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0050 FULLER ROAD
�0� ��r-l/P,iz � i��aQ- nr a" a t .. ., , r. < .., 1 .. ..._ ,... .. .. ,. � ._ _ a .. .. _ .. _ .. � '. .� ... ,.. .. e ,� .. .. � _ j }, r �. 9 r. u ' - ,. .. _ i .: :. v :. Town of Barnstable BLilldi Il .�. Post ,his Card So,That�t is::\/�sible:xFromthe Stree#-Ap' roiled;Plans Mustbe Retgmed on-Job and'this ardMust be Kept 1)A>31V8'[AB3$ ? "�.. .`a�,+;, •x „'�e .� '' ��,.'r:� PAsted Until iinallnspection #as5 BeenMade '` W.here;a ^e�#r ifieateof Occu anc s�Re u�redsuchBuild�n 'shall�Notbe�Occu`ie`d unt�la Frtal;lns ection has been made Permit it Permit No. B-17-3104 Applicant Name: . Jonathan Whipple Approvals Date Issued: 09/13/2017 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 03/13/2018 Foundation: Location: 50 FULLER ROAD,CENTERVILLE Map/Lot 188-029 Zoning District: RD-1 Sheathing: Owner on Record: ATLEE, KATE R D&AARON R'D h ME, Owner JONATHAN N WHIPPLE Framing: 1 Address: 50 FULLER ROAD. •" Contractor LicQnse CS-078683 2 CENTERVILLE,MA 02532 a '';� � Est PoectCost: $2,066.00 Chimney: Description: Insulation.Air Sealing.Cellulose-into that attic Add Ventilation. Permit Fee: $85.00 Insulation: Project Review Req: Insulation.Air Sealing.Cellulose into th, attic Add�Ventilation. ee Paid: $85.00 ©ate: 9/13/2017 final: Plumbing/Gas Rough Plumbing: 3 ' Building Official Final Plumbing: This permit shall be deemed abandoned,and invalid unless the work authorized by this permit is commenced within 9 mo the after'issuance. �� > � I Rough Gas: All work authorized by this permit shall conform to the approved application=and theapproved construction documentsfor which this permit has been granted. ,%. m _< x IMEWAll construction,alterations and changes of use of any building and structures°shall compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clear) visible from access street or road and shall be maintained open for: ublic msp' Ion for the entire duration of the Mlv PY .. P P , Z work until the completion of the same. .,. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by=theBwlding andFire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:) 3,. 1.foundation or Footing �: r Rough: 2.Sheathing Inspection .._ _ 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed_- _ Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable $RECEI�'1' � �nr�tss•X�t�e'. „ 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit AP g Application No: TB-17-3104 Date Recieved: 9/8/2017 Job Location: 50 FULLER ROAD,CENTERVILLE Permit For: Building-Insulation-Residential Contractor's Name: JONATHAN N WHIPPLE State Lic. No: CS-078683 Address: Webster, MA 01670 Applicant Phone: (508) 279-1110 (Home)Owner's Name: ATLEE,KATE R D&AARON R D Phone: (508)744-6137 (Home)Owner's Address: .50 FULLER ROAD, CENTERVILLE,MA 02632 Work Description: Insulation.Air Sealing.Cellulose into that attic.Add Ventilation. 3 c "a _J- i Total Value Of Work To Be Performed: $2,066.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance-with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other•code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least,24 hours in advance. 1 � Signed: Jonathan Whipple 9/8/2017 (508)279-1110 Applicant Date. Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $2,066.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $85.00 9/8/2017 $35.00 Paypal Paypal Total Permit Fee Paid: $85.00 9/8/2017� $50.00~ Paypal _ Paypal 1 1 Town of Barnstable *Permit#V;>RI Regulatory Services ee`6nrarrhsfro l�sdate ffiasa Richard V.Scali,Director JUN 27 2017 Building Division - --- �� ������� nl Roma,Building-Commissioner--- TOWN � --- 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 _ _ . a Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number (� / 1;5 Property Address ��� �-1 �✓ 1�i�� [Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address A ` LtFE: Contractor's Name C Telephone Number :50 2;7 -So(? Lf(oLC c7 Home Improvement Contractor License#(if applicable) t o`Z$� S Email: GCc4-`j CD17 Construction Supervisor's License#(if applicable) 107 