt or license is being requmbA not the Department of L rinstriaj A r etc Sbouldyou have azry grass ens regarding the:law or ifyou are req� to obtain a workers' compensation policy,please call the,Departneat at the nrmb er listed below. Self-insured companies should enter their s el f i s rra n ce license mmnber on the appropriate line. City or Town Of iiciaLs t Please be sate that the affidavit is complete and prinfedlegibly. The Department has provided a.space,aA the bottom of flit affidavit for you�f]1 out m the event the Office oflnve�sti moons has to contact you regazdmg the a-- Please be surer to fill m the penniiIlicense comber wizich will be:used as a mfereuce n omber. In-addition,an applicant at must submit m-ult�Ie p=3't ic=e,applications m any given year,need only submit one affidavit indicating con end th p olicy inbrn a-tion(if necessary)and under`Job Site Ad dre: "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 b e provided to the - . applicant as proof fiat a valid affidavit is on fie for futai permits or H=:oses. A new affidavit must be filed out each year.Where a home owner or citizen is obtaining a license or p=ait not relai>;d to any business or commercial V=3t= (ia. a dog license or permit to bum leaves efc.)said person is NOT rmgairtd to complete this affidavit The Office of 1n =would like to thank you is advance for your cooperation and sboBld you have:any questions, please do not hesitate to give us a call. The I}eparfm enfs a.ddressb telephone and fax mmMbeM- Tht co�wen*of Massa-chhusct#s ' Da�.t t��id�EdakA�dents - . �Q4 man Bosun,MA Edl 11 Fax 9 617`27 7M Revised 4-24-07 MRZ gQgIdia Client#:38860 2EXCELBU ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDm1rr)3/29/2016 THIS CERTIFICATEIS 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). -CONTACT PRODUCER NAME: Dowling&O' Neil Insurance Ag (PAN/ N E,d:508 775-1620 a.N,: 5087781218 973 lyannough Rd,PO Box 1990 E-MAIL ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# 508 775-1620 i INSURER A:National Grange Mutual Insuranc INSURED i INSURER B:Associated Employers Insurance Excel Building Systems Company,Inc [INSURER c:Safety Indemnity PO Box 436 INSURER D Forestdale,MA 02644 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. ADDLSUBR NSRR TYPE OF INSURANCE NSR WVD POLICY NUMBER MM1DDD/YYY MM/DDNYYP ' LIMITS LT A GENERAL LIABILITY I MP02774T 2/22/2016 0212212017 EACH OCCURRENCE S1,000,000 X COMMERCIAL GENERAL LIABILITY I PREMISES ERENTED �urrenee S500,000 CLAIMS-MADE I R OCCUR LMED EXP(Any one person) s 10 000 s/ PF ERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE 52,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000 POLICY PRO LOC ' $ JECT COMBINED SINGLE LIMIT C AUTOMOBILE LIABILITY 6231596 12/09/2015 12/09/2016�(Ea accident) 1,000,000 ANY AUTO BODILY INJURY(Per person) $ j - I ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS X AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ ti EXCESS LIAB CLAIMS-MADEJ 1 AGGREGATE S ' DED RETENTIONS WC STATU- 1 OTH- B WORKERS COMPENSATION WCC50050098182016A 3/05/2016 03/05/201 X Y LIMIT EB_ AND EMPLOYERS'LIABILITY I ANY PROPRIEfOR/PARTNER/EXECUTIVE�f �N'� E.L.EACH ACCIDENT 5500 000 OFFICER/MEMBER EXCLUDED? NJ N/A -EA EMPLOYEE 5500 000 E.L.DISEASE f(Mandatory in NH) ' - f If yes,describe under E.L.DISEASE-POLICY LIMIT S500,000 DESCRIPTION OF OPERATIONS below I i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,ff more space is required) 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 REPRESENTATIVES ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD trc�ar�aznlni a��o� r-Rn r fjr•e .rriuiniinrrr Office of Consumer Affairs K Business Regulation License or registration valid for individul use'only " > BIOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: .Registration: ,182094 Type. Office of Consumer Affairs and Business,Regulation Expiration t 512612017' Corporation 10 Park Plaza-Suite 5170 Boston,NIA 02116 EXCEL BUILDING SYSTEMS.COMPANY INC. RENATO DA SILVA, 8 JAN SEBASTIAN DR STE25 _ - SANDWICH;MA 02563 Undersecretary s ;_Not valid w out signature Massxhusetts ttm-Npaent of Public Safety Board of.Bullding Regulations and;Standards C.{Ans2 r[!.