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0125 GREELY AVENUE
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Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable`.ma.us Office: 508-862-4038 ' ' m F :Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - -RESIDENTIAL ONLY ot Valid without Red X-Press Imprint v Map/parcel Number Q Property Address12 , — . Residential Value of Work$ ' Minimum fee of$35:00 for work under$6000.00 Owner's Name&Address ��' ��, ��'f�!/7/r/�OG/' % Contractor's Name ��/���9� eyP .���� e4ep�one Number �F 32. G ti p or License#(if applicable) Email:`Home Improvement Contract Construction Supervisors License' #(if applicable) ❑Workman's Compensation Insurance w Check one: •, . , F ❑ am a sole proprietor ❑ am the Homeowner I have Worker's Compensati�o'Insurance U Insurance Company Name �. Workman's Comp.Policy# G�/ D�l y L 5<n G�� �/ � �, Copy of Insurance Compliance Certificate must accompany each permit w. s Permit Reque (check box) _� Y Y 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) Y ❑ Re-side ❑ Replacement Windows/doors/sliders:U-Value (maximum .32)#'of windows v; #of doors: f Smoke/Carbon Monoxide"detectors 4 floor`plans marked with red S and inspections required.'` Separate Electrical&Fire Permits required. _. *Where required: lssuance of this permit does not exempt compliance with other town department regulations,i.e.Historic;Conservation,eta . ***Note: Property Owner must sign Property Owner Letter of Permission.` ' x A copy of the Home Improv C o License&Construction Supervisors License is; required. GewG' Kl . SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 4 06/26/16 , . n e • -r4 T.. �"MET 'Town of Barnstable �4. Regulatory Services - ' i RlSn.7LTlRrF i 23AM Riclard Q.ScA nr K� Building Division 'ram rerry,Bmmd'mg Can=hsidner 200 Maim greet,HyM=3s,MA 02601 WWW towbarns4bh-ma.IIs office: 508-862-4038 F= 508-790-6230 Property Owner Must ' Complete and Sign This Section ifUSing ABuilde �© Owner of the sub'ect ra J P Pu•Y be�Iayazsthaaze ��dG� �7 ���/�� �O�!' LL�to act on b : { in all matters MbliVe to work 2.Mbo&.ed bytbis&0JIng permit appl rc on for. , (Add=s o job) Toolfences and alarms are the responsl&7of the applicant Pools are not to be filled or idled before fence is installed and all final inspections.are performed and accepted. t Sim tre of Owner S%n=m of Applicant Priur Name Pit Dame bate • - . . _ Q FDIZMS O DDIS ' 'dawn of Barnstable _ RegQIatorp Services Richard V.Sca%Director �+ RuadTQg bivbiori F Tom P rg,RM UCg OO 200 Main S(re:t Hyamis,MA a2601 QEDM� WwwrivWJ3-barIIdmhTrma Tm Office: 508-862-4-038 Fa= 508-790-62.30 H0nEXEIa'7ox per.,, - name_ h—aphanz# P�C T cuRRENT GADDREsS: _ e�jy//faiea - ¢ zip cod= The r-r,r=t=empfion for`t0-meowncrs"was extendedto mclpde owner-occupied dweIImes of six=its or less and to allow hnmeoq,ners to engage an mcividual for hirewho does notpossess a license,pi oyided that&e owner acts as supervisor_ • DSF'IIaIIC)N ORH011�O�PhTEB P mson(s)who opens a parcel of land on which helshe resides or intends to nsidq on whi ch there is,or is inteodrd to be,a one Dr two- family dwelling, attached or detached st ucta s accessory to such use and/or farm stuabn- A person who consftncts mw re than ono homy m a two--year period shall notbe cond&a- d,ahameawnm Such`hmeawner".shall submitto i1c Bm7dmg Official an a form arceptable to the Bm7dmg Of�ial,thathe/she shall be responsible for an such woke periinmed undertha bm7dm a omit (Section ID9.L1) The rmdemigned`homeowner"asses responsmi[itp fior compliance wi6ithe Staff Bm7dmg CodL and off applicable codes, byjwww...