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑�am the Homeowner L'J l have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# y Copy of Insurance Compliance Certificate must accompany each permit. Permit Reque (check box) [YRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to `41e�0,_r1( 1A4JVS4—,K, ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement ntractors License&Construction Supervisors License is �uii - SIGNA Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 01/25/17 t Bct to Wk-kers' Canpens3fi=In mace Affidavit:Seders/Confimet sMechici2� ers APPEcamtImfmm2atiun Please Print Naffie Ad&ess` p � � Are� an emplayer?fheAtbe appropriate b= Type of project(regime*-- L 4. ❑I am a general contractor.mdI ' 6.-❑New oaastr uction e�agees aadfor part•trtne * IMVe hh-edtira solr -actors 2. I am a sale aF orparlaar- Tisted ontl3e attached else 7- ❑Remade3iug ship and have s s employees. , These sob-c� ha fie &,0 Demolitioa waging formn is any capacity employees andbave workere 9. ❑Building afidition ENO WodmE ' Camp.fizsurance Comp-insura+mt $ -j 5. El We are a atiflnaud ifs IOL Eleddcal repairs or af9oas 3.❑ I am a bamea�er doing a1 vs*o officemhave exercmed{heir IL0 P3nadrsagrepaim or arcid2t om My�� ri of per n i�ecrriasire recpvred„j Y�- C.�.��{4pk,�SII�We bwe YYa 13-El Other Cozp- �$ap epg€fit Host cjetUbmc#1 mast also M ca llhe swffimb9oW sibling f5ekwa&e a C=Pa saSaupaTty 6ML fi ff en a 1=mbnx dtis i*i mg OMY IlmdaiaM alYaPaaic wdd5enhEm MUWAecDUtMCA saws#snUta aesvxT13a1dt 504L fCo �3�t d�et3�i s baoc OWU#g then—Of fe sd�-=a Xa l stile VdMd eF ar=7M se emfi&esbm employee;.IfthemU c stuse aMpjDye2%dL- =V5tpWMd &ek WMkWe COMP.paw a>Mbet I am ors evipl aver dtfrt is gr ' " Q�s�r�ets'comgreras ion is rarres�vr:rc�*empPv}�es Mow is Me puEcy rurd jab sita ir��ormcrlr'vn . ksu ancecomparTName: -POficy 4 or Self im IiC. . )6 S('C)�J �7�-/ / i iaaDzde:yt C3 •��' ' lob Site Addn=: Affacch a copy of the workers?commpensationpol'rcy-declaration page(showing the poficp amber and expiration cTa4 Faih m to secure cavmaf,,.a as required under Section 25A of MQ.c.157-can lead to the iroposiliaa of cfimma!p—,,%es of a Em up to$I 50D 4U awYor one-gearimprisor—ent as well as civil penalties in the fo=of a STOP WORK ORDER and a fme o€up to$Moo a fig against the vvioLdsr. Be advised ffid a copy of this statemed maybe 5xvrarded to 11he Office of kvwfigatioas ofthe DIA far ffisuEMc,coverage Vedffimlim , Iola k�x- i P arEdrpsrraTf��'s the a f armatimprot rLcrI abates is h=and arrreGt Bate- C. t?,�1d�af�f� Da uat �tl�cfxet��r be r�rtugb�csa7 by ritp Ortan�t m�`at City or'Faww Fermifficense:9 Issuing Anfbardy(care rune): L Sward of ffwiffi BmITmg Department 3.CdyjTowa Clerk 4.Electrical Inspector S.gibing hLvectsr 6.oI&W Can€act P'ersoa: Pl�� Tuformation and Ins cons Mamsaa+ c is GeherA Laws chapter M req==-a=ploy='fn M v&was' ensB±=fir fheir eglo9ee9- ParM= ta ibis ,an nnp&Y=is defM f-A m'%m=yperson in$le service Of err um&x any mIftad of yn expo e w err finpjfi4'onI orwtf" An�k7m-is A--fined as�in 1,par►n�yq,assoaisticm�cmpm.di;oa or oii�IegaI e�tif9,or say two or more ofl±=foregoer edged is a7oiat andmc�fac Icgal rqE¢rseazfat of a dosed employer,or fie rece=iv=or traSE of an kdMdnal,parft=aslrip,MD41iion or o$crIeg-A eaditY,emP°ying eE0P1D7=S- $owevez•Hie own=ofa dw Eb ghoumhzvmgaotmare•tiraatisee-spaitmeofs aadwlm resit a ffi eia,or$lj--oaf Off=- dweIlmg Fuse of aurffiez who employs pcss®s to do m cq cz nakuz iczn w repair wont as=rh dweI1mg house or on the gm=& or b= mg 8gPar=a:Itfbe7ctD shannotbecanm of surds emp1<symedbe&cnedto be an employer:" MM cl3Bpt=-152.§25C(6)also Sty that¢every sty or local al ricensing agency slrall wittih old Ih5;vas„ce or renewal of a Tc n=or permit to operate a business or to construct bmldhV iu the commonweaI$for any appHcant-vrho hers not produced a mptahle Mldems of cumplranmwn tim YasmancrLcovetager -n AdffibDnai r,M(-xL cbaptcr I52,§25dM stains=NcI ier the conmiamwcaM nor any of its poIi=1 subd ymms shall Ito wrtd Ie evidence of comphm=with tiie inscnsncei.