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Home My WebLink About0249 HOLLY POINT ROAD ;.a TIC— Ow, M1-,$ .r. F.. ,d�.,.nfs a ::. 3.... r=+s, 1 .. ,. a: ,C. e,.. .'..• z} v... F... v'py... .. :: r a a .� rt ,- .i, r,.,,w 4�F >l. y ,.: .. _. .�f-�.,., r'U,•z Y.::S�.. .rx. ... nr3,f.;,, :,J, � .a..� ,..5. •,. .:.:�. .:. ., .,- q,:- .s_ .TS�'� 5.> b`R! sti'� "Rri fr �,�:• o-°„��,k ,, 3'�'.. test Cft y u r h &Y ,TO ° , J Ry r „ y u SOVIET Y t Aq n 1 " a } r n �� vc Town of Barnstable Building Post stedfhrs:Cacd Soht.it is�/isibie'From the,5,treetA rovetl PlansMust bye Retalnetl.on-Job antl this:Card Must be°Ke t.. !::IAETi$CA,BI$ 1 �xr Pp ,•.�x - ay- J .`€. c fp" M �P E �llntil Final'ns Made- ' Faso " , .. pection lias Been �, z Where�a Certificate-ofaOccu anc:.�s°:Re u�red such Butldm shall.Notybe Oecu ied until aFinal Ins' action has been made Permit - ., . . x.. p u.y ... q. '.. ,... ;, .....gam . .< :: :.p _..,. ., .. E .. ... .. "P Permit NO. B-19-1801 Applicant Name: Troy Walls Approvals Date Issued: 05/31/2019 Current Use: Structure Permit.Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/30/2019 Foundation: Location: 249 HOLLY POINT ROAD,CENTERVILLE Map/Lot 232 070 Zoning District: RD-1 Sheathing: Owner on Record: NELLIS,WILLIAM J &CAROLE ANNE Contractor Name TROY A WALLS Framing: 1 ' Contractor Licensees GSA 044847 Address: 249 HOLLY POINT ROAD F y 2 CENTERVILLE, MA 02632 _ , f Est Project Cost: $8,400.00 Chimney: Description: siding& 1 window Permit Fee: $42.84 �� Insulation: Project Review Req: xr Fee Paid $42.84 �3 Final: Date _ 5/31/2019 2, g £. �W (mtS19— Plumbing/Gas B Rough Plumbing: ,,,Building .� Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved applicat on rid the approved construction documeh&for whichkWs permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures��hallbe in compliance with the local zoning by laws and.codes. .This permit shall be displayed in a location clearly visible from access! !t�or•rbad and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. MP Electrical We 31 The Certificate of Occupancy will not be issued until all applicable signatures by thpiBuildmg and;Fire Officials are,provided on thispermit. Minimum of Five Call Inspections Required for All Construction Work �a r ,. Service: 1.Foundation or Footing 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 priorto Framelnspection 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 t Application number.........x... . .. Qaa Fee............................. ...... 1........................ 13uiiding Inspectors Initials... ................. 3 � 01019 Date-Issued.IAB.......�....3 ).—[I............. Ok Map/Parcel....... :..... .................... .....:....:...... • TOWN. OF BARNSTABLE _ --- EXPEDITED PERMIT APPLICATION: ROOF/SII)ING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project:' 14J 14o 0 r iDv,,c,!- 120 ��/�/f�- lz V 1 L-- NUMBER STREET VILLAGE Owner's Name: �2y L Phone Number / 5 Email Address:- C;Wo A-1ls P2 (9694,14- Cell Phone Number S/b 3 -f 7 6il94 Project cost$ 40C) Check one Residential X Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: l� Date: TYPE OF WORK Siding Windows (no header change)# I 0 Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name ( . TZ.O\T- �4 A I L5 Home Improvement Contractors Registration(if applicable)# I C>5-1 Y 9 (attach copy) Construction Supervisor's License# 0 (4 u-7 (attach copy) Email of Contractor ( �C��Ca`.C��S `' CQSi Phone number �J�U� 3 �1-Zp5— ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY-IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER..................................: :..:.:..:..`.::.......:. *For Tents Only* Date Tent(s) will be erected Removed on number of tents total 1 Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No if yes, a gas permit is required. Natural Gas Yes No ,if yes,a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. 'Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date f APPLICANT'S SIGNATURE Signature Date All perm applicati are 1�'ecjtt a building official's approval prior to issuance. Town of Barnstable 1111d111g ' P.ostThis Card SaThat it�rs,Vis�ble;FromtheStreet A roved Pfans Must be.<Retamed on'Iob antl,•this C rdMus ,<be Ke t „ , ;~ eeni�te.+ate .� a:. e'er rPosted UntilFinal'.InspecLion Has Been Made y y ,y , a Permit . Where a Certificate of Occupancy„is Required,such.Buildmg;sh;all Not be Occupied'unt�l a•F„mai Inspection,has been made, , Permit No. B-19-1801 Applicant Name: Troy Walls Approvals Date Issued: 05/31/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/30/2019 Foundation: Location: 249 HOLLY POINT ROAD,CENTERVILLE map/Lot 232 070 Zoning District: RD-1 Sheathing: Owner onAecord: NELLIS WILLIAM J&CAROLE ANNE Contractor Name�,,TROY A WALLS Framing: 1 Address: 249 HOLLY POINT ROAD `� Contractor Lk ense; CS-044847 - 2 CENTERVILLE, MA 02632 _ Est Project Cost: $8,400.00 Chimney: y Description: siding& 1 window ?' Permit Fee: $42.84 p insulation: Project Review Req. °Fee Paid $42.84 Date 5/31/2019 Final: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six mo the after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which�this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structur s s all be in compliance with the local zoning b%laws`and codes. ` Final Gas: This permit shall be displayed in a location clearly visible from access street onroad and shall be maintained open for public mspection for the entire duration of the work until the completion of the same. � - Electrical The Certificate of Occupancy will not be issued until all applicable signatures',b`y he Building and,Fire Officials are 0r0v1decI On this permit. Minimum of Five Call Inspections Required for All Construction Work. Service: 1.Foundation or Footing 5 ` 2.Sheathing Inspection X �, Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 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). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: .T' The Commonwealth of Massachusetts ..._ Department of Industrial Accidents - Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `r Please Print Legibly Name (Business/Organization/Individual): Address: �) City/State/Zip: L J� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.ZZI 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.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g• ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• $ 9. ❑Building addition [No workers' comp.insur ance comp.insurance. required.] , 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers'- 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. . I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: AA AILUAL Policy#or Self-ins.Lic.#: �xlGL ' S:y U " S60 S8-7 Zb/ Expiration Date: :1t Tf-i-__ _ Job Site Address: 2 ct l ��y t�e�T e D City/State/Zip: A,)---le y< 44A Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a- fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby rtify and th and penalties of perjury that the information provided above is true and correct Si atur Date: Phone#. Official use only. Do not write in this area,to be completed by'city or town officiaL City or Town: 1 Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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." S An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#61.7-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.gov/dia i Client#:40463 2WALLSCO DATE(MM/DDNYYY) ACORM CERTIFICATE OF LIABILITY INSURANCE 1 0 5/1 612 01 9 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: The Hilb Group of N.E.dba "�NEO 508 775-1620 a,No): 5087781218 Dowling&O'Neil Insurance Agy E-MAIL ADDRESS: P.O.BOX 1990 INSURER(S)AFFORDING COVERAGE NAIC p Hyannis,MA 02601 INSURER A:NGM Insurance Company 14788 INSURED INSURERB:Associated Employers Insurance Company 11104 Troy Walls dba Walls Construction INSURER C &Remodeling INSURER D: 87 Cranberry Lane INSURER E South Yarmouth,MA 02664-1007 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. LTR TYPE OF INSURANCE NSR WVD POLICY NUMBER ADDLSUBR POLICY EFF MM/DDY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY MPK1492X 09/14/2018 09/1412019 EACH OCCURRENCE $1 000000 CLAIMS-MADE OCCUR PREMISES Eao ence $500,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY�JECOT FX LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY M1 K1492X 9/17/2018 09/17/201 COEa Maccdent BINED SINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY Per acc dent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION$ $ B WORKERS COMPENSATION WCC60050096872018A 11/05/2018 11105/2019 X PERT T OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/" E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? F—Y] N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) **Workers Comp Information** Proprietors/Partners/Executive Officers/Members Excluded:Troy A.Walls,Sole Proprietor Burke Job#055843389 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 Shell point Mortgage Servicing SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Pg THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 10826 ACCORDANCE WITH THE POLICY PROVISIONS. Greenville,SC 29603 AUTHORIZED REPRESENTATIVE ? ' re ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S235819/M235816 RPJX1 f • Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration H M Type: Individual TROY WALLS Registration: 105179 87 CRANBERRY LANE Expiration: 07/15/2020 SOUTH YARMOUTH,MA 02664 f Update Address and Return Card. SCA 1 di 20M-05/17 r.