=Ir--s aad one - Thm'-an dttsign `bon=wo ":cmdaes thathelsha undmstands Town ofBazastable Bzn mg Depaitmant�=inspectirnl pmrrdMies m3d rtqahe mks andffiat helshe will comply with said pmcednros madrequizrmc�s. • Sure ofgom=o� - ' - a fam�Ty dwellings 35,000=bie feet or larg=wMberegniredto conzply'whhthe StafeBm7dmg Code Tfiiee- Section 127.0 C^^stm�-Bn CaatoL HDMMW M•s rT The Code stadrs that: a9.ay homeowner performing work for which a binding permit is required shall be exempt from the provisions of this section(Section 109_I_1-Licensing of construction Supearvisars);provided t3iat if Hie homeowner engagPS a persons)for hire to do such work that such Homeowner sha]l act as sup ervfsor.71 Many homeowners who use$iis ercrapfioa are unaware:mat ffimy are assr** h g&e respoasffiHides of a supervisor , aoricang Cntrucinn$ pervor ,Set Z_1 ) is aof awns of (seeAppedxQWes&Regv7afioL s T results.in serious problems,pardenlarly when ffie bnmwwnrr hires mTcensed persons- In WN case,Our Board cannot prove d against the u nHc=sed person as itwunId with a licensed Supervisor_ The homeowner acting as Supervisor is ultimately responsible, ifi art of tba To eumn a that ffie homeawusr is f Loy aware of hiWher respow brMt es,manywamrua es requi eas, p permit appIir!!2 n,Slat the homeowner certdy that helsh-mmaerstanas the responssbi>ites of a Supervisor. On the bstpage of egs issue is a form mrrea$y ted by several tnwm You may care t amen d and adopt such a fbrmIcertificatiou form in your mmmu>zity. P� Er sed D61313 CERTIFICATE OF LIABILITY INSURANCE} DATE(MMIDar^rm 08/29/201 g THIS CERTIFICATE 19 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 kEPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE~HOLDER. IMPORTANT: If the cerflficate holler 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 EXTRA INSURANCE EDSON H.ANDRADEMA EXTRA INSURANCE "' PHI N , (617)8a2-1335 F471 aoDREss extrare inbox.com PO BOX 65 INSUR 9 AFFORDINGCOVBR4GE NAICi! MARLBOROUGH INSUREP MA 01762 INSURER A: AIM MUTUAL INS CO 33758 INSURERS; ' TOTAL CONSTRUCTION CORP INSURERC, • INSURER D: INS ' 293 MEETING HOUSE PATH INSURER ASHLAND MA 01721 INSURER F• COVERAGES CERTIFICATE NUMBER: 80898 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. LTR tiYPEOFIN6URANCE U ARDE POLICYrgymnER POUCYEFF � EXP UPATS -. CONIa1ERCtAL GENERAL uABILITY ` EACH OCCURRENCE $ ' CLAIMS-MADE OCCUR ,.. PREMISES $ .. MED EXP An one arson) $ NIA ' PERSONAL&ADV INJURY $ GENLAGG EU R REGATMITAPPLIESPE »; GENERAL AGGREGATE - $ POLICY❑JERCT LOC PRODUCTS-OOMPIOPAGG $ OTHER: $ AUTOMOBILELIAeILnY a MBBIINDGL SINEUMIT $ ., ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED Far acaklerd) $ Auros AUTOS N/A BODILY INJURY HIREOAUTOS N ED PROPF•RTY OE $ Per amiden a $ UMBRELLA IdAB OCCUR EACH OCCURRENCE $ EXCESS LU1a CLAIMS-MADE NIA AGGREGATE $ DED RETENTIONS q WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y l N STATURE OER T ANYPROPRIETORIPARTNER/EXECLMVE EL.EACH ACCIDENT $ 500,000, . A OFFICERIMEMBERBXCLUDED4 NfA NIA NIA AWC4007033685201SA 01/10/2016 01/10/2017 (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 500,000 If describe under 0)SSCRIPT10N OF OPERATIONS bftw - E.L.DISFAS1v•POLICY LIMIT $ 1,000,000 . NIA DEsCRIPTKIN OF OPERATIONs I LocAT19N8IvgmcLES(ACORD 101,Addltlonal kwwrks 500nle,may be Waehad if more apace is required) - •- - Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts K the insured hires,or.has hired those employees outside of.Massachusetts. This cerflflcate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue dots of this certificate of insurance)- The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification, Search tool at www,mass.govr1wd/workers-compensationtlnvestigations/. CERTIFICATE HOLDEN CANCELLATION SHOULb ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ' r Plymouth development properties LLC ACCORDAMCF.WITH THE POLICYPROVISIONS. ' 70 Bradford Rd AUTHORIZED REPRESENTATIVE Weston MA 02493 "-'t Daniel.M.Crs}y,CPCU,Vice President—Residual Market—WCRISMA 0 1988-2014 ACORD CORPORATION, All rights reserved.