- • c�actftatiie �a�c=of •eeo�c stab . ealint into anY F 1� r�e�ea� � softhMchapbaveliesprese�din�c�ding.ao or�ty_" Appjic-arrlr Please f EI obt fie ems'compensation affidavit comPleb;y,by ch=YMg the boxy s tiust apply to your srtaafran and,if nmmsary,supply sob--a�s)n=e(s), aw es)andpham==ber(s)aIangw&tT:L=tea s)of ==ace. Lmmitedl mbL Y Camper(LLC)orL=tedLiabfirtY Paz iFs(1�P)' no offer than e memb=s or pminesw.,are notrbqcied to cry compensatir imsaraxic'm If as LLC or LLP does have empIoyws,apoUcyisrujcdced. Beadvisedibatthsafi ftykmaybesnbmiifcd to,ihcDepaitneaztof Ind Accidents for confnmaiinn of insraance coverage Also b ea sure to sign and dafE the�� qbe affid"v't should be•r toibe city ortownt actB=appHcatia.for fir-pemdtorH=oseisberg not fEeDepaxtM=fofhjffiistu ' j Accid� Shouldyort have any gnestians regarding the haw or ifyon are rued to obtain a worloras' coapensaiionpoTcy;ple mmaf*Drpm me2tatthemmmbezlisfedbelnw Self-M=BdcampanicssbnnIdeaMrtheir self films-nce Hc=se amber on fie 4woprisfe B= City or Town Offrcials t - Please be sru� the affidavit is cxm�le and p legibly. The Depar(menthas pmvidcd a space at the bottmn ofthr,affida�fnr youto fill outiafie=M±thc Office ofS�yesfigaf;eri�has bo c actyourega�mg73ae ap�Ti� Pleasebesureto fllinthepe Iicensesomber wMbe:usedasarefi ===mbec Inaddiinn,anagPHcm± fiat must sabmit multiple p=t ==apphtebms m arty g maTesr,need only solmnt one affidavit bwH= ing c=mt policy inf:)=afi a.Crf nxessaiy)and Tm,5 "Job 55fe Ad&e&-fbe applicant should wr>$"sII lacaiigns in (dfy or town)--A copy of tho affidwaffiat has beet offiCiaIIy wed or mazy by tho city o2 town maybe:provided to fze cruses. An&w affidavit=tstbe filled oiot earls is on file for fufire' canes or fi applican#as�onfibat a valid affidavit - P year.glherc a:home o�or cifzen is obtaining a use or permit not zr.Iafzd to arty business err commeasial vr�� (ie.adogHc:enseorpeamitinbinsIeSvzsmac.)saidpersonisI�TOTxe dtocon�Ie#ethisaffidavit Tho ormo ofTnvcsfigdkwwouldlb-,tofdiankyouiaadymmfaryavrmpperafimandsbovldyou.haveanyqursfims, - pI se do notb=italetn aveus a caIL �e]]epsrim-eats ate,�rpbome anti�aX�.bea: - ._ . �M&oil II e Te,-L 4 6I7-7 -4M eat 4€6 or I-M-M CAM Fagg 6I7=727 '74 Rzvised4-24-07 - -T 1 Town of Barnstable Regulatory Services of Richard V.Scali,Director Building Division r RAJIMMASM .Paul Roma,Building Commissioner KAM �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXE1ViP'TION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: cityhown 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\R'PMES\FORMS\building permit fonns\EXPRESS.doc 0620/16 r , H - f 4 . Town of Barnstable ` Regulatory Services Richard V.Scali,D vcWr HA88. Building Division. Paul Roma,Building Commissioner 200 Main Street,Hy=iis,MA 02601 www.town.barnstablemaus Office: 509-862-4038 Fax: 50&790-6230 Property Owner Must Complete and Sign This Section ' If Using A Builder L . ,as Owner of the subject property hereby authorize to act on my behalf in all matters relative to work authorized by this building pem31t application for: (Address of Job) ** responsibilityfences and alarms are the of the a licant Pools Pool en pp r utilized before fence is installed and all final are not to be filled o . inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date QTORNMOWNE ERMIS51021TUOIS f KELLY ROOFING INC. MA CSL #99167 PH 508 509 4640 8 RHINE ROAD. MA HIC #128957 YARMOUTHPORT MA 02675 kellyroofing@icioud.com June 06' 2017 Proposal submitted to Aaron and Kate Dunigan of 50 Fuller Road Centerville MA We propose to supply all materials and labor necessary to remove and replace the. existing asphalt roof at the address above All debris to be removed to town transfer. 8" White Aluminum drip edge to be installed on all eaves. Ice and water damage protection membrane to be installed on the first six feet of eaves, in valley areas and around all protrusions. Remainder of deck to be covered with #15 Felt Paper. Lifetime limited warranty Architect style shingle to be installed, (Color to be Specified) All shingles to be storm nailed. (6) We generally use but are not limited to Certainteed Products. Bathroom vent pipe boots to be replaced with new. Repair/Replace all flashings as necessary. i Replace Rubber Membrane Roof over rear Porch with new. Install Shingle Vent II Ridge vent on all ridges with Hand Nailed Caps. Protect all walls, windows, decks, plants, shrubs, etc. during roof strip. Complete cleanup of area during and after procedure including all nails and cleaning of gutters. Obtaining of Town Permit. At a Total Cost of $5200 Payment schedule: balance upon completion. 