��i-�o�itiiu�trnrrrlll r�r'6lnJ.ItrclriJc//J ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. B found return to: lReglstratiort Wirstion Office of Consumer Affairs and Business Regulation 10.5170 07/15/2020 1000 Washington Street-Suite 710 TROY WALLS Boston,MA 02118 TROY A.WALLS 87 CRANBERRY LANE SOUTH YARMOUTH,MA 02884 Undersecretary Not valid without signature 5 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrvcttb 'Supervisor CS-044847 .. expires:0 7/W 05/2�019 i p f TROY A WALLS 87 CRANBERRY LANE F; x SOUTH YARMOUTH MAr02664 +, Commissioner 4A AA OVAL �170 Pv, T .,ty111 III, IOWA } yr r '?4l wa.{.iuol, t+! wG'i w t' I l r' ..•t �� .' .,. �"� l _\>v... i� `i•I his , �. .�. 1�a• :�r , t Town of Barnstable *Permit# Expires 6 months from issue date f Regulatory Services Fee Richard V.Scali,Director Building Division'N slz �- `(�1N�� 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 sZ Not Valid without Red X-Press Imprint Map/parcel Number � D�Q _ Property Address Residential Value of Work$ �2 COD Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address CA 06Z �ir xX LL/5 J J��LL`l ni,i/T 1Z� Contractor's Name lZ©y \A L S Telephone Number !ZOS Home Improvement Contractor License#(if applicable) OggL tl7 Email: I (l�iL/ Construction Supervisor's License#(if applicable) 11 by ( 7 0Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance a Insurance Company Name Workman's Comp.Policy# 560- vrT? 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.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,i.e.Historic,Conservation,etc. ***Note: Property Owner,must sigp Property Owner Letter of Permission. A copy of t "Home Iid rove nt Contractors License&Construction Supervisors License is required. SIGNATURE: v Q:\WPFILES\FORM uildipg p it fo s\E E c Revised 040215 Tlie Commortwed th of-Vassad iusetts Depfert went o,f Ind-ostrialAccidews , i� OJ) ce ofimwnstiga ions 600 Washington Street r_ Boston,MA 02111 ?Pfm masmgovIdia Workers' Compensation Insurance Affidavit: S.nilldersiC:antracinrs/Electticians/Plumbers Applicant Inkirmatian Please Print Leeib Name(BI]CmP Address: 0) G2n;y1'y-�¢�iL;✓ City/statel :.`5 `. c, Phone 01 -s 4 y lZ o Are you an employer?Check the appropriate box: Type of project(require I d): 1.q'I am a employer mith 1 4 ❑I am a general contractor and I employees(full aud!`or part-fiime). * have hired.the sub-contractors 6. ❑New cons mction 2.ElI am a sole proprietor or partner- listed on the attached sheet, 7. ❑Remodeling ship and have no employees These smb-contractors have g. ❑Demolition wod-ing for me in any capacity. employees and have woik rs' 9.. Buildingaddition [No urorkem'camp.irm=nce comp.msuranml ❑ regnired_] 5. ❑ We.are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homecumer doing all work officers have exercised their 11.❑Plumbsngrepairs or additions myself [No workers'camp. . fight of exemption per MGL 7 c.152 § (4h 1...❑Roofrepairs _ inmxnce required j Y I andwe have�o _ employees.[No workers' 13.ENOther 5 1. 0%Xl(9— comp.insurance required-] *Azy Wficant&ac,becks box#1 I also fill outthe sectioabelow wag flmkwalere compeasatianpoHrY'iafn®sBion 1 Homeownerswho sabmFt due affidm9f huH=ug they amdaing all wal end&mbim ou=decontnctorsmast submit anew afi4davk indicating sUCIL TCaattactors lhat,.heck this bout mast attached an sddifiand sheaf sho the name of the sub-coodcsctoxs aad state whether ar not those entities have employees.If thesnb•-toatadmisbave employees,t6eymoutpmtiddet1Lgir worken'•romp.polio•number. I urra arz errrployer fleatis pro�zdir�rvarkers'conrperrsati�xrt iasriraRce,fvr�vr}*enrpTn}�ees $eIoty is#Ire pnliry and jab ritR informaliom - Ir uranceCoaztpanyi�Tame: JA k1,i2Uf,J r' Policy or Self--ins.L-ic_t WCG S7SO - 1�bo�;?•7 Z c)t (_P ExpirationDate: I, (� Job Site Address: Z L �� City/Statelzfp: Attach a copy of the wort-ers'compensa'onp.olicy declaration page-(showing the policy number and espim on 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$1,50D 00 anjifor one-yearimprisoumeut,as well as civil penalties in the fo=of a STOP WORK ORDER and a lime 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 yerification- I do thereby eryf atder ti prrr�ts cind�pSnabyes ofpedury thattTie in fbrmatimi-pro ideif abm e" b=acid earrect Sitmature: / Date: (� Phone i C ��— Offi al use only. Do not aerate in this area,to be compLeted by city ortown officiaL - City or Tomm: PertmtUcense RE Issuing Authority(circle one): L Board of Health 2.Buil fiag Department 3. ity/rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person:- - Phone#: J f 1 faformation and lnstructions r to de workers'c aiion for their employees. GeheralLaws chapter I52 req�es all e�loyers- ProYl °mFens pursamtto this sib,an.eMpLvae is defined as."_.every person in tiie service of another under any contract of hie, express or iuplied,oral or writ " An anplay�is defined as"an individual,parfnersTi�,assocnaii63 corporation or other legal entity,ar any tWo or more of the foregoing engages in a joint erterprise,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 dweEi]ag house having not more than three apartments and who resides therein,or the occupant of the - dwPT-Ting house of another who employs persons to do matntnance,c^nstru on or repair work on such dweIling ho-ase or on the grotmds or building appurb aztthereto shall notbecanse ofsach emplaymentbe deemed to be an employer." MGL chapter 152,§25C(7 also sites that"every state or local licensing agency Shan withhold the issuance or renewal of a license or permit to operate a business or to construct buildings k the Co_-Onwealth for any applic-nt who has not produced acceptable evidence of compliance with the insurance.coverage required-" Additionally.MCrL chapter 152, §25CM states-Neither the commonWwealth nor gay of ifs political subdivisions shall enter into any contract for the perfbi an ce ofpubhc woik until acceptable evidence of compliance with the insuramce.. regtm-emen±s of this chapter have been presented to the contracting authority-" Applicants Please till out the woiken'compensation affidavit completely,by checking ftLe boxes that apply to you situation and,if necessary,supply sob-contractor(s)name(s), addresses)and phone numbers) along with their cmrtificate(s) of n,crn,-a„ce. Limited Liability Companies PLC)or Limited Liabi-Lity Partnerships(LLP)with no employees other than tilt, members or partners,are not regret ed to carry workers' compensation i nsarmce- IF an LLC or LLP does have- employees, a policy is requited. Be advised fad this affidavit maybe submitted to the Department of Industrial Accidents for conffimation of insarmez coverage. Also be sure to sign and date the affidavit The affidavit should be retrmmed to!he city or town that the application for the permit or license is being requested,not the Department of Ind,. a Accidents. Should you have aay gnestions regardmg,the law or if you are requaed to obtain a workers' compensation policy,please call the Department at the number listed below.. Self-insured companies should enter their self-incur auce Rc mse number on the appropriate Ime. City or Town Offizcials . f Please be sore that the affidavit is completa and priatrd 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 per it cerise number which will be used as a reference number. In addition,an applicant that must submit multiple pemsitllicense applications in any given year,need only submit one affidavit indicating current p olicy ij l =aation(if necessary)and eider"Yob Site Address"the applicant shoT,ld write"all locations in (city or town)_"A copy ofthe-affidavit that has been officially swamped.or maiked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or liD=cs_ Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (L e_ a dog license or permit in burn leaves etc.)said person is NOT regnaed to complete this affidavit The Office of ffivesdgaiions 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 Departu ent's address,telephone and fax number -Tht C:G.MM twealtb;of Ma ssachuse,� Delta i mmt cif Licl�al Aocidenta . - �of�•�e�fig�tZo-->� 8agtan�MA G2111 T�I.4 617727-49QO Qx- 4€l6 or I-�977-MASSAFF Fax 9 617-727-77-49 Revised 4-24--07 1c,as �Qgf�a Gf OFtHE 1p� 9� MAS& ,�� Town of Barnstable 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 s Owner of the subject property 'hereby authorize '-_7—?O�� 5 to act on my behalf, T in all matters relative to work authorized by this building permit application for: A, (Address of Job) - Signatute of Owner 1 Date s Print Name ` If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side.. QAWPF1LES\F0RMS\building permit forms\EXPRESS.doc Revised 040215 Town of Barnstable Regulatory Services t` �drTHE Teti Richard V. Scali,Director Building Division BAaxsrasrE Tom Perry,Building Commissioner MASI v 16 9. 200 Main Street, Hyannis,MA 02601 QED www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: d 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 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. 