-iitlrt�Si7T68iS'iiil� - ` - 'Lice�se:"CS-098849 'RENATO F.DA SI�W 8 Jan Sebastian Dtive. Sandwtcb IYIA 02363 ram.. ` A, Expiration Expiration " C.onanissiorter 0612012017.:. i ■ ■ Ii � G � N � ME MOM ME MOM MOM o NEMS ME OEM MOM NNE 'ME MEN ME MENEM MENNEN MEEMME ME MEME M mom MENEM mom 0 MINE M MIN No 0 rmmmm MEMO No OEM mom MENEM m 0 r.1 - a MEMom N No ME mom M MEMEM MEN ME 0 ■ - 1 I T mmi ME m =1 mmm m mmommm mml ml ME m m ME mmmm Elm INN MEE m INN I ME ME C. E.. M. . ... C 0 m mullmm Mom m IN Elm m I m m ir ■ ME 0 m No mom �Cii�i�i,� ■ ME �. m ME INNC::: C ': 0"No 0 mom 1101 No :C . m MON 0 m m m NEE momlom ME NNENN mom m 0 ME ENE o �■ rA. 44 14 ' - - - 1 - - -- - - - - -fir-- - j --- - -fi 0 0 mMENOMONEE MEN 0 BONN mmi mm ON MEN 0 MEN ME INN m MEN 0 MEMO ME M ME ONE m - ON eMEN ISMENE M MENE No 0 No No MENEM ME M ME 7M BONN ME ME MEN IN NIEMEN- v i i F _ 4 ! T-t i I. TZ I l a I-T 1 • r n y�u�l� �' ;� Town of Barnstable *Permit# ' J 2016 Expires 6 months from issue date APR 13 S�PLe�9ulatory Services Fee - i RARNRP1Rr�,F. a f` Richard V.Scali,Director, Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town barnstable.ma us Office: 508-862-403 8 4 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY -Not Valid without Red X-Press Imprint Map/parcel Number a _ Property Address Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �� U� CA\bJaS PGA p1b- Contractor's Name gFW�Mo bN` Telephone Number Home Improvement Contractor License#(if applicable) 1`1 Email: Construction Supervisor's License#(if applicable) 3dWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit.' Permit Re est(check box) l J i � Re roof(hurricane nailed)(stripping old shingles) All construction debris will be taken ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) 1 ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#'of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,Le.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy o&the4ome Improvement Contractors License&Construction Supervisors License is requir SIGNATURE: Q:\WPFILES\FORMS\building permit fotmsm .doc Revised 040215 17ie Comrtran}yeah*o f manadr=efts Depfirtrnent&find=-&iaiAccidesdts J Offwe ofrm-lemvizezem Boston,IM 0211-7 +v m,Max orldia W(WI ers' Campensafim Inturauce A davit B..utriersiContradnrsMecricLmmThr mhers Applicant Inforlmaf gn Please Print 1,mbIy Name L f3y.I S` address ' �--� a _ c ta: X S t i ale Are ::a employer?Check the appropriate bow ,�, Type of project(required): L�I employes v�ifb.�_ � ❑I am a general contractor and I' i� �� s 6. Io * 1F4Ye hued ❑New coast=ucEiarx employees felt a�l`or art lime. the suFr-coatiat-Eors P � 2.❑ I am a sole proprietor orparhn r-. Tisted onthe altached sheet< ?_ E0&modeltag sbip and have no employees These sub-conftactars have, 8- ❑Demaldioa WoA ng forme is any fy. employees aiidhave workers' 9..El BRt3cltng ad jNo iro�ers'comp-inso�ce comp-M7suranc• dition required-] 5. ❑ We are a uorporafinn avdits 10-❑Electrical repairs or additions 3.❑ I aura hamemmerdoing all Work officers have exercised their 11-0 Plumbsngrepairs nr additions rtrys [No workers'romp. ri9U of eserup6on per MGL 1?❑Roafrepairs MMranre required j 1 c.1.52,,§In andwe have no employees.[No woAoe& 13.❑Other camp-inmrznne re{iiSlred-] '6ayagp[icaa �atebet s6osrl— also fM0Dt*esec6onbt7awsho=gthekwaffas'compersatiaapoHeyitflM=UML Hameoarderstrbosabmdis�sisaffidaruiaHcatmg they asdabgallwataaai&Mhire Outside rautc +*s— sdTh=kanewafndreFtindiessria_-sacI TCOat<ac�cstEat cbeclsildz bmc must attaClle$ffi additional sheet aowing the naneof the sib-ccutrscto and stafewheihs or=1hose ent<tieshrm enxp�ye�.IftbesnhtOatoadfleslu�e empIo�s,tfie]'�rstpmuide#heir workers'•tasap.paltry number_ . lain an eurplayer fliatis prauhurg warkers'couperrsatfan irrsrtrattre far 3'empf gees BeLaav is Ae pvHcy arzd jah tits information 1USMMceC0mgaay1xM=: . Policy 44'or ins-Lic-4 F�pir�iga Date: Job Site ttddres --------------- Cifyl5tafe� p: Attach a copy of the wort-ere compensation policy declaration page(showing the pohcp number and expiration date). Failure to securmi coverage as regoiredunder Section 25A of c.15 can lead to the ianposition of criminal penalties of a fine up to$1,54a Ua n d for one-year impasozzm—f as well as civsl penalties is tine form of a STOP WORK ORDER and a fine of up to 0-Da a Clay again the violatur. Be advised that a copy of this swerve t maybe farward,ed to fbe f)ftice of Itrvestrr c ofthe DIA for insu ace-coverage vedfkation- I tfa hereby cgrbfy us tltR 'rs and periahYks 6fFe&tY flsatf ze iiaformi mpravi&d abma is bars and correct Si�afixer Date: U• ' ' `O Phone i OJO aI tree anly. Do slat wrke in flds area,fa be caump£etesd bf city vrtarrn vffic&L City or Tawu• - PermitUcense 5 Issuing a rthar€tg[circleonej: L Board of Healtlm Buff mg Department 3.Cityfrosrn.Clerk d.Electrical Inspector S.Plumbing fuTeofor 6.Other Contact Person: Phone#: - - 6 orm ation and Instmetions ; . . Isz all employers'tD WM&warke&compensation fin:rites employees. hl`ac_car3rrr¢e(�S C=D a Laws chVb �� exsciain$�e se5vice of er�det aaY c°�xacE°fb� dafined as."