4 k i ky 6f N t Respectfully Submitted, Oliver Kellv. Proposal accepted by; Date 6 / 12 /2017 If acceptable please sign and remit one copy to the address above, keeping a copy for your records, this proposal is valid for 45 days from date above,.please call to verify thereafter. F 4 .p ACOI® CERTIFICATE OF LIABILITY INSURANCE DATE o5-;5-2017 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 INS PHONE Fax 9731YANNOUGH RD a No A/C No): E-MAIL HYANNIS,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:ACE AMERICAN INSURANCE CO INSURED INSURER B: KELLY ROOFING INC INSURER C: 8 RHINE RD YARMOUTHPORT,MA 02675 INSURER D: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD ( MM/DD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea oaaurence CLAIMS-MADE❑ OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JEa LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMfT $ Ea accdent ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ - AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED qOPERTY AMAGE $ AUTOS Per accede UMBRELLA LIAB OCCUR EACH OCCURRENCE $ r EXCESS LIAB HCLAIMS-MADE ,AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH_ AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTIVFN � N/A E.E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? UB 05-10-2017 05-10-2018 # (Mandatory in NH) 8H085809 EL DISEASE-EA EMPLOYEE $500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space Is required) E I TOWN OF YARMOUTH BUILDING DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 534 WINSLOW GREY RD CANCELLED BEFORE THE EXPIRATION DATE THEREOF, SOUTH YARMOUTH,MA 02664 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I -;c JOHN J.LUPICA,President ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD THE -FOLLOWING . IS/ARE THE BEST - IM,AGES FROM POOR ' QUALITY ORIGINAL (S) DATA t 5 T mawskftuse�Deparfinent of Public.Safety ' Board ofBuiidi Rations and Standards e�p� �s Est a LiCe[3S2L9`1��7 '-' , Construcfion SupervisorSpeci -} k p...HJNE AR .... k YARMOFf'H s �•.M l Jl 1Ex ►zration: Commissi ner 1 1 01T SY Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home ImprovemenContractor Registration 73 Type: Individual � `" '� Registration: 128957 KELLY i w 's Boration: 06/13/2019 - E RD �#r tlTHPORT,MA 02675 " a , _ Update Address and return card. Mark reason for change. eneeval I =» cment.D Lost CardAddre- t ; ---- '^ r:rzr�a.ccretcftl a C/jla�tac uJeff `+ Dtrke.of Consumer Affairs&Business Regulation . HME fMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. ff found return to: l€egonExpiration Office of Consumer Affairs and Business Regulation 06/13/2019 10 Park Plaza-Suite 5170 , A 02116 OLIVER M.KELLY - 8 RHINE RD. - r Not valid without signature YARMOUTHPORT,MA`02675 Undersecreta . i r -)-?I15 r Town 'f Barnstable *Permit# ® Expires 6 my the from issue dale �l Regulatory Services Fee saaxsraBs.E, ' - ' Richard V.Scali,Director 26_39. Building Division PRESS PERIWIT Tom ferry,CBO,Building Commissioner APR i 200 Main Street,Hyannis,MA 02601 16 2015 - ww—town.barnstable.ma.us TOWN OF B Office: 508-862-4038 Ug jTA81U30 EXPRESS PERMIT APPLICATIONn - RESIDENTUL ONLY er T� Not Valid without Red%Press Imprint Map/parcel Numb / (�o�Property Address S-D -Ft,-[,�e r l2 A C e h +ec'v Residential Value of Work$ I S O0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address A o-r-on U P\ �D ,F1,1I er 2C c e,+e_r V 1)e Contractor's Name P Tie-t-Telephone Number Lf Home Improvement Contractor License#(if applicable) 19/A Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ i rt a sole proprietor El 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) t ❑ Re-roof(hurricane nailed)(stripping old shingles) Ali construction debris will be taken to ❑�roof(hurricane nailed)(not stripping. Going over existing layers of roof) LJ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum .32)#of windows #of doors: El Smoke/Carboni Monoxide detectors 4 floor plans marked with red S and inspections r quired.