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:\WPFIL.ES\FORMS\building permit forms\EXPRESS.doc Revised 040215 -- Office of Consumer Affairs and Business Regulation - 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 105170 Type: DBA Expiration: 7/16/2016 Tr0 255284 WALLS CONSTRUCTION & REMODELING ;" Troy Wails 87 CRANBERRY LANE SOUTH YARMOUTH, MA 02664 Update Address and return card.MaA reason for change. SCA 1 t'r 20M-W1t ❑ Address [-] Renewal ❑ Em ® Lost Card J"KA, vrrnn�certlU n � �u s�«zrt/3 Office of Consumer Affairs&Business Regulation License or registration valid for mdividol use only �. ME lS9PROVEMENT CONTRACTOR before the expiration date. H found return to: _ egistration: 105179 Type: Office of Consumer Affairs and Business Regulation =E piration: 7/16/2016 DBA 10 Park Plaza-Suite 5170 Boston,KA 02116 WALLS CONSTRUCTION&REMODELING Troy Walls 87CRANBERRY LANE ��a, SOUTH YARMOUTH,MA 02664 Undersecretary out ' nature Massachusetts.Deparhnent of public Safety Board of Building Regulations and Standards License:CS-044847 :a Construction Supervisor TROY A.WALLS 87 CRANRERRY LMIE SOUTH YARMOUTff 0lfA 02604 n . Expiration: Commissioner 07/06f2017 — � � — ZC-i(o TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �m. FI�I1� ff(T� j Application # II L=i C L� I_.l Health Division VV Date Issued Conservation Division FS 1 6 REC,D Application Fee Planning Dept. By Permit Fee Date Definitive Plan Approved by Planning Board - S - Historic - OKH _ Preservation/ Hyannis Project Street Address o� °/ Village Owner "S• A/ I`,, Address S. c Telephone S-e C r`f Permit Request c Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation '-� 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 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name MiEke, McCarthy Construction Telephone Number PO Box 52 Address — West Dennis, MA 02670 License# Cell (508) 280-6964 RAT� : < Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL'BE TAKEN TO SIGNATURE j' DATE -S FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCELNO. 6- ADDRESS VILLAGE x ti OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Town of Barnstable Regulatory Services Richard'V.Scab,Madar _ Biod�ng Division Tom perry,Bmldbng Comi6o3ssio.>ier 200 MakI.Shvd,Hyannis,MA 02601 www�bwo�airusfabieananst Office, 508-862-4038 _ Fax: 508-790-6230 ProperV Owner Must Complete:-a&SR 1 Ws Section Xf V A- Builder " PAY , hembp authorize to act m,b , in atl matmrs:mb in:to NO& uthonQ by this buil&ng pemricapplication for.. 02 1 ?014+ "`1?00l fences and alarms are the i�espoEnss .of the"applicant Pools are not to be:f�l+ed o.rut ized,before fence's-.I sW.W.and all final inspections am pedo ned and accepted. Signature of Ovt S IDf#0 pllLuxarI1L'; Print lvarue Q;P6RMS:0WNERPERMMSWN?00 S 1 �� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: individual ` Expiration: 6/16/2017 Tr# 264961 MICHAEL MCCARTHY- MICHAEL MCCARTHY P.O. BOX 52 '> — WEST DENNIS, MA 02670 — - _ Update Address and return card.Mark reason for change. L7i Address Renewal Employment J,.Lost Card SCA 1 20M-05/11 __. !'%fie�anirrecneurec/C�c/�?�'`al�acfaNeh`� ,• _ �\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ;: 1'69393 Type: Office of Consumer-Affairs and Business Regulation Expiration ,6/16/201:7 Individual 10 Park Plaza-Suite 5170'- Boston,MA 02116 MICHAEL MCCARTHY MICHAEL MCCARTHY =, &Notl�Mid 6 RANGLEY LN.SOUTH DENNIS,MA 02660 Undersecretary ` ith t signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License:CS-058633 MICHAEL J MCCAR - PO BOX 52 W DENNIS MA 0267 Expiration Commissioner 04/10/2016 it The Commonwealth of Massachusetts Department oflndustrialAccidents _ 1 Congress Street,Suite 100 Boston,MA 02114-2017 wn,m mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.. TO BE PILED WITH THE PERMITTING AUTH61ilTY Applicant Information Please Print Le ibly Name (Business/Organization/fndividuai): Mike McCarthy Construction ox52 Address: West iDennis, MA 02670 City/State/Zip: Cell 08)#280-6964 _ 11Ic-169393 Are you an employer?Check the appropriate box: Type of project(required): l.�am a employer with � employees(full and/or part-time). 7. El New constnuction 2.0 I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.(No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.(No workers'comp.insurance required.)1 9• ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure Ihal.all contractors either have workers'compensation insurance or are sole 11:0 Electrical repairs or additions proprietors with no employees: 12.❑Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' 13 comp.insurance.l . oo re p ❑Rfairs P 6.❑We are a corporation and its officers have exercised their right ofcxcmption per MGL c. 14. Other b✓C.f 152.§1(4),and we have no employees.[No workers'comp.insurance required.] •Any applicant that checks box it l must also fill out the scclion below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lConiractors that check this box must ellac6d an additional sheet showing the name of the sub-contractors•and slate whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. M Insurance Company Name: AT i M��"� �'� co Policy#or Self-ins.Lic.#: V�l✓L )r'r'-�O 17(S(p -ao{S� Expiration Date: 11 �rs J I 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 MGL cc 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certrfy under t a' s enalties ofperjury that the information provided above is true and correct Si ature: Date: Phone#: (YUk1 mac.-CfCr� Dfficial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - > DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12/07/2015 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 01962-001 AME:NTp CT Bryden&Sullivan Ins Agcy of Dennis Inc �I}�e,Ems; (508)398-6060 Ne,; (508)394-2267 PO Box 1497 996SS So Dennis,MA 02660 INSURER AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 33758. INSURED INSURER B: Michael McCarthy Construction Inc, INSURER P 0 Box 52 INSURER D West Dennis, MA 02670 INSURER E 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. iLTR TYPE OF INSURANCE I SPR POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES (Es RENTED $ ne e CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY. $ GENERAL AGGREGATE $ ENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY f RCOT OC COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION $ $ rMSEEAKS€ Or X T§fjAl i s cliff �yPR�p��EToR�pRT�,�E YIN E.L.EACH ACCIDENT $ '1,000,000.00 A WICEWMEMBER EXCLUO CUTNE� NIA VWC-100-6017656-2015A 12/15/2015 12/15/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 (MandatoryIInnMNB�HEd)Rs�EX LU cur UWICRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space Is required) CERTIFICATE HOLDER - CANCELLATION Cape Light Compact . PO Box 427 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Barnstable,MA 02630 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(2010105) The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION U )0 ) Ma 2 3-z Parcel C ii P Application # Health Division Date Issued Conservation Division Application Fe S Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis cProject.Street-Addressiu V"1'i_ GVillage —Ow`ner C14OP-01d AXE Address qGi NT_ Telephone Permit Request f C�m ov, C>u Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio 1 �"v 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 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coil stove:.a®Yeses No g Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ exi`s�ing ❑,new Vie_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size — Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION _ (BUILDER OR HOMEOWNER)- -- - ` -Name I_(�d�j ��c.� �� > Telephone Number_ �5oS 3q 4 lZ.[ s— y Address .-n4p-V Z,"k-ice License# 4 4 !2 4-7 Home Improvement Contractor# l 0 7 Email Worker's Compensation # _WL4 5QQ- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU E DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER . DATE OF INSPECTION: FOUNDATION ii FRAME�� 2I1j l y' - INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH l FINAL GAS: ROUGH FINAL FINAL BUILDING C - 2�Z�tS Ib DATE CLOSED OUT ASSOCIATION PLAN NO. °F4WEP01Y Town ®f Barnstable Regiflatory Services , BMWST'mLE' * Mass. Richard V. Scali Director ctor 1639 Building Division Tom Perry,Building Commissioner 200 Main Street,.Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-7907623 0 NOTICE TO THE BUILDING DIVISION OF LICENSED CONSTRUCTION SUPERVISOR ASSUMPTION OF RESPONSIBILITY S Construction Supervisor License hereby certify that I have assumed responsibility.for the project under construction as authorized bybuilding permit#-�Qu�-;ccco \ , issued to (property address) WI(A 'Dr, on , 201 The following dqcuments are.attached: copy of my Massachusetts State.Construction Supervisor's license or Homeowner's License Exemption form (if applicable) copy of my Home Improvement Contractor registration(if applicable) Commonwealth of Massachusetts Workers' Compensation Insurance Affidavit. Road Bond(if applicable) LI ENS DER. A q/forms>newcontrb rm040414 4 Town of.Barnstable Regulatory Services MASS. Richard V.Scali,Director ' .59. � Building Division w Tom Perry,Building Commissioner 20.0 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, �iQ,2EiLr ��L�t T ,as Owner of the subject property e a hereby authorize` - y l-/AL,� to act on my behalf, in all matters relative to work authorized by this building permit application for. I (Ad ss of Job) .. al.: "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. - Signature of Owner 4 Signa o ' pli ant Print Name_ T Print Name /� Da` „ Q:FORMS:O WNERPERMISSIONPOOIS J Town of Barnstable Regulatory Services oFE rOiy Richard V.Scali,Director Building Division t ReRNt.RART.,� « Tom Perry,Building Commissioner E 639- 0. 200 Main Street; Hyannis,MA 02601 www.towiLbarnstable.