_eveiy Pmsaamto this statute, Ls P esprress or iarpliA oral or wufte " czn,corporation or other legal entity,or any two or more An ded as"andam P .associaii �T�3'� fine mg.�legal r se�[Ves of a deceased e3player,ar Sic of the foregoing edged is a joint eoinrpr 30,andincbff receiver or trustee of as in�vidiial,par�ecsb�p,assocaon or other legal entity,emploY�=Pl0Y�• However the owner of a dweIlmg homc having not more than.Scree apara. ds herfis and who resides therein,or the occapa�ofthe- *ac on or repair wow on such dwelling house dwelling house of ano5iet who�l�Pes®s iD do II1 Cr+a rrm 1 be deemed to be an employer.„ or am the,groun or bmldmg appur�na ttherato sb MnDtbexaase of sash enlp aymeat MGL chapter 152,§25C(t7 also sus that"every state er local ficeaszag agency shall withhold ffie s�ce or renewal of a license or permit to operate a bgsiness or to construct buildmgs iu the cofamoa4Pealffi for crag aPPlicIntwho has notprodamd acceptable-evidencm of compliance with fire insurance-covexage (n al snregmired shall Additionally,MGL chapter I52,§25C states a1�TeitZbeathe carnm r yealthnor:y P enter into airy contract fin:tbz perf o=13n ce ofpublio woIkUE±il acceptable evidence of campIiancewith ffie . reqair-euienfs of this chapter have Been presented to the corfta;ting anfhoiity_-7 PH easati°n ar'hdavit completely,by chug�boxes that apply to your soon�,if Please fill out the v,�or s'cnmP es phone along"WILtheir cet f'cate(s)of necessary,supply snb-ca�rac(nr(s)�e{s), address( ) pho er thm the amen or I.iffited Liab�7iLy Pa t=mbigs(LIP)wtthno Ioyees oth insur�mce. Limited Liability Come (1-I� members or partners,are not required to caay woffiers'camp ensafian mSM7ancj—, If an LLC or LLP does have a Policy is Be advised fad this a$daQit may be ambmitfedto the Department of Industrial employees,cci P �' ° Also be sure to sign and date the afadavit The affidavit should Accidents for confamahon of insor•�ce coverage• not the DeparEmeuf of be retnzned to Idle city or town that the application for the permit or license is being requested, LmAnstial Azcldentr, SlopIdyou have any qIIestions rmgmiag ffie kw or ifyou are rcgaied to obtain a worms' Compensation P ofiCnpleasecalltlie•Departenfatthermmb=Usiedbelow' Self-ias redcampaniessbonldeatrrtheir self- sat-ice license mmubm on.the appropriate line. City or Town OfElriaJs t Please be sale that the affidavit is complete and prime legibly. The Departmenthas provided a space at the botbom. of the affidavit for youth fin out in the event the Office ofinvest gations has to co�actyouregardmg the applicant ease be sure t o fill inthe p=itllicense mmber which VM be used as aref nce rrnmber Iaffi addition,an applicant PI year;need only snbmrt one affidavit mdtcatmg that must submit mu}.fiple P=IUficense applications is any given Y policy inl�znatian Cif neccs`azy)and under`Job Site 1�mess"the applic�&DUICI we e"all 10catins in (�Y or b town);'A copy of the-affidavit that has been officialfY stamp ed oz marked ythe city or town maybe provided to the a valid affidavit is on fzZe for fofnre pezmzis or licenses A ne�Y at�idavlz must be f>Jled out each applicant as 'roofthat ersial venters aPP P ahcease or e�itnotrelatedto my business or comet year.Where a home owner or citizen is obtain:mg P .� Iete t'ais affidavit . (ie. a dog license orpemlrt to bum leaves etc.)said person is NOT required P The Office of Invesfigations would hlce to faank you in a& ce for your cooperafion and should you have any questons, e do not hesitate to give us a call- and ll . The Deparlmenfs address,telephone and fax number: ' Dega�mt oflzid zalAccident% • ��e��'e�frgaf�o� 4ton 4 617- -4900 61t 4-06 Or 1-977 MA GAF Fax 9617 ` 277749 Kevised 4-2-4-07 w W W ma sg-goWdia. CAW r r MASS. Town of Barnstable Regulatory Services Richard V.Scab,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' P rtY Must . Complete and Sign This Section If.Using A Builder as Ow net of the subject property l P .Pay hereby authorize to act'on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) _ 4 • • s . �d i3, l� Signature of Own4 Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. r "Q.