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HomeMy WebLinkAbout0131 LAKE ELIZABETH DRIVE _ : _ _ . �. . . . .. . x. � - a . �: x .. . y,a.' � r t_. ,. d I�121112, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map a a 6 Parcel U 6 Application #Zo/z o / Health Division Date Issued " 07-Qe Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 31 L kka h I z Village ; Owner &k Akt d b g I anpy Address 3541) log6tg , %oOrook L Telephone 50$ '�--45 a 4 Permit Request ►�eASe 2G S w ► 4-I rZ 13 cc I l k o s e a, vtfA foaw, 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) r`3 -4 y e2 p Age of Existing Structure 0 Historic House: ❑Yes ❑ No On Old King'S Highway:`_;L3 Yes❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout 0 Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq ft) Number of Baths: Full: existing new Half: existing new 74 Number of Bedrooms: existing —new s Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: S Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes 14 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) Q Name W'.11io„m M s 0t Telephone Number 50S - 398- Address 1 m�I'Uun License # Eou.-A �Ixrmoebf NIR n6b 4 Home Improvement Contractor# Worker's Compensation # c ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TOj '�'� SIGNATURE / DATE II A&, f g FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. r - . ADDRESS VILLAGE OWNER - DATE OF INSPECTION: FOUNDATION FRAME INSULATION i FIREPLACE ELECTRICAL: ROUGH ' FINAL r t PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT c ' ASSOCIATION PLAN NO. 1 ' ti Building Permit Authorization I, Delaney, Richard , as owner hereby give my permission to Cape Save, Inc.. 7-D Huntington Avenue South Yarmouth, MA 02664 Office: 508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 131 Lake Elizabeth Drive Centerville, MA 02632 f Signed Date /lZ i Z l ; ( ' Tlae Connhomvealtli of Massaclutsetts..' Department of Inditstrial Accidents Office of Investigations 600 I3'ashin;ton Street Boston,M4 02111 wwiv.nzass.,ov/din ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information " Please Print Le6ibiy Name(Business/Organizddonllndividual): . Address: ' fl F}tA,ntinq�on �vet1H,� City/State/Zip:_a,r4 YaeCnoyA. MA 03W Phone#; 50$- 3 4'$ - O 3 9 g 'Are you an employer?Check the appropriate box: Type of project(required}: 1.0 I am a employer with l 6 4. El,I am a'general contractor and I- •• employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet., .,7. ❑ Remodeling shipand have no employees - These sub-contractors have ' 6 8. ❑ Demolition working for me in:any capacity. employees and have workers' [No workers'comp.insurance comp:insurance.* 9..❑Building addition required.] 5• ❑ We area corporation and its 10:❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself.[No workers'comp. . right of exemption per MGL insurance required.]t c. 152,§1(4),and we have no _ 12.❑ Roof repairs - ll t employees.[No workers' 13.X Other 7'r,StA.lpts�ion comp,insurance required.] *Any applicant that checks box Ifl must also fill out the section below showing their workers'compensation policy information. ` 'Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit anew affida-trit 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 n employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. ' I am art employer that is providing workers'compensation insurance for my eiployees. Below is the policy and job site information. Insurance Company Name: T eoh no to a Tn s wr an C e Gen n 'TW Policy r or Self-ins.Lic.r: C 3 318 Expiration Date: (4 1 I [ 3 t Job Site Address: tQ L La kP t i City/State/Zip: Cet1*V1,1 fe, M� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to-secure coverage as required under Section25A of MGL c. 152 can lead to the imposition of criminal penalties of a. fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa 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 Investieations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provi4abois true and correct Signature: T _ Date: _ Phone e • :J O S - 3 9 Official use onlp. Do nor write in.this area,to be completed by_chy or tnwrr official. City or Town: Permi%License Issuing Authority>(circle one).