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: 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. 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 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 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:IYIPFILESWORMS\building permit foimslEXPRESS.doc Revised 061313 °FTHE Town of Barnstable Regulatory Services snxxsrnst.E v Mass. $ Richard V.Scali, Director 1639. • '0rfc Mc+°i 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 NOTICE TO THE BUILDING DIVISION OF " CHANGE OF CONSTRUCTION SUPERVISOR I, C, owner of property located at -_--;_ , hereby certify that is no longer . Construction Supervisor listed on the application for the project under construction as authorized,by building permit ', issued-on —25�Y• a), 20 I understand that the project under construction must cease until a successor licensed Construction Supervisor, is submitted on the records of the Building Division. PROPERTY O DATE q/forms/newcontrowner reference R-5 780 CIv1R rev:040414 Details Page 1 of 1 Licensee Details Demographic Information Full Name: TROY A WALLS Gender: Owner Name: License Address Information Address: Address 2: City: South Yarmouth ' State: MA ipcode: 02664 Country: United States License Information License No: CS-044847 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 7/23/2015 Issue Date- Expiration Date: 7/5/2017 License Status: Active Today's Date: 8/6/2015. Secondary License: Doing Business As: Status Change: License Renewal Prerequisite Information No Prerequisite Information Discipline No Discipline Information Documentum http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_i... 8/6%2015 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 105179 - t a Type: DBA O;. � 7 Expiration: 7/16/2016 Tr# 255284 WALLS CONSTRUCTION & REMODELING m Troy Walls- -_ 87 CRANBERRY LANE = { SOUTH YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. SCA I Co 20M-05/11 [] Address Renewal Employment Lost Car Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: :105179 Type: Office of Consumer Affairs and Business Regulation xpi ration: 7/16/2016 DBA 10 Park Plaza-Suite 5170 Boston,MA 021.16 WALLS CONSTRUCTION,&REMQQELING F Troy Walls ablid 87CRANBERRY LANE SOUTH YARMOUTH,MA 02664Uudersecreta '� bout ' nature T71e Comrllorrivealth of-Hassa iusetts Deparmment o,flndustiial Acccdews r� l�,- we of lmw sfigaftons 600 Washington Street _ Boston,4 02111 nt-'1Vn1.mass.,go Idlll Workers, Compensation Insurance Affidavit Boil'derslContractors/EIecfricianslPlumbers Applicant Infcarmatian Please Print F,ei?ibly Name Addrtss CitylStatel - l-� P}ioae i Z Are you an employer?Checkthe appropriate box: ' Type of project(required): 1_,4I am a employer with t 4 ❑I am a general contractor and I employees(fish aridfor part-time),* have hired the sub-contactors 6- ❑New construction listed on the attached sheet 7. gremoeling 2.El I am a sole groprietur or partner- R d . ship and have no employees. These sub-contractars have. $.,❑Demolition w a for a in an capacity. employees andhne workers' o. �n. y 9- ,❑Building addition: nr[No orkars' camp.insurance camp.insurattt # required-] 5. ❑ We.are a corporation and its 10.El Electrical repairs or additions � 1 3.❑ I am.a homeoumer doing all work officers have exercised their 11.❑Plumbingrepairs or additions myself[No workers'Comp- right of exemption per MGL 12_❑Roofrepairs insurance required.]i c. 152,§1M andwe have no employees.[No workers' 13.❑Other , comp.insurance required.] 'Any app&mt bat checks'bos#1 mast also fi l out the section below slsoRiag i L&tunr]leis'ca mpematia'a policy iafonmau= #Homeowners who submit diis affidavu;ndkztmz they am doing all waal sad then him outside contmaorsmst sa'6mit anew affidavit indicating Well ZCantractoesthst cbec3cibis box mast attached an additional sheet showing the name of the sub-coau mclurs sad stale whether or not those enfitieshave employees.IMesub-contiaaaeshive employees,they mustpxuuide their workers'comp.policy number- I am an employwr that isprn ding workers'compaisafiun inmiranc4rfor my etrrproyees Below is the poficy and job rife information.Insurance Company Name: AIIA� L Policy#or Self ius_Lic_ CL W C� �( .'797•2©f 5 Rxpiratio'n Date: l l Z/ Job SiteAddre&-.: �{4 0�.�� r�/,�y City/StitelTM: 4:: �J i- Aftach a copy of the workers'compensationpolicy declaration page(showing the policy number and expiration date). re Failure to secu coverage as.required.under Section 25A of MGT-c_ 157 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and:'or one-year imprisonments as well as ciml penalties.in the form of a STOP WORK ORDER and a fine s of up to$250_00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage ver Ecation_ I d'o here-by�a i" ,mr, r tice p�ri r ,gFrjat}thatdre iqformada7s prmided a �e'.tru8 and correct Si Bate: Phone ct Z Of ciaL use only. �Do not aFrite in fFi€s urea,to be ctrtnpletced by city artotr�n a ffeiat City or To-nu: Permitffikense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical inspector S.Plumbing Inspector ' 6.Othe7• Contact Person: Phone#: r Taforma ion and Instruct our eral Laws 152 all I err is 'de worisers'compensation for their employees. M�crarhusefts Gels chapter reputes emp oy Pry omP Pursuantto this statute,an e F&5I ee is d$Imed as_6_.everypersonin the service of another under any contract of ire, express or implied,mal or written." An employer is defined as"an individual,partamrship,association,corporation or other legal eatify,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 as individual,pa tnersbip,association or otherlegal entity,employing employees. However the owner of a dwelling house having not more thhan three apadmeuts and who resides therein,or the occapant of the - dwelling house of audher who employs persons to do mahtmaace,construction or repair work on such dwelling house or on the grounds orbuildng appurtenant thereto sh all notbecanse of such employment be deemedto be an employer." MGL chapter 152,§25C(6)also states that"every statE or local licensing agency shall withhold the imance or renewal of a license or permit to operate a business or to construct bnildmgs in the commonwealth for any applicant who.has not produced acceptable evidence of compliance with the insurance-coverage require.1" Additionally,MGL chapter 152,§25dM states"Neither the commonwealth nor nay ofits political subdivisions shall enter into any contract for the perfoimaam ofpubho work until acceptable evidence of compliance with the ins rrancd._ reqLdrenients of this chapter have Been presented to the contracting authority." A-pplicants Please fill oirt the workers'compensation affidavit completely,by checT ihe boxes that apply to your sitaadon and,if necessary,supply sub-contractor(s)name(s), address(es)and phone numbers)along with their c d ficate(s) of in crrra c Lmmited Liability Companies(LLC) or Limited Liab�ity 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 a.ffidayit may be submitted to the Department of Industrial Accidents for confirmation of in.saran ce coverage. Also be sure to sign and date sre affidavit. The affidavit should be retrrmed to time city or town that the application for the pemait or license is being requested,not the Department of Ln-dnstiai Accidents. Should you have any questions regmdmg'the law or ifyou Ea e repaired to obtain a workers'. compensation policy,please caIl the Department at the number listed below. Self-insured companies should enter their self-fi surance IicemD number on the appropriate line. City or Town Officials f Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at tht: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 pmnit/Iicense number which will be used as a reference number. In addition, an applicant that must submit multiple perm.itJI D=e,applications in any given year,need only submit one affidavit indicating cnzrent policy inlfbmation Cif necessary)and under"Job Site Ad±ress"the applicant should write"all locations in (cry or town)_'A copy of the affidavit that has been officially stamped or maiked by the city.or taws may be provided to the ' applicant as proofthat a valid affidavit is on file for future permits or licenses A new affidavit must be filed out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial vent n-C (ie. a dog license or permit to bum leaves err:.)said person is NOT required to complete this affidavit The Office of lavesiigadons would at 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 CmmoawmZth of Massaohus:�-tts DegarC�nent czf 1rid�s�ia1 Aacid�nt~ - �r<e 6QQ Washington.St=t Bastw-.,MA G2111 ` (,-L 4 617 727-49W(',Xt 406 or 1-9 MASS-� Fax#617` 27-7749 Revised¢24-G7 mash gagf dia Client#:40463 2WALLSC O CORDIM - CERTIFICATE OF LIABILITY INSURANCE DAIE(MM/D°/YYYY' 8/0612015 IS 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). PHODUCER CONTACT NAME: Dowling&O'Neil PHONE 508 775-1620 'A" 5087781218 (A/C,Nu,EAI): (AIC,Nu): Insurance Agency E-MAIL ADDRESS: 973 lyannough Rd., PO Box 1990 INSURERI3)AFFORDING COVERAGE NAIL 8 Hyannis, MA 02601 INSURER A:National Grange Mutual Insuranc INSUKED - - INSURER B:Associated Employers Insurance Troy Walls dba Walls Construction &Remodeling .. - INSURER C: 87 Cranberry Lane INSURER o: / INSUKEK E South Yarmouth, MA 02664-1007 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. NOTWTHSTANDING 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. SK TYPE OF INSURANCE INSR WVD POLICY NUMBER. (MM UU/YYYY) (nPiM/DD/YYYY) LIMITS A GENERALLIAtlw1Y MPK1492X 9/14/2014 09/14/201 $1 000 000 X COMMERCIALCENERAL L"BILITY DAMAGE T11 RENTED - rrcrMl;yr;i $500 000 Cl AIM',;.MAI)I- n CJCCJIIK MFI1 FXF'(Any mr..prr..nn) $10,000 rFM;0NAI R Al1V IN.IIIHY $1 000 000 GENEnALAGGREGATE $2,000,000 C*-N9 ACiGHfAAIFI IMII APVI IHi Nf K: VKCJI)11(:IR-COME'/ON AGG s2,000,000 F-IrOLICYF 2:11- LOC $ AU OMOtldE LIAl9LIIY C0MHINHJ',;IN61 F I IMI I (Eeecudenq $ ANY AUTO BODILY INJURY(re,yeleuu) $ ALL OWNED SCHEDULED HC11111 Y IN.IIIKY(Prr arr.lArnQ $ Al l I b:; Al l 10,; NON-OWNH1 S F'H(]F'FK IY IIAMAGI,- MIRED AUTOS All l iJ',; , r'a euuidei11 $ $ UMtlKELLA LIAM occun I-ACH OCCA WRI-NC- $ " EXCESS LIAB CLAIMS-MADE ) AGGREGATE $ DED RETENTION $ B WORANDICERS PLOYI:COMPENSATION WCC50050095872014A 1/05/2014 11/05/201 X jokyIinm,is �-k .' f AND EMPLOYERS'LIAtlIL11Y ANY NKCINKII-ICJKMAKINFWF%F(:111 IVF Y/N - - E.L.EACH ACCIDENT $SOO OOO OFFICER/MEMBER EXCLUDED? 