-MPFIL EWORNIMbuilding permit formAEXPRESS.doc Revised 040215 Town of Barnstable Regulatory Services P�� y Richard V.Seali,Director Building Division sAaxsrwB, • Tom Perry;Building Commissioner NAM 9e6�1 200 Main Street, Hyannis,MA 02601 RD www.town.barnstable.ma.us Office: 508-862-4038 Fax 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number sb get village "HOMEOWNER": name home phone# work phone# . • CURRENT MAU ING ADDRESS: - city/tnwa 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. DEFDMON 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 ear 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. Signah=of Homeowner Approval ofBuilding 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 Construc tion Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt this section Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowne r from the provisions of ( g 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 The homeowner actin as Supervisor is proceed against the unlicensed person as it world with a licensed Supervisor. g P g ultimately responsible. . To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the ermit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page P PP on for use in of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certificafi your community. QAWPFMES\FORMSIburldmg permit forms=RESS.doe Revised 040215 Client#:38860 2EXCELBU ACORD.. CERTIFICATE OF LIABILITY INSURANCE DAT 3/29/20°"YYY' 9/2016 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:It the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Neil Insurance Ag P"o,"ENo Ell):508 775-1620 �,No):5087781218 _ A/C 973 lyannough Rd,PO Box 1990 EMAIL ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# 508 775-1620 INSURER A:National Grange Mutual Insuranc INSURED - INSURER B:Associated Employers Insurance Excel Building Systems Company,Inc INSURERC:Safety Indemnity PO Box 436 INSURER D Forestdale,MA 02644 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. EXP INSR LTRTYPE OF INSURANCE- NSR WVD POLICY NUMBERADDLISUBRI POLICY DNYY MMtDD/Y LIMITS A GENERAL LIABILITY MP02774T 2/22/2016 02/2212017 EACH OCCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES(EaEoccou RENTED ) $500 000 CLAIMS-MADE ❑X OCCUR MED EXP(Any one Person) $1 O 000 ' PERSONAL.&ADV INJURY $1 000 000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY JC PE 07 LOC $ C AUTOMOBILE LIABILITY 6231596 2/09/2015 12/09/201 Eadnt acel e SINGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED rx SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS IxHIRED AUTOS NON-OWNED PROPERTY r axidentDAMAGE $ AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ ° DED I I RETENTION$ $ B WORKERS COMPENSATION WCC50050098182016A 3/05/2016 03/05/2017 X I WCSTATU- orH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $5OO OOO ' OFFICER/MEMBER EXCLUDED? N N/A , (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 OOO It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) f Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. a L Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. k CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE fl THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD A1Qi A77ozme1I A77c9 rRn, 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: Registration: j82094 Type: Office of Consumer Affairs and Business Regulation Expiration 5/26/2017, Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 EXCEL BUILDING SYSTEMS COMPANY INC. RENATO DA SILVA 8 JAN SEBASTIAN DR:STE25'J' SANDWICH,MA 02563 Undersecretary iot valid w out signature Massachusetts-Department of Public Safety Board of Building Regulations and Standards C tin tr uctinn Siinei ti iiirr - - -_ License: CS-098849 RENATO F DA SW'VA ' 8 Jan Sebastian DAve '= Sandwich MA 02363 - Expiration Commissioner 06/20/2017 r FtKE T Town of Barnstable *Per® PLO Expires 6 months from issue date Regulatory Services Fee IA _ w MAS&LE • an oF Ebb p�-� IT 1659. A,�� Richard V.Scali,Director ®® FF3a.'aaa 11 TFO MP't Building Division APR 10 2015 Tom Perry,CBo,Building CommissiI"e+WN OF,BARNSTABLE 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY f Not valid without Red X-Press Imprint Map/parcel Number �O t� / `3 Property Address %Residential Value of Work$51000 g Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address NS &Ptg� Contractor's Name Telephone Number S-O Sr Home Improvement Contractor License#(if applicable) ��ot'd.'-� Email:- ESt'6M5�L�V�.tA . Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: I am a.sole proprietor ❑ I am the Homeowner ® I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requir d. SIGNATURE: QAWPFILESTORNIMbuilding permit forms\EXP SS.doc Revised 061313 ne Cernzrlronnveafth of Mnassachusetfs Department Qflndus&ial Accidents N Office of Inw-stigadOns 10 ;Ws 600 Washington.S&eet NO Boston,M4 02111 /., wmv.mas&gov1dia Workers' Compensation Insurance Affidavit:Iluilders/Costa-actiDrs/FIectr nstP umbers Applicant Information Please Print Le ffi Naive(BusinesvOrganizationg.ndividual). 