� - • - _ - 1. Board of Health 2. Building Department 3. City/Town - CIerk P �.Electrical Inspector �.Plumbing Inspector b. Other a Contact.Person: Phone •,. DATE(1111=01Y" ,aco ?,0® CERTIFICATE OF LIABILITY INSURANCE � 10/22/20I2 TAIS 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 CNAOME:NTACT Shannon errazza _ Risk Strategies Company PHONE (781)986-4400 FAc o:(781)963-4420 No 15 Pacella Park Drive FAM -L .ssperrazza@risk-strategies.com Suite 240 INSURER(S)AFFORDING COVERAGE NAICp Randolph MA 02368 ' INSURERA:Selective Insurance INSURED INSURERB:Safety Insurance Company 3618 Cape Save, Inc INSURER C-TechnologyInsurance Company 7 D Huntington Ave INSURER D• 5 ` INSURER E• South Yarmouth MA 02644 [INSURERF: COVERAGES CERTIFICATE NUMBER:CL12102253933 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. POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE INSR VIVOADD S BR POLICY NUMBER OLIO POLICY LIMITS GENERAL LIABILLTY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAr E TO RENTED PREMISES Ea occ mence S 100,000 A CLAIMS MADE OCCUR 199448001 0/16/2012 0/16/2013 MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY S 110000000 k� GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER - 1' PRODUCTS-COMP/OP AGG S 2,000,000 X POLICY PRO LOC S AUTOMOBILE LIABILITY COMBINED SINGLESINGLE LIMIT S 1,000,000 B ANY AUTO ' i BODILY INJURY(Per person) S ALL OWNED X SCHEDULED 6208200 - _ 1/6/2011 1/6/2012 BODILY INJURY(Per accident) S X AUTOS AUTOS N NON-OWNED PROPERTY DAMAGE S HIRED AUTOSAUTOS r acrid Underinsured motorist Bl splid S 100,060 X UMBRELLA LIAB OCCUR l EACH OCCURRENCE S 1,000,000 A EXCESS LLAB CLAIMS-MADE AGGREGATE S 1,000,000 DED RETENTIONS 199448001 0/16/2012 0/16/2013 S C WORKERS COMPENSATION fficers excluded X WC STATU I IR TH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE from coverage E.L.EACH ACCIDENT S 500,000 OFFICEPJMEM13ER EXCLUDED? NIA C3318007• /9/2012 /9/2013 (Mandatory In NH) - - EL DISEASE-EA EMPLOYE S 5()0,000 If yes,describe under DESCRIPTION OF OPERATIONS below _ EL DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,tf more.space Is required) Issued as evidence of insurance. Issued as evidence of insurance. Thielsch Engineering, Inc. is listed as.additional insured as respects General Liability as°requ_ired by written contract. CERTIFICATE HOLDER. k CANCELLATION, msong@ capelightcompact.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION .DATE THEREOF, NOTICE WILL BE DELIVERED IN ` C3pe Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Margaret Song PO Box 427/SCH ' AUTHORIZED REPRESENTATIVE - 3195 Main Street r ' Barnstable,. MA 02630 Michael Christian/SMS ACORD 25(2010105) .' ©1988.2010 ACORD CORPORATION. All,rights reserved. INW125 tininn-a n1 l ,. .�. Tha Af AnPn n2ma�nel Inns nre mntafamri rnarlrc of Al"non • 7 V r , z - �l:l��achUsltts- Depariiticni (it Public s:ltitN f Board oi' Builtlin!g Re�,ulatinns and Standards . _ Construction Sup-rvisor Specialty'Lic n'n License: CS SL 102776 Restricted to. IC fi WILLIAM MC CLUSKY ; V- 14 37 NAUSET ROAD - , WEST YARMOUTH, MA 02673 rExpiration: 6/28/2013 r r=: •102776 Office of Consumer Affairs and us: Regulation 10 Park Plaza-'Suite 5170 " r Boston, Massachusetts 02116 Home.Improvement Contractor Registration ,Registration: 171380 ;. TYPe: Corporation - Expiration:' 3/14/2014 Tr# 222184 CAPE SAVE INC., - WILLIAM MCCLUSKEY _ - 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA,02664 r4L Update Address and return card.Mark reason for change. . i Address 1 Renewal i Employment i Lost Card PS-CA1 is 50M-04104-G701216 -- --- 'offie n umer Affairs Resin:�� License or registration valid for individul use only . Office of Consumer Affairs&Bdsiaess Regulation -" HOME IMP before the expiration date. If found return to: ROVEMENT CONTRACTOR _ " office of Consumer Affairs and Business Regulation q Registration: . 