7 MIA (Mandatory In NK) ... F.I•111SHAi4-FA FMVI CJYFF $500 000 If yes,deuulibe undid . 19-SCKIP l ION OI-OPI-KAI ION;;hrinw E.L.DISEASE-r OLICY LIMIT $500,000 DESCRIP I ION OF OPERA I IONS/LOCA I IONS/VEHICLES(AWIch ACOKU 101,Addtllonml Namarks Schadula,If more space Is raqulrad) Workers Comp Information Voluntary Compensation Proprietors/Partners/Executive Officers/Members Excluded' ,. Troy A. Walls, Sole Proprietor Insurance coverage is limited to the terms;conditions,exclusions,other limitations and endorsements-` (See Attached Descriptions) ' CERTIFICATE HOLDER CANCELLATION r Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBBD POLICIES BE CANCyE�L D BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE 'lJtsLIVERED IN 200 Main Street ACCORDANCE WR'H THE POLICYJPROVISIONe� Hyannis, MA 02601 AU I NOKIGED KEPKESEN I A I Wit @ 19M2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010I05) 1 Of.2 The ACORD name and logo are registered marks of ACORD #S155610/M155609 CBD ` ` ` ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Zn Parcel Application # cO& l S Si Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village Owner , A. tI I-, Address S��c Telephone 4-1 7—C t Permit Request �Jc1_14%CV14'I )o Ce,I�„�� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed � Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family p/ 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 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other w Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woo°d/coal stove: L`des ❑ No L Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn:`'O0xisting"D new size_ Attached garage: ❑existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: t Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ' Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Mike A40_r_n h3, Constrict} Telephone Number PO Box 52 Address o�,�,,�,. 2670 License # Cell (508) 280-6964 Home Improvement Contractor# Email Worker's'Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 7L-)- 7 )' L t FOR OFFICIAL USE ONLY " q . APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION ' r FIREPLACE y ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. O. Town.of Barnstable R%tp-Watory Services t` ,� Bn�dn�g Division . Tom Parry,Bo tdIng,Comm loner 200M&.Sft4 Hyannis,MA_02601 W W W town.barnstablema os Office: 508462-4038. Fax: 508-790-6230 PrVprty Owner omrp q&and$--ign This Sectfon If Um-,&ABuilder I, as Owner:o#:fie sob Pp�Y hereby;authorize01% in6 ta.acc pig ury blalf,. all matters relative m wodc a xthonU by this bmId'nS Pern°u application for. V .2 4-J)q ?. M+ &� "Ve- MA Add�si `3 o-�, `Pool fences and alarms are the iesponsl*..* .of the applicant Pools are not id be fiDed'oruxlazed before fence is.ins6a and all final inspeCtons are petfonaed.and accepted. Sipuature of p cant \44 -16 e 11; Wj Pria[c Name .Print Name D Q.FORMS:OWNRRPF.RMaS O NP40IS d as i "7 a� Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-058633 MICHAEL J MCCAR PO BOX 52 W DENNIS MA 0267 , Expiration Commissioner 04/10/2016 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual i Expiratio /2017 Tr# 264961 MICHAEL MCCARTHYg MICHAEL MCCARTHY r P.O. BOX 52 -- _ — - WEST DENNIS, MA 02670 ` = -- ----- ` Update Ad ess and return card.Mark reason for change. 20M-05n1 Address Renewal j Employment Lost Card _.4 The Common►vealtlt ofMassaehttsetts Department of Infitstrial.Aceidents - I Congress Street,Suite 100 Boston,111A,02114-2017 Ivfvlv.mass govAlia 117orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Pitimbers. TO BE i'IT,ED WITH THE Pl'RYIITTING AUTHORITY. Applicant Information Mike c a lease Print Le ibl y Narne (Business/Organization/Individual): „O BON 52 Address: West Dennis, MA 02670 e280-6964 City/State/Zip: r L-5$16W#: HIC-169393 Are yoy an employer?Check theapropriate box: Lrl'QY/ Type of project(required): 1. 1 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. 1 am a homeowner doing all work myself 1 9. ❑Demolition ❑ g y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp,igsumnce.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MOL c. 14.90ther 152,§1(4),and we have no employees.[No workers'comp.,insurance required.] *Any applicant that checks box#[.must also fill out the section below showing'their workers'compensation policy informalion. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, iContractors that check this box must attached 9n additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'cornpensation ins►trance for my employees. Belo►v Is the policy Unit job site Information. �[ M Insurance Company Name: / ' / (J"J'1 Tn5 IM92s,� Policy#or Self-ins.Lic.#: V l�C�, �- t�i I(S'C aai�( �j Expiration Date: Job Site Address: (h �- City/State/Zip: Attach a copy of the workers'compensation olicy declaration page(Showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. - I do hereby certify tin tl ni s and allies rjtrry that th ei-information provided abore is trite and correct. Si nature: Date: 1 1 - Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORM 'PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusefts 01803-0970 (800)876-2765 NCCI NO 26158 POLICY NO. VWC-100-6017656-2014B PRIOR NO. I VWC-100-6017656-2014A ITEM 1. The Insured: Michael McCarthy Construction Inc DBA: Mailing address: P O Box 52 FEIN:**-***3862 West Dennis, MA 02670 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 12/15/2014 to 12/15/2015 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000,each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease. $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration .Remuneration Premium INTEA 0712979 INTER SEE CLASS CODE SCHEDU E Minimum Premium $550 Total Estimated Annual Premium $29,332 GOV GOV Deposit Premium $7,748 STATE CLASS MA 5479 State Assessments/Surcharges $28,601.00 x 5.8000% $1,659 This policy, including all endorsements,is hereby countersigned b � 9 Y 12/15/2014 Authorized Signature Date Service Office: Bryden&Sullivan Ins Agcy of Dennis Inc 54 Third Avenue PO Box 1497 Burlington MA 01803 So Dennis, MA 02660 F�� WC 00 00 01 A(7-11)Includes copyrighted material of the National Council on Compensation Insurance,used with Its nermissinn. • „ ' r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel V 0 Application dal Health Division Date Issued l/1-bS Conservation Division Application Fee Planning Dept. Permit Fee 4� Date Definitive Plan Approved by Planning Board Historic - OKH — Preservation / Hyannis Project Street Address �`� 9 A J�� a`"� Awl Village 64-�V' �- Owner �� YJ Address Telephone 5` u -1 -7- 1 4,9-y Permit Request (,Vzd p 4,, f - ram•..t� F /- ( c'ei/� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation o2 0.0 0,JA�> Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) y . Age of Existing Structure Historic House: ❑Yes ❑ No On Old King. ighway:. ❑YeT- ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) _ cn Number of Baths: Full: existing new Half: existing new3 1 Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use �-- APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name y3� C('°'J Telephone Number -5"D �� - -5't, Address �� "`� 6 ' License# CS 2 S 2, Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE /Z// x FOR OFFICIAL USE ONLY 4 t J4PPLICATION# DATE ISSUED 5- MAP/PARCEL NO. 1. Y t j ADDRESS VILLAGE f OWNER t` DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE _ E 'i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL f F FINAL BUILDING S 12J 7 /se l DATE CLOSED OUT - ASSOCIATION PLAN NO: Tfw Cw mm=h*gfMassac.hrrsr y_ Dqwftmt qf1wdkY&id Accidenls 00 W ba SWee� Bosfvvs MA 02 wt4nu.t�e�g-vt�r�rc� Wurkersa Campe=fFuu TasuranceAf'fidav-EL-Seders/ tract-ors/Elecfrici &=umbers Applicant l farmation Please Fir ihly ISFa. Add,,,, city -&Zip: - y Phones Are you an employer?Check the apprGpTiate btk= T � a ect r �_ I�a ci�nficactar and I 33'e �'. I ��= L❑ I am a employer with ❑ � �_ ❑Nv amployaes{full a4dforpm-time * fra hires the sub co $ofzxs 7_[ I am a StAe proptidor orpartuer listed on the attached shut F_ ❑ReMadeiing ship sod have no employees Z sob aoutrsctozg have g- ❑Demolitioaz voting forme many capacity eu3playee and have workers' Q_ .