'Rzw p tk S`Lmtk Address_ '6 ) SQPJR-t Ortj bV_ a7, CitylStatt/ ipc SW' vtia PM Phone# 50' Ili\ 0\ 3 Are you an employer;? Check the appropriate.box: Type of project(required)_ 1.�k I am a employer with 4- ❑ I am a general contractor and 1 - 6- ❑New construction. employees(full anaror part:-time).* have wed the sub-contractors 2.❑ I am a sole proprietor of-partner- listed on the attached sheet. I Remodeling ship and have no employees These sab-matractors have 8_ Demolition working for me in any capacity- employees and have workers' 9. 0 Building addition a woricers'co incu,-mce comp.insurance 1 rewired-] 5. ❑ We are a corporation and its. ld.❑Electrical repa,11S or additions 3-❑ I am a homeowner doing all work offcros have exercised their 1I.❑Plumbing repairs or additions myseif ' right ofexemptionperPMGL [No workers c�P- 12.❑Roof repairs insurance required.] c. 152,§1(4),and we have no employees_[No workers' 13.0 Other comp.insurance required.] ;Any sl)pficant&ai cheers box#1 mms*also fill out:the secirou below showing then wor&eW compensation policy information- Homeowners who submit ibis:affidavit indicating they ale doing all wcak and then hire outside contractors nmst.subunit anew affidavit indicating sack r—ontmiurs ihst check ihis box must attached an adduional sheet showing,the name of the sub-comet UGn and state whether or not Those manes haste euap7oyees. Ifthe stab-contractors have employees,they1m, p ovide their workers'coup.policy mmnber. I am art empFoy,er thatis prodding nvorkeers'co,n-gmzsatiort iras7iranrce for rrr_y ennnpl'a}?ees Below it thepoHV rutdjob site - informatiam Insurance Company Name_ - - - Policy 9 or Self iris.I c.4: Expiration Date. 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 hfGL c_ 152 can lead to the imposition of ctiniinaI penalties of a. fine up to S 1,500-00 ancUor one-year imprisonment,as well as civil penalties irn the foie of.a STOP WORD ORDER and a fine of up to$250-00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification_ d do hereby c-ertrf r and prreris and,penalties of perju.rt'1hatthe inforruation prmlided a bosw is tnte and correct Siestature_ Date_ Phone a- Q\�� O ffirfal use only. -Do not ivrite in this area,to be c4inptete f by city or town of eiaL City or Town: Fermit[License 4 Issuing Authority(circle one): 1.Board of Herilth I Building Department 3.CiVrown Clerk 4.Electrical Inspector 5.Plumbing hgpector 6.Oth-er Contact Person: Phone#: cf Q�OE THE T�ti RARNS UBLE, MASS. of Barnstable i639. `0� �'rEn MP't a Regulatory Services Richard V.Scali,.Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I� �,Pry RzE YRA) , as Owner of the subject property hereby authorize ?JGt'ipt0 SwNl to act on ray behalf, ' in all matters relative to work authorized by this building permit application for: �0�� 2��I11i13� (3bAU� i�D (Address of Job) rigna'tRe of wner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 Town of Barnstable Regulatory Services P�oFsr+e Totyp Richard V.Scali,Director Building Division &UMSPABLE• * Tom Perry,Building Commissioner 9 MASS. 6 0 1 9• 200 Main Street,3 . Hyannis,MA 02601 a rFD � www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 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. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doe Revised 061313 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-098849 s , t bi RENATO F DA SILVA - �'r _ 8 Jan Sebastian Dr:ite.#25}�? Sandwich MA 02563 ' k' Expiration Commissioner 06/20/2015 Office of Consumer:affairs&Business Regulation � �HOME IMPROVEMENT CONTRACTOR 1 � rRegistration: 160124 Type: Expirations _6/25/2016 Individual RENATO F DA SILVA RENATO DA SILVA 8 JAN SEBASTIAN DR.STE 25 ��- SANDWICH,MA 02563 Undersecretary E Client#:38860 2EXCELBU DATE(MM/DDNYYY) ACORD.. CERTIFICATE OF LIABILITY INSURANCE -- 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 CONTACT NAME: Dowling&O'Neil PHONE rj08 775-1620 Ax 5087781218 A/C No EM: A/C,No: . Insurance Agency E-MAIL ADDRESS: 973 lyannough Rd., PO Box 1990 INSURER(S)AFFORDING COVERAGE NAIC s Hyannis, MA 02601 INSURER A:National Grange Mutual Insuranc INSURED INSURER B:Associated Employers Insurance Excel Building Systems Company,Inc INSURER c 8 Jan Sebastian Drive#26 INSURER D: Sandwich;MA 02563 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 TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MWDD/YYY MWDD LIMITS A GENERAL LIABILITY MP02774T 2/22/2015 02/22/2016 