- ACORD 25(2014101) The ACORD name and Ioao are registered marks of ACORD ®� Massachusetts Department of Public Safety' Board of Building Regulations and Standards License: CS=067393 , Construction Supervisor 1 ERNST POLYAK "► ^ 6 SALAMANDER WAY of SHARON MA 02067 � , CA— Expiration: Commissioner 06/12/2018 . rt,CJ/ze tpayroy��ruc o�C%uaaa�uaeCti� r ffice of Cdasumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 1;23637 . Type: ® xpiration zz3/20/2017 :'; Individual Ernst Polyak � Ernst Polyak 'µ ' Ai y 5 Solamander Way ;. Sharon,MA 02067. Undersecrctary trt • ?Ire Comrnarnrealth o— assacbmsetts Departiwerrt.af1nlustria1Accidews f!}fire of.£mmwtigatians. 600 Washington Streit Baston,MA 02111 ' }I�FV11LT1masmgovldia Workers' CumpensatiaFn Insurance Affidavit.BmldeimlContractarsMectricians/P'Iumbers- APPUcant Infarmaf an Please Print Levi -Name Adages City/State0jr- Phone 7c?e/ Are you an employer?Check the appropriate bo • Type of project(required); 1.❑ I am a employer with 4 C91 am a general contractor and I 6. ❑ ar Ne constriction employees(fan andfor part-time)-* 'have,hired the sub-contractors 2.❑ T am a sole proprietor or partner- listed on the attached sheet. I- E]Retnodeling s*and have no employees. . These sub-coudrac#ors have 8. ❑Demolition wotdng forme in any capaEty. employees and hne waricers' 9._El Building addition INC workers'camp.insurance. comp_insurance l - rewired] 5. ❑ 1Q❑Electrical We are a corporation and repairs or additions 3.❑ I am a homeoumer doing all work officers have-exercised their 1L Q P grepairs or additions. self o workm' �t of exemption per MGL ray [N canzp.� 1.._ Iigofrepairs fimar nce required]T a-152, §1(4�and we have no employees.(No,workers' 13.0 Other coop_insurance required-) 'Any apptiesutefut rhed ubos O.El nmst also fill m tthe sec6oabeiowshussing their wod'sere compe%mtiaapormy imformssti= #Samem mersUha subarft flm affidavu ind2ratiug they aredoing agcrones and then him outsidecontzactarsmast suhmit s newaffidaeit'mdicatine sadL ICcnmctars that checkthk box must attached au additional sbeet shouiag dan=eot the sub-cauthscto-rs snd state whether ornatthose eatitieshame emplayees.Ifthesub-contactorshaceempioyers,tW=ntpmtidetiLeir workers'tomp.policy amnber- I ant an euipToyar tthatispr4n acing workers'conumisrdion hmirance-for my enrpluyees.HaNv it tJtepoticy,and,job site' infornzergan. Insurance company flame: Policy orf-ems.Lic_ ExpirationDate: Job Site A.ddm= citylstawrip: Attach a--copy of the wort-ere compensationpolicy declaration gage(showing the poTicy,number and expiration date). Failwe to secure coverage as required.under Section 25A of I_GL t~157 can lead to the imposition of criminal penalties of a fine up#a$1,54a t)0 andfor one-ye$rimprisonmenk as well as civil penalties iu the form of a STOP WORT ORDERand a f me of up to 50-00 a day against the violator. Be adszsed that a copy of this statement maybe fx warded to the Office of Investigation of1he DIA for insurance coverage ve�frratiom I do hereby cerhfy,tzatde�r lie 'ns and n s r1'fJ to informa6mi protiritd a is fare ar:d arrest Sstntattzre: Fake: Agd - DfiTcid use.oril}. ,Do not avrrta in this axon,ter be carnpi<eted by tafp artairn a, L City or Taws• Perm itUcense# Issuing kutharity(drde one): L Board,of Health I Waing Department 3.Ci#yffown.Clerk,4 Electrical Inspector-'5.Pfuzr b- g Inspector 6.Other Contact Person: Phone#: -- - --- 6 ormation and lastruefions � Massachusetfs