\ Separate Electrical&Fire Permits required. *Where required: Issuance of this pernnit does not exempt.compliance with other town department rea latiens,i.e.Historic;Consen�ation,etc: - ***Note: Propc Owrtcr must sign Property Owner Letter of Permission. A py f the ldd I rovem ont ctors icense&�Const�ru'ctionSupervisors License is r quire . SIGNATURE: C:\ilsers\Decoilik'vlppData ocal' rosoft\Windows\Temporary Internet riles\Content.Outlook\�')PIOIDHR\EXPRESS.doc Revised 040215 Town ®f Barnstable Regulatory Services - �g t Richard V.Scali,Director Building Division * snsrrsrADM 1 nss Tom Perry,Building Commissioner 039. 200 Main Street, Hyannis,MA 02601 o ° www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOME ONN NER LICENSE EXEIVWnON /� � Please Print DATE: AD( 20/c I l J JOB LOCATION: -5-D F I I Qr u n�mber /� I street village ..HOMEOWNER': //�-G.ro P� D✓,,I q Oy'1 pko--L SD 4 Y4 G/3 name home phone# -,vork phone# MAILING CURRENT ADDRESS: 5-0F t R el- trw` cityhown state zip code The current exemption for"home0l3merS"was extended to include o rmer-occupied dwellings of six units or less and to alloy: homeowners to engage an individual for hire who does not possess a license;provided that the owner acts as supervisor: DEFINITION OF 11O1iIEOWNER Pcrson(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"shalt 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 un ersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection pro( u es and recce rc nt at she will comply with said procedures and requirements. S a 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. 110MEOSVNER'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. C:\Users\Decollik\AppData\Local\Microsoft\WindoNvs\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 E* c + �4rzE� � F�fC �F aaJ1a Y Boston,MA 02111 Eia Applicant Wormafion Please Prmt Le-gibt Name /-A-U CAI to A--f Le—.e Actress: F-,A 12.f 4U. 632 'City/State/zip. CE�.✓� V�' 0'n� �Z S y�g - �Cf Are you an employer?Cheek the apprmpriate boa: T of project(required): I a�$general ctnt�cts?*�d I 31� p 3 { ��� = 1.❑ l am a emplo w R ❑_ ❑,�7 eruployees(full and/or Part-time).* have.1 d the sub-o �•st� New c t tictica I —❑ i am a sole proprietor or partn�- 1i-sted on the attached sheen � 7- ❑1?emodel_in ship and have no employees There sue-contractors ha-we 8- ❑Demolition tv fbr me in sn--capacit a !oyeez and 1 :� cerv' . carlssng y 9_ ❑Building add?iog �Io wow'come insu�ce. comp.insurance,I . 3.Zd 5- ❑ ,l=e are a corporation and its 1U.❑Electrical repairs or a R I u doh all c Q ceps have exercised their 11-❑plim_r, g_r.epwu-c_r additions an"W%[i3o Worms'COW- ribt c f xempticn pr 561GE- t 2.❑R--Gf repay iusuvmce reauifed..11 c 152, 1 },as have.no etuployees.Nido ww4ous 11 L►J'"((9#1�r comp.insurance regnured.] 3w;a=g" s 4:1 a also 9311 oat ua�,e1 a= -�; ,g&Eir -,—A s'so�,y st��o goL info tEsb i a =eaaa,;who submit=his.E�viE eiry m-dais,a11'wcil and then try Out-like czntm-a-ars suh+s:a zs=afi ds€it indicz#g s cL tcantrwo--M.tnt cis t '.s'box Must stts hM m dd daw-I steel =the m�e of d e sub-cm=-Mn sad` vurhEth m w met[hose ecuries b.::e e 9lf!fe 15 the Sub-i6'_^'L*!lCtif!s L,,s a em4hy--s;?h8y SnSt pmri1je&OFF w--r$ET-'comp..gCallicy 39imber. , I,arn an einpl yer that 8 provi-Ai g ir-orken'con4mnsadon insurxa we.,ear qv enipLol em Below is the pole'fildiab site tltfiit^1rSlt�C:tt, Insurance COMPm"Y'kNia-Me: Glicy r L 1 c. `: ?cxp-ation;Bate: Job Sire Address: - uity statelZ-4p: . ttach a py of the workers'compensation policy declaration page(Shouing the.policy number and explzndon ate-)s -afiS.ve'tosecire�i��'� � as r�lx'red.under Se an 5-A of NI.