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY PREMISESOERENTED cr nce $500,000 CLAIMS-MADE F_x1 OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY ECOT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50050098182015A 3/05/2015 03/05/201 WC X STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 OOO OFFICER/MEMBER EXCLUDED? FN N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE s500 OOO It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500 OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) 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 j i SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFORE }-- -- - ------ _- _ i. "THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1 ACCORDANCE WITH THE POLICY PROVISIONS. `C. ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks-of ACORD ltC1A7RR4/M1A7RRa I Ci Mass. Corporations, external master page Page 1 of 2 yK. r� Corporations Division Business Entity Summary ID Number: 465650735 Request certificate I New search Summary for: EXCEL BUILDING SYSTEMS COMPANY INC The exact name of the Domestic Profit Corporation: EXCEL BUILDING SYSTEMS COMPANY INC Entity type: Domestic Profit Corporation Identification Number: 465650735 Date of Organization in Massachusetts: 05-22-2014 Last date certain: Current Fiscal Month/Day: 01/31 The location of the Principal Office: Address: 8 JAN SEBASTIAN DRIVE UNIT 25 City or town, State, Zip code, SANDWICH, MA 02563 USA 4 Country: The name and address of the Registered Agent: Name: RENATO DA SILVA Address: 8 JAN SEBASTIAN DRIVE UNIT 25 City or town, State,.Zip code, SANDWICH, MA' 02563 USA Country: The Officers and Directors of the Corporation: Title Individual Name Address PRESIDENT RENATO DA SILVA . 269A STEVENS STREET HYANNIS, MA 02601 USA TREASURER RENATO DA SILVA 269A STEVENS STREET HYANNIS, MA 02601 USA SECRETARY RENATO DA SILVA 269A STEVENS STREET HYANNIS, MA ' 02601 USA VICE PRESIDENT RENATO DA SILVA 269A STEVENS STREET HYANNIS, MA 02601 USA DIRECTOR RENATO DA SILVA 269A STEVENS STREET HYANNIS, MA 02601 USA a http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=465650735&... 4/10/2015 Mass. Corporations, external master page Page 2 of 2 Business entity stock is publicly traded: 5- The total number of shares and the par value, if any, of each class of stock which this business entity is authorized to issue: Total Authorized Total issued and Class of Stock Par value per share outstanding No. of shares Total par No. of shares value CNP $ 0.00 100 $ 0.00 100 r r Confidential FA Merger* r Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS Administrative Dissolution ! Annual Report Application For Revival ' 101 Articles of Amendment k 1 View filings Comments or notes associated with this business entity: 1 I New search r http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=465650735&... 4/10/2015 aFtNe roy, Town of Barnstable *Permit#Expir ti Regulatory Services_ Feees6"'°"`t' ow.rss"ed"`e * BARNSTABLE',A Thomas F.Geiler,Director 9 MASS. 0 gyp,-1610. Building Division ®PRESS PERMIT Tom Perry, CBO, Building Commissioner j 200 Main Street, Hyannis,MA 02601 JAN 2 4 2008 www.town.barnstable.ma.us TO �_®F S Office: 508-862-4038 �F?NS X.�0�p'? 30 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid widrout Red X-Press7nrprint Map/parcel Number—a2el 6 J Property Address /o j_Z z:,Z ❑.Residential- Value of Work v, 'Minimum fee of$25.00 for work under$6000.00 t - Owner's Name&Address 714 v �� •_ ;! f it _r ; Contractor's Name .'`" g Telephone Number Home Improvement Contractor License#(if applicable)L � Workman's Compensation Insurance Check one: - [ ]' I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance , Insurance Company Name Workman's Comp. Policy# . Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All.construction,debris will betaken to ❑ Re-roof-(not stripping. Going over existing layers of roof) ❑ Re-side` ❑ Replacement Windows/doors/sliders.' U-Value .(maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. I ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:buildingperm its/express Revise 112807 i i ' The Commonwealth of Massachusetts Kzx Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111, wiww.mass.gov/dia ' Workers"Compensation Irtsuriince Affidavit: Builders/Contractors/Eleetridans/Plumbers Applicant Information .Please Print Le6bly Name(Business/Organizatiowb&vidual):. Address: City/State/Zip: Phone.#: Are you an employer?Check the appropriate box: :Type of project(required):, 1,❑ I am a employer with 4. I am a general contractor and I 6 New construction . employees(full and/or part-time).