❑$uilcimg addition UNo w 2>�S' camp_insurance comp-insurarrr¢l 1 5_ ❑ We area corporaticnandits 10-oElecEricalrepRTTY.Craddifians 3_❑ I am a homt ner doing aH work exru;sed their I1E Plumbing repairs ar additions of exemption per MGl myself [No�u�kara'�1P- right, 12-0 oaf repairs ituz ur n_ce required].l C.15Z §1(4),andwe frssna ua l3'_❑other empl0u�_wa wodon& . comp_ins=ance r5qntred_1 - *gzxywp that checksbos�1wm alsof. out the section b9owshawing their wodcets'c mp—tiaupaIic3 �fit¢i o-metxwne�s crlx srbm hiss d� i icatiag y a e mine=II t-^ te_h aside cont 7CIm Est mibmit a new ai5da dt inaa i=such orsrthstcheckthisbucmuststffichedm:a6;hansasheetshowing die mareof62sxkt- Ls and state whether ornmt$fuseezrtitiesSave emgloysrs_ If the soIr<aUtXa=S haze easplayee.%they m1Lst provide theme Vvuk s'tamp.Policy mm>ber_ lam Betvtr is ffte pvZic}cucd job site ir�orrr�mfiatt. ii Insurance Comp auyNam: P-0ficy#or Self-ins_Iic.# Fxpiiatio.0 Date.` Job SiJ32.AAdress. Citys atelZrp_ Ati ach a copy of the vmrkers'cbrapeusatirm poiiLT declaration page-(shzNving the policy number and expiration date): Fa7um to secure-caverage as required nsrder Sectioaz SA ofMGL c 152 can lead to tb e imp=ilion of rriminal peaaldes of a fine up to L 50(}:Ol?and/or one pearimpris as well as cizrsl pesa16 - the fumm of a STOP WORK ORDER-and a fine ' of up to V-50.00 a day against the violator_ Be advised that a r-Dpy of this statement may be fxwarded to fhe Of-Mee of Inve:stigatiom of the DIET€or insm-anm coverage itriic diorL I do h6reb 'c�rfffp order tkaptatis curd penahties ofFeo'rr3'thatfha unj vnrcer#ian prm2ded rube e is hiss and caFrsct 33ate , /1 phone g- Qf citd use unly. Ikr not wrihr in this area,fa bg camplew by c h�or town u ficuML. . City or Toww rt=r Mir Uamse# L Buard of Health 2.RuMing Depactrneut I Ciiia'Ftxtsar CQesk 4. Iechcical luspec#ur 5,.Pfumbi tor 6.Other Cantact Person: PIFo-ne#: 5 Massa&ausdts General Laws chapter 152 requires all employers to provide workers'compensation far their employees- Pmmant-to this s`at ,an errzp£oyee is defined as`-every person in the seavice of another tinder any contract of,hf% express Cr implied, oral.orwritti- " { An�joyur is drfned as'an individual,partnership,association,corpozaiion or other legal enfiiy,or any two or more of the foregoing engaged in a joint enterprise;and includi gthe legal representatives of a deceased employer,-or the receives or trustee of an individual,partneship,association or other legal entity,employing employees. However the owner of a dweIImg house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs pesons to do maintenance,mnstnnction 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." MCrL chapter 152, §25C(6 also stafas that'every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in.the commonwealth for_auy applicant who has not produced acceptable evidence of compliance with the insurance.coverage required.' Additionally, MGL chapter 152, §25C(7 states`Ntithm the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the in�rn'ance requirements of this chapter have been presented to the.contracting authority.' Applicants Please fill out the woikers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), addresses) and phone number(s)along with heir certifcatis) of in= ce. Limited Liability Companies(LLC) or Limited Liability Partnerships(=)With Do employees other than the members or partn=s,are notregnired to carry workers' compensation insane. If an LLC or LLP does have employees;a poliq is requitecL Be advised that this affidavit may be submitted to the Deparbnmt of Industrial Accidents for confirmation of in cttr m coverage. Also be wire to sign and date the affidavit The affidavit should be retuned to the city or tcnm that the application for the permit or license is being requested,not the Department of lndustrial Accidents. Should you bane any questions regarding the law or if you are required to obtain a workers' compensafion policy,please call the Department at the number listed below. Self-ii=n d compani es should enter their self-in=nce license number on the appropriate lime. 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 Hl in the pea itllicense number which will be used as a reference number. In add=won,an applicant that must submit multiple pm nitlIicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under',job Site Address"the applicant should wiite"all locations is (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtanamg 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 mqui ed to complete this affidavit- The Office of Investigations would like to thank you in advance for your cooperafion and should you have any questions, please do.not hesitate to givens a call . The Department's address,telephone and fax number ` Tht CommanwUIth of Massachus tks Dc��e t Gf Indt>stdal Awide�ats affire of kv4gagatiGm 6 wa mgtan Td..f4 6I7 727- 9-�5 w±466 ar I-&'7 hLk3 E: . Fa# 617-727-' 4 Revised 4-24-0 I W 4 Yt� o�dia Town of Barnstable Regulatory Services - 9anxr' igg Richard V.Scali,Director 1639. �ArFOMpIA,O Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ina.us Office: 508-862-4038 - -•• - Fax: 508-790-6230 _. Property Owner Must Complete and Sign This Section If Using A Builder ' A411111 ,as Owner of the`subject property hereby authorize ri L4� to act on my behalf, in all matters relative to work authorized by this building permit application for. (Ad ss 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. ig afar o Owner Signa e o plicant Print Name y Print Name Date ' Q:FORMS:O WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services TxE rolyy Richard V.Scali,Director Building Division IARNST"M Tom Perry,Building Commissioner 16 200 Main Street, Hyannis,MA 02601 RFD MA'I a www.town.barnstable.ma.us -•_ Office:' 508-862-4038 - -_--Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: _ - number strut 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&ReguIations for Licensing Construction Supervisors,Section 2.1S) 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 fbnns\EXPRESS.doc Revised 061313 r-71� 0/ R _ = Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 141496 ' Type: DBA Expiration: 4/26/2016 Tr# 51426 CONGRO REMODELING BASIL CONGRO 7 DANA RD. FORESTDALE, MA 02644 Update Address and return card.Mark reason for change. Address F] Renewal E] Employment Lost Card SCA 1 C 20M•05/11 �1/eyi�rn,rnrr�ae�cl(�a 'c?/l��c:ranc/rrac�fi License or registration valid for individul use only Office of Consumer Affairs&Business Regulation g ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ,egistration: 141496 Type: Office of Consumer Affairs and Business Regulation xpiration 4/26/2016 , DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 CONGRO REMODELING BASIL CONGRO 7 DANA RD. FORESTDALE, MA 02644' Undersecretary , Not valid i ou si nature Massachusetts -Department of Pi..,.:_ Safety Bozrd of Building Regulations and Standards rnnstruc.tion supenisor License CS-082529-'of BASIL J'CONGRC 7 DANA RD , FORESTD:ALE 1V3A 02Ga41a Ex pirati9n 3 211-0/2615 1 ' 1 s . _ 1 41 t 1 4-4 -i`--�^^---*---'-i----`i----� •_._. _...a.__-.+_—w�:�(-.:-. _/�,._..,T- _� �..-�+ ----i- �._ ....;.F.--.-, `_-. -..-tip..... � ', )� —,.,a.*... � t , _.'_�..__,..--._-1.__ -.. -5:'.-^t:'-�--F ' ,.—}— -� - 1-.--'J-- � 1. i^--.#.. .' -- - -'-•i ---+ - '---" .. .i 113 11 It f-'--- � --� ! --,--t--; --;•-L•� ��-��' .Z__Np�-CIS � �--; '---i.-NS'�,�,t�. �. __ ��_;_-____�._._._.;�� --,•.__�.�.-;--_ { i { i 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION y p074 / ,q 7- � t �� L pp W� 6 Ma Parcel �� O (kj�_ < Application # Health Division Date Issued xj Conservation Division Application Fee Planning Dept. Permit Fee 4 4qr'! Date Definitive Plan Approved by Planning BoardI ' Historic - OKH _ Preservation / Hyannis Project Street Le �Lf� b `l� &Ioi f Village�ki f-W V1/lc Owner 1�4 0!& Nellis Address -2- /X I fo 12 Telephone 6,5-10) Y`f-7 - 1,,/kN / /_ Permit Request Add b4A a-vr1 4 /V W-e� f,V L',l d� /l owt"t. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay k d Project Valuation �. . r tT 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 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) : - -- - Name _ S1 -1 Telephone Number Address -7 i)4" License # Home Improvement Contractor# n J, Email 0�t C e"gYP �✓ C��iS-'.4 ET Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ,gou rn e SIGNATURE DATE /,// t FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED 4 MAP/PARCELNO: r + ADDRESS VILLAGE k OWNER t DATE OF INSPECTION: FOUNDATION FRAME I i j- INSULATION W i FIREPLACE t ELECTRICAL: ROUGH FINAL 1 y PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ` EINAL BUILDING 4 DATE CLOSED OUT a ASSOCIATION PLAN NO. t' c F 2,5 IJ Hie Comynonnste*h off assachuseffs Deepartnrent ofladmsb al Accidents Office o,f InVeStkalioru' e 600 fnshutgton Street Ifastan,MA 02111 wtcnv.inass:gmtldia Wor-ker-s' Compensat GnInsuranceAffidavit:Bualders/Contra:ctorsMectricians/Plumbers Applicant Infarmatiun Please Print Legibly Name 03usim Orp izationlfndividual)_ Address. City/stat:e/Zip= Ke5 Phone 47 Are you an employer?Check the appropriate boa; T of.project(required): 4. I hire a contractor aizc I �� J 1.❑ I am a employer with ❑ 1 6- ❑New construction ` employees(full andlorpart-time)* have hired the sub-contractors. 