��L�:c, 1521 can lend to the im-posi-t,Vn of cri T i"21 penalties o1 a fine up to S1,500.00 and/or one- ear imprison ,as urell as ci-41 penalfies in the form of a STOP IVOPa ORDER and a fine . of tip to$250.00 a day againsm the violator_ Be advised that a copy of ihii!aatemeut may be fo wed to the Office of t-vestigations of I--D1.46 xor i m-ance coverage verificanou. I do hereb--r erti ran es 1Pf s r7 h ys r� ;r ist treatt3ar i€i ar rr�ariorepr e, r/l above d true and cerr//r��rt. (\ yL-1-6 B-i O tad use a ely. Do;aril Waite in th&afaa,to be cot.op ed by eity ai tow.a tea€ ----— g� f[ �1 iF-"_ �. T$'�3ir: £'E'rF�1t+�tes¢se T . e iss A—Utht'rit?`tl:A4•tl`1.9 one".: , 1.Board of ealth 2.Building Department 3.Char rGn-a Clerk 4.Electrical Inspector 5.Plumbing,Inspector d.{lther 1� Contact Person: Phone 0: Q0 G� 3(-e o�'VKE r� Town of Barnstable *Permit# Expires 6 months from issue date �7 Regulatory Services Fee • BAMSTABM « MA & Richard V.Scali,Interim Director 1639. Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �j Not Valid without Re -Press Imprint ,Map/parcel Number /0 0 © q Property Address r gat ❑Residential Value of Work$ `J y v _ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 4 Contractor's Name Telephone Number —4pe:_ 74Y^ 613 Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) X-PRESSS PERMIT ❑Workman's Compensation Insurance Check one: 0 C T 15 2 013 ❑ a sole proprietor Q,am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE 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 ❑ roof(hurricane nailed)(not stripping. Going over existing layers of roof) ( = Re-side ❑R placement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑d 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. 4 ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement tractors License&Construction Supervisors License is quired. y "SIGNATURE-I Q:\WPFILESTO \building permit forms\E;P doc Revised 061313 0 .._ -- --- r ti T ie CommonmeaUh of Massachusetts Deparftnent ofhdusftwd Accadents 0,,Tce ofInvestigafions 600 Washington Mreet Boston,MA 02111 wwiv.Ynasmgar/dia Workers' CompensatianInsurance Affidavit:BuildersfContractorsMectricians/Plvmbers Applicant Laf irmatian Please Print Leobly Name(Il - 'on&diidual): �. mess: - ��� Ctyfstat�rz�p �s' r � q(�3 f3 " Are you an employer?Check the appropriate box: T)Te of project(required : 1._❑ I am a employer with 4. 0 I am a general contractor and I 6- ❑New construction employees(full and/or part4ime).* have hired the sub-cantractrrs. 2.-❑ I am a sole proprietor or partner- listed on the attached sheet. 7- ❑Remodeling ship and hate no employees These sub-oontractors have g- ❑Demolition, working for me many capacity_ employees and have workers' 4. ❑Building addition [No• orkers' comp.insurance comp.insurance.l 5. ❑ '%Te are a corporation and its 10..0 Electrical repairs or additions 3.VI am a home6wner doing all work officers have exercised their 11_❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12..0 Roof repairs insurance reguind_]1 c. 152, §1(4),and we havena employees [No workers' 13.:❑Other, COMP_insurance required.] *piny qT cmn that checks boa#1 mast also fill out the:section below showing their wo&ers'compensation policy nformaticn- T Ho-meowners who submit this affidavit inducting they are doing all wmk and then}tire o=de contractors host snbnrit a new affidavit iadirsting such tConhactors that rhack this bout must attached as additional sheet showing the name of the sob-touxacbots and state whether ornot those agities have employees. If the sob-conttactots hwe employees,they must provide their wakes'comp.policy number. I am an employer that is prmidirag workers'congwundfon insurance for my empLayem Belau is thepayty rind job site information. Insurance Company Name: Policy#or Self-ins.Uc.