*• have hired the sub contractors 2. T am a'sole proprietor or partner- listed on xhe•attached sheet. 7. ❑Remodeling ship mid have no employees These sub-contractors have g, Demolition '*orkin for me in an capacity. employees and have workers' g y p ty 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. [] We are a corporation and its ME]Electrical repairs or additions 3.❑ I ani a homeowner doing all work . officers have exercised their 11.0 Plunnbing repairs or additions myselt[NO workers'comp. right of exemption per MGL 12.0 Roof repairs insurance.required.]t c. 152, §1(4),and we have no employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant 1hat checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowacra.who submit this affidavit indicating they are doing all work and dicn 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 arnot those entities have employees. If the sub-contractors have employees,ihey must providb their workers'comp.policy number. I ani an employer that is provlding workers'compensation insurance for my employees. Below isthe policy and job site' information. Insurance Company Nahne: Policy#or Self-ins.Lic.#: • Expiration Date: 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 lip 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 thq violator. Be advised that a copy of this statement maybe forwarded to the.Office of _ Investigations of the DIA for insurance coverage verification _ I,do hereby certify under thepalns aitdpenalties of perjury that the information provided above is true and correct Signature � f Date Phone#• 7 G 411 7 Offccial use only. Do not write in this area, to be completed by city.or town,officlaL City or Town: '- Yermit/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#: f �tr Town of Barnstable Regulatory Services f f • BARNS?ABLE, f MASS. Thomas F.Geiler,Director ru.. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must f Complete and Sign This Section If Using A Builder I, .✓'lJ %�c`� /;'�: `'✓�i�� , as Owner of the subject property hereby authorize i �> �/ � to act on my behalf, x in all matters relative to work authorized by this building permit application for. , (AM ss of Job) p 2- Signature of Owner Date ' Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&OWNERPERMISSION ' i i Town of Barnstable t)F'THE rpm " Regulatory Services WP t) t BARNSfAB[E, t Thomas F.Geiler,Director MA-%& 1639. �.� Building Division ArfD �a Tom Perry,Building Commissioner 200 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 phone# work phone# CURRENT MAILING ADDRESS: 4 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. Q:fonns:homeexempt IiA E �$n`��tru�f��n SUpef;�iisgr Lfcen`se. �`j r „ F11/2009 firk' 11876. ; ARt L DAL lVi [T' 19 Mcailk w K k g W BAFNSTABLE M` <, r Commis3ioeer r„ 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: r) AND C OR Search Search Results Reg. No. Applicant Street City State Zip Name Title Expiration ART DOLGOFF 19 104499 BUILDING/REMODELING McCormick Barns able ' 02668 DO hf' President 7/14/2008 INC Dr. Total of 1 Records matched. N Back to Home Page BBRS Privacy Statement • Z _ http://db.state.ma.us/bbrs/hic.pl 1/24/2008 . ' cn�(7L-� Auoemomr� mop and �� number ----��—..�=�—�---_. ' \ ^ ° ' Sewage Permit number ------..--.�—...--.�^---'—' ' [ y-&�� ' ^ House number -- ~0' ^x./ ..............................................' —`' ' ' � � 1639* NAM ' ` r��-��77l�T ' �� l�T�3 r�� l�� l� �� ' �� _�TOWN � �� ) �� _ p� �� ]� �& �� u . , ` . . . . . ' BUILDING � N0NN �� 0N N 0-00 � �� = �� m� ' APPLICATION FOR PERMIT TO —�—.---. .. ................ ' ~ ' � xy TYPE OF 'CONSTRUCTION '-----.---...--��-1-..)L '-'^~_.�._—_._—_--.~ _ . � T] THE |NSPECt6G OF BUILDINGS: The undersigned hereby applies for u permit according to the following information: , , —�6 . —�^�� ` . .......�.��e --_----. --------.Location Proposed Use -- —r----------.------`'----------------,--------.| Zoning District R District ------.—..-----.---..-------, | ---------------- � � Name of None of Bvi| 6 —.v' -------'— - ' . Name of Architect ............—...................................................Address ---.-----..-------.--..—.--.----. . ~ . Number of Rooms ---'^— —��------'----:..Fouodohm� —/��-----------------.---- , Exierior ...................................�y---------------'Roofing ----',/----------....---------.. Floors ---------------_--..----------|nterior ----..-----~.----...— ............................. Heating ---------------.r—_---------.F1umbng ---�-----.. . '/ Fireplace -------.:---------_.............................Approximate Cost ........ ............................... Definitive Plan 6v Planning �mr6 lA . Area 1�� Approved ' --'-------------' ---- -- — .. Diagram of Lot and Building with Dimensions Fee —'�--'---- � ^ / SUBJECT TO APPROVAL OF BOARD OF HEALTH t� C� - ' [X�-�� \V\ / ~�~ , \ ` . . . . v . . � . ` . . . 'OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS .'• u4 _ SMALL, RICHARD & ST. GERMAIN, R„ obert No 25472 Permit for ADD DECK ........... .................................... �. Single Family Dwelling •Y ..`.............1�05.4..•Craigville•.•Beach...Rd. � '' - •' _ �- Location ................................................................ . rr � :..... Centerville.....................:............ f, Owner Richard Small, & Robert St. Germain " _ - Type of Construction Frame .......................................... y ............................................... ............................. 1' Plot ............................ Lot ........ ................. , tAugust- 25, , 83s- Permit Granted .........................................19 Date of Inspection .. ....19 Date Completed ....... � �.., yew. :19 " h '>.4 4. � �• 1. . F�� f �- 1 f �� a..T. �� - Viz,: ��, ' ' � ,'�• " '�. .• � s, V •��jjjj//�r. - ' fin • - r • • �+ Assessor's map and lot number .... ..., ', Sewage Permit number ........................................................ Z BARNSTABLE• i House number ...... ...................................................... voo NAG& Om a� TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION M 4......�. y�......'`........................................................ ....................................... ........ ........�....�.......... ' '..............19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..../..: ................ . :: :*ff!f ::`:�:........!f 1 '. t i�Gvy�j.Y:� •y• ProposedUse ...... .................................................................................................................................. U ZoningDistrict ........................................................................Fire District .............................................................::............... Name of Owner................... I f% Y "�'` ................. ..� . �tlik:Ccn...Address ..'. .r..'..... i tcfi 1 ;� ?.. "/,; :° 1� +[ it/ L✓ Name of Builder- T .t ;x.......;� ••. ..�. 'j€ id ,Address ...................................................� � f ..�1` ............................. Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ........................................Foundation ....�::°:..................:........ ................................................................... i Exterior ....................................................................................Roofing .................................................................................... Floors ......................................................................................Interior ...........:........................................................................ Heating ..................................................................................Plumbing ................................................................................. Fireplace ............................ ....................................................Approximate. Cost ........ .................................... Definitive Plan Approved by Planning Board -----------_-------_-----------19_______. Area ...........I.:?�`..��.......��... Diagram of Lot and Building with Dimensions Fee ' ../ SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. t� , Names ::' ............ I � Construction Supervisor's License ....5/...!.::.' SMALE,_ RICHARD & ST. GERMAIN, ROBERT A=206----*4:- a-a 25472 ADD DECK No ................. Permit for .................................... ............. Location 105X C.raigville. . . . ...Beach. . ...Road .. .... ....... .... .. .. .. .... ..... .... Centerville ............................................................................... Richard Small & Robert St-. Germain Owner ................................................................. Type of Construction ......Frame .............................. ................................................................................ Plot ............................ Lot ................................ Permit Granted .. August... . 2 5, 19 8 3 ..... ............ Date of Inspection ....................................19 Date Completed ...................:..................19 t67o 4 l 1