2-9 I am a sole proprietor or partner- listed on the attached sheet_ 7- rA Remodeling slop and bane no employees These sub-contractors have g_ ❑Demolition working forme many capacity employees and have workers' 4_ ❑Building addition [No workers, comp_ins nce comp-insurance-1 required_] 5_❑ We are a corporation and its 10_❑Electrical repairs or additions 1❑ I am a homeowner doing all work ofcers leave exercised their I1_❑Plumbing repairs or additions myself [No workers'comp_ right:of esemptionper MGL 12. Roof repaim insurance r F c_152, §1(4),and.we ham no ❑ required-] I311 Other employees-[No work�ess' . comp_insurance required_]. * uy appEcawnt that cbed€s boa-1 must also fill out the section below shnwing-heir wmkers'coaspensatian policy infiurmadan_ T Homeowners who submit this affidavft indicat ieg they are daimg RR tsorld and then hag outside coutractnrs most submit a nzw afd3vit indicsiing such- £Cmtdacturs-dw check this box must sttached as addifitmA sheet shnuvrg the name of ffie salt-camas and state whether oc not those lilies have ealployees. If the sulr-contractors hate employees,they must provide their workers'comp,policy numbez -Tam an empk�wr that is prmidiag workers'campenswtion insurance for my employees. Relaw is the policy and job site information. Insurance Company Name: Policy#or Self-ins-Uc-4. Expiration.Date: Job Site Address: qq City,'Stat&47 //k4' Attache.acopy of the workers'compensation policy declaration page(shaming the policy number and expiration date). Failure to secure covet$ge as required.under Section 25A of MGL c_ 152 can lead to the imposition of'criminal penalties of a fine up to$1,50G.OG and/or one-year iuTr soammt,as well as civil penalties is the form of a STOP WORK ORDERand a fine of up to V50.O0 a day against the violator_ Be advised that a copy of this statement may be forwarded to the Office of Imestigations of the DIA far insurance coverage veriEcation- I do hereby cerh;fy tinder the pains andpenalt es o-]`penury that the inf orrnatipn pratided abm a is bus and carrect Signature: Bate_ Phone#: 2- Official use only. Da not write in this:area,to be completed by city or town official City or Town:. Permit/License# Ls wing Authority(circle one): 1.Board of Health 2.Budding Department 3.Citylrown(Jerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#_ 6 c� Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to tLis 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 s`atas that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth,`.or;uzy 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 aibdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." ---Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), addresses)and phone numbers)along with their ce]_dficate(s)of insurance. Limited Liability CompaDies(LLC) or Limited Liability Partnerships(LLP)with no ean-ployees other than the members or partners,are not required to cant'workers' compensation insurance- If an LLC or LLP does have employees, a policy is required- De 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. 71re 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 Depz._rtment at the number listed below. Sell 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 permitJiicense number which will be used as a reference number. �Ia addition,an applicant. that must submit multiple pen mtllicerse applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be`provided to the applicant as proof that a valid affidavit is oa file for future permits or licenses. A new affidavit m,.?st be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i-e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit- The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax numbez: The Co=anw-alth of Massachusetts Department of Industdal Accidents Office of havestigatiaxts 600 Washington Stet Bos-touz Imo.G2111 D L 9 617-727-4900 W 406 or 1-977-KASW. -E Revised? 24 07 Fax#617-727-7749 - �uw�.mas�gnv�dz'a - .S i t dry.` J F Yea __� �J ��%V./'..��oC/Bd f%B.�'iA VVV��9/L6 Y� ��`�•-�)��13' '!/�Yli3�l"C/f/l/�YJC/Y/�"L%(/V� ' Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 141496 I-XType: DBA Expiration: 4/26/2016 Tr# 51426 CONGRO REMODELING BASIL CONGRO 7:DANA RD. FORESTDALE, MA 02644 "Update Address and return card:Mark reason for change. Address 0 Renewal ❑ Employment Lost Card SCA 1 ti 20M-06/11 - - - - - C7��c CFO.%/l/1G171lU00111"'I'C �(,t7:1:IC1.lf�MMIIJ =. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration 141496 Type Office of Consumer.Affairs and Business 6/2 Regulation " .10 Park Plaza-Suite 5170 Z Expiration: 4/2016 DBA ,. Boston,MA 02116 CONGRO REMODELING BASIL CONGRO i 7 DANA RD. � a / I FORESTDALE, MA 02644 Undersecretary Not valid i ou si nature ^Massachusetts -Department o r .� .- gaiety 50. ; o`S�,fcine� =gulations and Sta yards f nn.ttvction'Supenisor 1. License: CS-082529 p w BASYL J CON�R� 7 DANA RD F®RESTDALE 1V�A 0264� � .: CommissiCa . 1 y �1HE lq�� 'Town of Barnstable Regulatory Services • snxtasTes[.s, MAS& Richard V.Scali,Director 16. 1% 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 Property Owner Must Complete and Sign This Section If Using A)guilder I, U 94 U I� 1� S as Owner of the subject J property hereby authorize /3/7-s/ 4r>1 tti to act on my behalf, in all matters relative to work authorized bythis building permit application for. (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. . Signature of Owner Signa plicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS Town of Barnstable Regulatory Services ��pFTHE Tp�� Richard V.ScaIi,Director Building Division * �nxxsznsI E K Tom Berry,Building Commissioner 1.6 9. �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: lease Print _ Z7I`''f// r JOB LOCATION: T g /Tl7�/�'1 i�Ol T 144W V l 11 number street village ••HOMEOWNER": —_. ©`'�i name I ' 61 home phone+ work phone 4 CURRENT MAILING ADDRESS: a L/ 11414 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. DEFLNrrION 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 subrait 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 1`lote: 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. QAWPFILESIFORMSIbuilding permit forms\EXPRESS.doe Revised 0 613 13 4cwb Zo IV7 l -0-0 . h NO VAN 1 j t 9 - i 1—Avz o V �LOS� 7-� - Senn �� Zo t 3oCoy0 I , aK t�I C) No T T �v�� \, ,ALLS I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 'Z3 Z Parcel ® 70 Application # 00 13.0(0 Lt� Health Division -0/� Date Issued <<2 Conservation Division '�7�✓ Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board l�— Historic - OKH _ Preservation/ Hyannis Project Street Address Z-y q L A'a 2D Village Owner bLJ-1 &&6, /iS Address 2�IQ IL/ PVi,yr Telephone 74,0 ©S 4- 1 , 6684 Permit Request ?S m" (DA!j l k OW 44 J&nU p mc. ---r1- oe --1 WS TA B 46w- c/ 001 y W1ad( � 1'c(- � 3+e, 3 ate-4 1:l,v rn T�L- Alm W VA-M(r T Square feet: 1 st floor: existing L7 proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 7 Construction Type Lot Size ® O 4 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure L/Z. Historic House: ❑Yes OdNo On Old Kin, Highway-,,) ❑Yep ❑ No 00 Basement Type: 9Full ❑ Crawl Walkout ❑ Other00 Basement Finished Area (sq.ft.) Basement Unfinished Area (sq ftm Number of Baths: Full: existing Z. new ® Half: existing new Number of Bedrooms: existing 0new I Total Room Count (not including baths): existing 7 new 6 1.0 First Floor R om Cou r,1!1t� Heat Type and Fuel: WGas ❑ Oil ❑ Electric ❑ Other Central Air: 'Yes ❑ No ' Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size — Barn: ❑ existing ❑ new size_ Attached garage: 14 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial_ Yes____Wf_No-___ If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name \)</,ALLS Telephone Number y083g4 I Z 05- Address 70 eAo 6= y I-AM-� 1,�,2•t eQ14 License # `-Emdl IL Cv -AL-1-Rome Improvement Contractor# /O 5- /� 0 Worker's Compensation # W&- ;srre 1[gjo/Z a Z ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE / R FOR OFFICIAL USE ONLY ' APPLICATION# DATE ISSUED MAP/PARCEL N.O. r ADDRESS VILLAGE OWNER `F 3 i DATE OF INSPECTION: `r �AFOUNDAITIONIUATIL, fv>L .NDP(T!' y FRAME INSULATION.L: 0 v,iU n'",'W. -FIREPLACE ELECTRICAL:. _ROUGH FINAL PLUMBING: ROUGH FINAL '4 GAS: ROUGH FINAL FINAL BUILDING- DATE CLOSED OUT ASSOCIATION PLAN NO. a The Commonwealth ofMassachuse& ' Department of IndunWd Accidents 4 Office of InveWgatfons 600 Washington.street ,. Boston,MA. 02111, www.mass gov/dia _ Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumberi. Applicant Information Please Print Legibly Name(Business/Orgmdzationandividual): =_p—d Y,-�IA L[,S Address: C ie A,,4J9sl:fLV LAB City/State/Zip: c�T6� C 4-Phone#: '?'31? /Z 0 Are you an employer?Check the appropriate box: Type of project(required): �T 4. I am a general contractor and I YP P ] 1.6 J am a employer with 6. ❑New construction employees(full and/or part-time).* have'hired the sub-contractors 2.❑ I am a sQle proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees These sub-contractors have, g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance l required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumb' repairs or additions 3.❑ I am a homeowner doing all work ❑ � p myself:[No workers'comp. right of exemption per MGL 12.❑Roof repairs in mnrance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Offer comp.insurance required] *Any applicant that checks box#1 must also fill out the section below showing their workers'compcnsafion poIcy informafion. t Homeowners who submit this affidavit indicating they are doing all work and then hire oxide contractors must submit a new affidavit indicating such. $Contraztors that check this box must attached an additional sheet showing the name of the suh-contractors and state whether or not those entities have employees. If the sub-mutractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ,-ldl GL 15-ct>( Expiration Date: !zod 3 Job Site Address: .'o-r P0 City/StatelZip: C,NTe.