#: Expiration Date: Job Site Address: City/StatdZip- Aft$ch at 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 imprisonnent,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 vetffication- I do her.eby.,1jert9y,tinder t 'ns and hies :wry thatthe information prolided abime is t nw and correct -Y� S Bate: /5 e) 0,f cial use on[ . Da not write in th' rea,to be completed by city or town official. City or Town: PermitUcense# h,�Authority(circle one): 1.Board of Health 2.Building Department 3-CityfJ`own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other a Contact Person: Phone#: 6 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 shaII 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 subdivision 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-contractor(s)name(s),address(es)and phone number(s)along with their cert6.ncatc(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. "I'he 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 add tzon,an applicant that must submit multiple permitllicense 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 M. (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,rifled 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 lrlke 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 Massachuse,t Department of Industrial Accidents Office of lmvestigatlons 600 Washington Street Boston,IAA 02111 Tel.A 617-727-4900 w 406 or 1-9 -MASSAFE Revised 4-24 07 Fax#617-727-7749 Nv .mass-gav/dia �SNE� Town of Barnstable Regulatory Services ` AM Thomas F.Geiler,Director nsnss. fn;p+"`0� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION 2-DATE: Please Print - �� 3 _ _ JOB LOCATION: 'emu I�V N�/' �Y Ville - ' ---number street village p I ' \ / "HOMEOWI\�ER.,. �C V� i G{,o name ) home phone# work phone# CURRENT h1AILINGADDRESS: MA _ ✓ v ' '^ �lX/� I .-_,�_rity/town state zip code The current exemption for"horrieowners"was extended to include owner-occupied'dwellines of six units or less and to allow Homeowners to engage an individual for hue 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 workperformed 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 un ersigned"homeowner"certifies th he/she understands the Town of Barnstable Building Department minimum inspection pros and r ents and h e will comply with said procedures and requirements. &griatuure_f Hornrowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or Iarger 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 persons)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. C:\Users\decollil:\AppData\Local\Microsof'\Windows\Temporary Intemet Files\ContentOudook\QRE6ZUBN\EXPRFSS.doc Revised 053012 5T$ A °pTFiE T Town of Barnstable r * Regulatory Services EARN9 hUss.c g Thomas F.Geiler,Director �p 1639. rEn rna�" Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 F 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of e subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building p t (/ddb **Pool fences and alarmility of the applicant. Pools are not to be filled or utilis installed and all final inspections are performe Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 62012 f Tie Town of Barnstable *Permit# Expires 6 nuinP jrom issue date Regulatory Services Fee snntvsrasM MASS.1 $ 'Thomas F.Geiler,Director II DMA ���3011� Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 671 Property Address �j� FlA t l e.r i2.ocicr 0 2 G 3 2. Vesidential Value of Work /f?D Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address O-r ot'%, t f— Contractor's Name 0,-) Telephone Number Home Improvement Contractor License#(if applicable) /1J 1A Construction Supervisor's License#(if applicable) N E ' : l f ❑Workman's Compensation Insurance . Check one: ❑ I am a sole proprietor [rI am the Homeowner TOWN OF.BARNSTAB3�F_ ❑ 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 #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#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 requir SIGNATURE: C:\Users\decollik\AppDa ocalWicrosoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 ���Po,Faoaaa�s-c �of��ss�ac�xds,�tt�,.:��'`•'x -y De tmeret of IndustrirlAceit�deias -- -i � r e odi �-s� eaie a Al Boston,MA 0211 pHcant Infoi-mafion Pie-aw Print Legibh arxe� 'i7rga3' ti •' vit°�aa:): Address:— 50 FLA K� (Z 0 �2 +1=irvistatli� : C. r v 2 M 4 �{y — r 3 Are ycu or.emplaye£"Check the app.:arp. ate box: 1 4- I mn a gcueral contractor and I ���of project{a eq�riree�. ' ❑ I am a plo yf vvitla ❑ j employees(full and/or part-time).