General Laws chapter 152 reguum all empIoyers Yn provide workers'compensation for their=plU es. t Pmsaant'to this side,an mpkyee is defined as_"_evezypersonin the service of another under any contract ofhiie, ' express or implied,oral or wriffr:rL" An e27TIoyM-is defined as"an indiviaaA partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged is a Joint enterprise,and including the gal representatives of a deceased employer,or the receiver or trustee of an individnA partnership,association or other legal entity,employing employees. However the owner of a.dweLlmg house having not more than three apadmeots and who resides therein,or the occupant ofthe - dwelIing house of another who employs persons to do maintenance,contraction or repair work.on such dweEing house or on.the grounds or other appurtenant thereto shall not because of such employment be deemed to be an employer." -MC3L chapter 152,§25C(6)also states that'every sitte or local licensing agency shall withhoId the issuance ar 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 cdmpUance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states Neither the commormeahh nor ray ofitS poIi:tical subdivisions shall enter into any contract for the performance ofpnblic work u atiL acceptable evidence of complia ace with the filsorS ce._ requsenients of this chapter have been presented to the contracting azd ozity." A-Pplicaats Please ffill.ozc t the workers' compensation affidavit completely,by checlang me boxes mat apply to your situation and,if necessary,supply sob-contractDr(s)name(s), addresses)and phone nnmber(s) along with their=tCacate(s) of n,cr a ce. Lire t LiabUity Companies(LLC)or LimitedLiabilayPartnermips(LLP)withno employees other thm the members or partners,are not mgTmed to carry work=' compensation insurance. If an LLC or LLP does bate employees,apolicy is required. Be advised that this affida: i maybe submitted to the Department of Industrial Accidents for confirmation ofiomrance coverage. Also be sure to sign and date the affidavit The affidavit should be retrmmed to the city or town that the application for the permit or license is being requested,not the Department of ; Turinct aT A_cciderds. Should you have any questions regarding the law or ifyou are regmkedto obtain a workers' compensation policy,please.call the Department at the number listed below. Self-funned companies should enter their self-ice Hcemse number on the appropriate line. City or Town Officials Please be sore that the affidavit is compleiz;andprinted legibly. The Departmenthas provided a space at the bottom of the affidavit for you t o fill out in.me event the Office Of has to contact you regarding the applicant Please,be sure to Ell in the pen�itllicemse number which will be used as a reference number. In addition,an applicant that must submit mul4le ptroat(Iiceose applibations in any given year,need only submit one affidavit mdicaimg current policy information cif necessary)and under"Job Site Ades"tie applicant should write"all locations in (city or town)_"A copy of the•affidayh that has been officially stamped or mrrked by the city or town may be provided to the applicant as-proofthat a valid affidavit is on file for fntare permits or licenses_ A new afFa&vitmust be filled olt 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 orpenuit to bum leaves etc.)said person is NOT reqaired to complete this affidavit The Office of Tnvesligaiious would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Departments address,telephone and fax n= err Depailmmt of IudilEfzal Accidents �Qt1�asbingtan Sit - B.a IAA E1 II Te,-1.#617 -4900 cxt 4-06 ox 1-.977 MASSA`F Fax 9617727 7M Revised.4-24-07 -Mass-gav/dia