171380 Type: 10 Park Plaza-Suite 5170 '•O"IEF5 Expiration: 3/14/2014 Corporation —� Boston,MA 02116 CAPE SAVE INC... ' WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH"MA`02664' Undersecretary Not valid wit o signa o k 31L�1�3 �-�- Cape Save Inc. TO, ` 4 IARIN_ # r 7-D Huntington Avenue .T , South Yarmouth, MA 0266 3 Tel: 508-398-0398 Fax: 508-398-0399 D 12/1/12 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 131 Lake Elizabeth Drive has been inspected by a certified Building Performance Institute(BPI) Inspector Walls: R-13 dense packed cellulose All work performed meets or exceeds Federal and State Requirements. Sincerely, J William McCluskey t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 47,2, cel ®�r� Application# Q1 lY 054) Health Division Conservation Division ��' Permit# '11Tax Collector Date Issued �� Treasurer Application F Planning Dept. Permit Fee •CD Date Definitive Plan Approved by Planning Board 9)7-ylo' Historic-OKH Preservation/Hyannis Project Strelet Address L S 1 LA1G� CL\z���-C'4 Village L,YL lGlJl l-t_ Owner —DGYLq W11F DtFLAK)tr'Y Address 131 Telephone 50S -775_ a7..L[4 Permit Request 17 W IJ!( ams �1Uq��C>Li'►ZC--� USA LAID VlJ%1Jd6tUS o7Y Square feet: 1 st floor:existing proposed 2nd floor:existing`�— proposed F Total raew Zoning District Flood Plain Groundwater OverlayUn Cu r `" Project Valuation Construction Type t _ Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting ddcumentat on. Dwelling Type: Single Family ZTwo Family ❑ Multi-Family(#units) Age of Existing Structure 40 q2S , Historic House: ❑Yes o On Old King's Highway: ❑Yes Q'No Basement Type: ❑Full ❑Crawl UtWalkout ❑Other Basement Finished Area(sq.ft.),�;DD Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing 1 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 &'tither "" Central Air: ❑Yes C�No Fireplaces: Existing !4!eS New Existing wood/coal stove: ❑Yes 0 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 4No If yes, site plan review# '- Current Use ',S0fT M- l)6E Proposed Use BUILDER INFORMATION rrnn ►Ij RQ p 'Name Telephone Number Gu'`1-`� l Address .(I V t SEA C LCA6_ License# 659376 - AO A. M`Lq Home Improvement Contractor# 10 d q0 t Worker's Compensation# ALL CONSTRUCTIOIA DE RIS SULTING FROM THIS PROJECT WILL BE TAKEN TO CASeL,-A SIGNATURE DATE b 12-0 7 FOR OFFICIAL USE ONLY r ~PERMIT NO. DATE ISSUED R ; MAP/PARCEL NO: ADDRESS VILLAGE_ OWNER DATE OF INSPECTION: FOUNDATION r FRAME INSULATION r r FIREPLACE . ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT t. ASSOCIATION PLAN NO. 1 • •�q \ 1lLG l.V//LlJLV/L 1'YGWL}./i V,J 111W7il WL.lLµV GLLN Department of Industrial Accidents . _ Dice of Investigations ' e 600 Washington Street Boston,M4 02111 _ www.mass.gov/dia ' Workers' Co'MP ensatioin hasurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le "bl Name(Business/Organization/Individual): . Address: ►SX A .Nac,Le City/State/Zip: r"J&Al 6`iQ Phone:#:_ S�b ��b •�q2� Are you an player? Check the'appropriate boa: -Type of project(required):. . 1.❑ I a em toy er with 4. I am a general contractor and I p• 6..❑New construction . employees (fall and/or part time).* have hired the sib-contractors 2. I am a'sole proprietor or partner- listed on fhe•aitached sheet, 7. ❑Remodeling ship and have no employees These sub-contractors have g, Demolition workingfor me in an capacity. employees and have workers' •$• . 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5• Vice are a corporation and its 10.❑Electrical repairs or additions officers have exercised their '3.❑ I am a homeowner doing.all work 11.❑Plumbing repairs or additions myself. [No workers' comp.' right of exemption per MGL- 12.[]Roof repairs insurance requized.]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 af6davitindicating 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 ermpldyges,they must provide their workers'comp.polidynumber.. T qm an employer that isproviding workers'.compensation insurance for my employees. Below is.thepodicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic,#: Expiration Date: Job Site Address: City7State/Zip• Attach a•copy of the workers compensation policy declaration page•(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year' risonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a da ag t the io or. Be advised that a copy of this statement maybe forwarded to the Office of - Investi ations of the IA• or' an covera e verification. I do hereby Gerd de t ns• ces of perjury that the information provided above is true and.correct,- Si ature:. Date: _ Phone : y28''•�'7 19 official use only,.Do not write in this area, tb be completed by city or town offrciaL City or Town: Permit/License# IsFmng Authority.