* a h �e mks-e�,�� 6- El New s�.st=ustrcn II I El _am a sole propri-etor or partner- listed on the attached:fit_ !- ❑A nz.ode i--g ship and lie no employees Then sub-contractors laze S. ❑Demolition ers�ees and have L_-hers' workingworking for me.in any capacity- a�lo' 9- EI.Buddiog additimi (N markers'comp-itee I ❑ 4��e are camp.iu-^are+ - cpatsed.j .a earpoat tier.and its M EI Electrcal repairs.or additions 3- 1 am a homeowner doing `I vek officers have exercised Their 11:0.Pl g repairs or wddihms myself[No workers'coax. right.of exeWtion per MGL Q.-❑Anof repay= msm*amce* _ ired 2 c_ 152,y 1(4� and:v-e have no - emplo- es-[No workers' 13-LJ thec re -5 t -\ coal-aa:sisanc reg3mred.] -+teak sat t 9�l-sum T}€.urn=owes mM mbm t ibis of da at mdizstLg am domg EU Wcih sal dim Mre au7side c ays.;an�:-sutmis:a r=-vv affidavit aadks?iag m:b- tconu mm ft-,b--',this to-=t ettu ez addis aasi 0---M sh anz-the mine of the sit:-ct�mars sad stue wtfdt:,a3 net those ead ies havE eMV!aww. IE tre s_-ca-_=ctan have emphYME,Mey oast mm*+ide ftir warke±s'ct2--p.paLr-e 4umben pert an empla yer,r3te&PM-'ti&r'sak?r,en,cverWnsad on insurance-for rrtt•Gar W5. Bede is titepaur and job Site in�at�rredir�ra Insurance Company Name: Polic-,#or Self-ins-Fie.4: Exp irah on Date- Job Site Address: CityiState/Zip- Attach a crap;of the workea s'compensation policy declaration page(showing the policy number and expiration,date). failure to seeire cm-erage as required under Ser-ion 25 A of NIGL c- 152 can lead to the itmpnss ticm of criminal penalties of a fame up to$1,500.00 andfar acne-year imrprisonment,as well as ch ii penalties in the:fora of a STOP V.-TORY,ORDER and a fme- of Lip to$7250-00 a day-against the violator- Be advised that a cop;of this statement may be forwarded to the Office of Investigations of the DI for insura nce.eov-.ge verifieation- da rasa e y ce aaa€rter tie as marl raa�i o,f;pedaaey gat far is forffio ian pr€r ided a a is sae nea:�c. �pncL j tie: Date: Iz I Z In otz. ?ro 1 l Phone r±: :4 `f L1 - 0 1 3 T Qei€al use atradJ: 1Jze raot seeaw sea,tais arraq,ta be cosraJa?ered by city or a`o.=ra affl-1-ciat i t 31 City or Town: T Lssning Authority(cuTit ore): 11 0 1.Board of Health I Building Department 3.CityiTunn desk 4.Electrical Imspector 5.Platmbing,Inspector H 9 d.a iher 3 II Contact Person: Phone#.- i AWE Town of Barnstable MLIA Regulatory Services EAW(STti "M " Thomas P.Geiler,Director '° nrvto+a Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: I ` � Z O ( ( i JOB LOCATION: (�V �� I(, I ,K Ce,4,x4er V l II e., number q street villaee "°HOMEOwNER": {�G A+rav% �vtH;gUYI t'..e t F0 e)_7 q _(0(3+ name home phone/e# work phone# CURRENT MAILING ADDRESS: S� F,-c fj e - PL__j Cam ya(e_ 02G 32 city/town state zip code The current exemption for"homeowners"was extended to include o:vner-occupied dwellings of six units or less and to allow homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Persons)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 Batnstable Building Department minimum inspection proce es and rp9u. ent&arW th t he/she will comply with said procedures and requirements. Sign1dtElfe 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(Sectiotn 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 problem,,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. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doe Revised 072110 f Town of Barnstable EVE tpy, do Regulatory Services * Thomas F.Geiler,Director * BAMSTABLE, MASS. Building.Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PERMIT# / FEE: f SHED REGISTRATION 120 square feet or less T_x Location of shed(address) Village Property owner's name Telephone number Size of Shed Map/Parcel# ignature f Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? 4 onserva6on Commission(signature required) `! S, 7 �s Y PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg r REV:121901 �7 1 ------ 1 ............ ------- --------------------- AP 188 0 8 u , ------------------ ......... ---------------------- ------ ......... ----___ ---------------------- I M 188 //Ao/ c:\conservation.dgn 7/27/2005 1:55:53 PM