-te U t`tL Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as.well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do her , certify der the azm and penalties ofperjury that the information provided ab a is a and correct Si tore: Date: -r Pho e#: /W Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persons Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their employees. Pursuant•t:o 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 repay work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(UP)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 r Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be retumed 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 lime. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for futore permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to-bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commwvngth of M ssachusetts Degaz#ment of Industdal Accidents Office of J.vestigatiGw 600 Washington Street Boston,MA 02111 TO.#617-727-4900 ext 406 or 1-877 MASSAFE Revised 4-74-07 Fax 4 617-727-7749 WWW.massgov...a Client#:40463 2WALLSCO DATE(MM/DONYYY) . ACORD,. CERTIFICATE OF LIABILITY INSURANCE 11/27/2012 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 CO A T NAME: Dowling&O'Neil PHONE 508 775.1620 F 5087781218 A/C No Ext: A/C No Insurance Agency E-MAIL ADDRESS: 973 lyannough Rd., PO BOX 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A..National Grange Mutual Insuranc INSURED INSURER B:Associated Employers Insurance Walls Construction&Remodeling,Inc. INSURER C 87 Cranberry Lane INSURER D: South Yarmouth,MA 02664-1007 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. ' TR TYPE OF INSURANCE ADDNSRLSUBR WVD POLICY NUMBER POLICY EFF MPM/DDY EXP LIMITS A GENERAL LIABILITY MPK1492X 9/14/2012 09/14/201.3 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES°Ea o" °nce $500 000 CLAIMS-MADE F x1 OCCUR MED EXP(Any one person) $10,000 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 JECT LOC COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR a EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I J RETENTION$ y $ B WORKERS COMPENSATION WCC5009587012012 t 11/05/2017 11/05/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY IER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT 000,000 OFFICER/MEMBER EXCLUDED? I N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO,000 - ° • required) it DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is RE: Wildman-Pool permit Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S103565/1101103564 _ LS1 , Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ' Boston, Massachusetts 02116 Home Improvement Contractor Registration � � Registration: 105179 Type: DBA Expiration: 7/16/2014 Tr# 226538 WALLS CONSTRUCTION & REMODELING Troy Walls 87 CRANBERRY LANE SOUTH YARMOUTH, MA 02664 µ : Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA 1 Co 20M-05/11 V lie t(�anr��zarr,�ue�c�lfi a�C�a�eno/zudeG� �_ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: ;10517g Type: Office of Consumer Affairs and Business Regulation xpiration 7/16/2014, DBA 10 Park Plaza-Suite 5170 0094,, Boston,MA 02116 , ?� a WALLS CONSTRUCTION&REMODELING 04 Troy Walls ' ' t 87CRANBERRY LANEf F; SOUTH YARMOUTH,MA 02664: Undersecretary i/.yl'Yot vali out signs Massachusetts -Department of Public Safety !' Board of Building Regulations and Standards t Construction Supervisor } License: CS-044847 TROY A WALLS -` j!66Z ) 87 CRANBERRY�.1V'S YARMOUTH NA 0 � I Expiration Commissioner 07/05/2015 Town of Barnstable } ♦ Regulatory Services arnss g, Thomas F.Geiler,Director - 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 Property Owner Must Complete and Sign This Section If Using;A Builder as Ownet of the subject property hereby authorize ( d`/ �A I-A LL-5 to act on my behalf, in all matters relative to work authorized by this buRding petmit . (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. Signatute of Ownet ' Signat c plicant CA-j20L-:= Print Name Print Name Date SI0NPPOOLS 62012 > Town of Barnstable Regulatory Services "•` '••�F Thomas F.Geiler,Director �`ag Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-962-4038 Fax: 508-790-6230 HOMEOWNER UCENSE EXEMMON Please Print DATE.- JOB LOCAMON: number strId village -HOI%MWNER:k name home phone# work phone CURRENTYukaINGADDRESS: city/town state up 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. DEFMMON OF HOMEOWNER Person(s)who owns a parcei 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 shaU 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.L1) 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 EI AIMON The Code states that: "Any homeowner performing work for which a buRding-permit-is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);"pr'ovid'e`d'fhat if thehomeowner 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 personas 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 helshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may rare t amend and adopt such a form/certification for use in your community. C:\Users\d=nBc\AppData\LocaDMemsoM mdows\Temporuy Fatcrnet Fflcs\ContmtOudook\QRE6ZUBN\ID2RESS.doc Revised 053012 �--2/A.M .140 A VV,q.Lt-5 )-A A(V'G yz `( 0,(y v/,4/ tzo G� 416 x4�) `` t 13"u I Town of Barnstable �ZHE Tn,- Regulatory Services o Richard V. Scali, Director Building Division BASTLE + EAMSTABLE, • e MASS. u°"ca.S.s s o ui` �a.K`i""n i639. �� Thomas Perry, CBO M9-2014 �'FD fAA�6 Building CommissionerDg 200 Main Street, Hyannis, MA 02601 www.town.barnstable.maxs Office: 508-862-4038 Fax: 508-790-6230 October 14, 2014 , Troy Walls 87 Cranberry Ln, South Yarmouth, MA. 0266.4 F , RE: 249 Holly Point Rd., Centerville, Map: 232 Parcel: Dear Mr. Walls, This letter is to inquire on the status of building permit application number 201306401 issued to remodel the above referenced property.-As you may recall, this office issued a building permit on or about September 16, 2013 and you are the construction supervisor of record. To'date, this office has no-record of any inspections being conducted. Please contact this office to explain the status. Thank you,for your anticipated cooperation in this matter. Respectfully, re L. Lauzon Local Inspector j effrey.lauzongtown.barnstable'.ma.us (508) 862-4034 PyofTNETp�y TOWN OF BARNSTABLE PARNSTAILE, MASIL 039- M BUILDING INSPECTOR APPLICATIONFOR PERMIT TO .................................................................................................................... TYPEOF CONSTRUCTION ..................................................................................................................................... .......... .......19..7/ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .............'42. fX(9................. ......... .P..0. r..........0..Wzf�.................................................... ProposedUse ................VAW-6.4.4.0ja . .........................................I.................................................................................. Zoning District ........................................................................Fire District Name of.Owner ... ......1:10-eme.0..............Address ...... J,;.........z W Name of Builder ....141awd-1.. ............Address .......... .........dol: Name of Architect .............Address a,41or...... ......xvz Numberof Rooms ..................................................................Foundation .......... .few.. ................................................. Exterior .........................V.e.W1,V 6.:44.0..................................Roofing .............4.,rQWWO! r...................................... Floors ............................ ............................................Interior ............... ........................................... Heating ................... ........ZA.J'.r.413.40.jOAD....Plumbing ......................v2 ................................ Fireplace .........................0 A ........................................................Approximate Cost ..............a� ...cltv........................ Difinitive Plan Approved by Planning Board -------F!57�------------19 ldpw Diagram of Lot and Building with Dimensions ts /07 02- ,4- 7-38 4) 26'-o Ta 0 CD lei 0 Qn z 4 0 '63 art 0 0 V 0 0 0 " I ,IT C-11 I 0 0 Ul t:: Ln 6� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name---�- .... .. ........... C71-0 Mar Corp. ' ~ �� ^ /^ x^ � . � ~-~�n='�� ooe � No —��?.. Permit for ----.uz�7............ �a�i dz�� -----.~---.--.------=.-----.. � Rq ` �:�� Road | ^"`°=/ --' —.��--"--------. � ------'' f ' ------------------.— ' ' Owner ........ylacr. .O",�`�_______.. > � ' Type ofConstruction .................f rAmg----.. ................^.............................................................. r P|c» ............................ Lot .......#35.................. | ` / ` ~ Permit Granted 27 l� �l' -------------. / � ^ Dote of Inspection u�—.lQ � . Dote Completed ------------..lg � � . . . ^ . � ~ PERMIT REFUSED ----------..--------.—.. 19 ----..---.—.----.---..-------.. ! _.._.—.--.~--....-----...—~.—.....— / ^ . —.--._---.-----.—.----.--....—. --.------.-----.------..----.. ' � . . � Approved .................................................. lV . � ' -------.-------.—.~.---~—..--. � - ----.---_—..---.-----...~--..,, . . - � � � ��