(circle one): :1..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbisg Inspector 5.Other ContactFerson: Phone#: Informs ati®i� and Ins4tucti®n Massachusetts General Laws chapter 152 requires all employdes to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, :express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal'representatives of a-deceased employer, or the -McLler nr trate&-of an individual,partnership•association or other legal entity, employing employees, However the owner.of a dwelling-hawse having not Mora than three apartments and who resides therein;or the-occupant of the . dwelling house of another who employs persons to do maintenance,constriction 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 renewaj of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicaut.W.ho has not produced,acceptable evidence of compliance with the insurance coverage required" Additionally,MGL eliapter 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 oompliarice with the ins�nce 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, necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s) along with their certificates)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other.than the' members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required, R. advised that thus 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.licenseis 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 ToWA 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 aff davit 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 biim 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,�— pleas a do not hesitate to give us a'call, The Department's address,telephone-and fax number; ��az�m.¢nu�al. of Massaeb,�s��s • `. . Department of IndusWal A,oe dents- Office of Investigations 600 washingkoi Street $.astaa,MA U111 Tel.4 617-727-00.4 ext 406.air 1-$—MASSATE Fax 4 617-727-7 f49- Revised 11-22.06 www.mass.gav/clia ' . a �oFTHEr Town of Barnstable Regulatory Services BAMABIX r i vMAM Thomas F.Geller,Director �p 1639. �0 'FCMA'�a Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: 2W494141(40 jyp Estimated Cost �! ��W. Address of Work: I Sk LaQia 'rd2ASeW pg� Cl;jFL"6jLw " Owner's Name: D1A, I Iv►�LL1L Date of Application: 1' ?.--orl I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 E]Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for pe s the agent of the owner: ,SCE ���J �A,UJ Date ��Contracto Name �� Registration No. OR Date Owner's Name Q:fo=homeaffidav �ortIME�° Town of Barnstable Regulatory Services 9B' irsnM Thomas F.Geiler,Director Building DM—sion Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 W WW.town,b arnstable.ma.us Office; 508-862-4038 Fax: 50.8-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I,-Mall,ura ze\6- , as Owner of the subject property hereby authorize " J15t0AAS to act on my behalf, in all matters relative to work authorized by this wilding permit application for; . (Address of job) Sig tore o Owner Date Print Name Q:rORMS:O dTt�Iti'T;RMISSIOAT ✓!ze -�oorrnzo�ru.�lll� o��/�aoaac�, l �oard of Building Regulations and Standards Construction Supervisor License wri License CS 58376 Birthdate 8/19/1959 Expiration 8/19/2009 Tr# 3676 ' i a Restriction Q0-:� DAVID P SHASTANY 12 VISTA CIR MASHPEE,MA 02649 Commissioner---_— ✓die °•'L�YdO Lulations nd Standards 1 Board of Building Reg NTRACTOR HOME IMPROVEMENT CO ;' l= _ Registration_ 108901 Expiration v812712008 Type. f'nvateYCorporation }. REVISIONS,INC. r. David Shastany ,,GbQ . 12 VISTA CIR Deputy Administrator MASHPEE,MA 02649 1 i. f �h Z/O� Town of Barnstable *Permit#aoa oo'a Expires 6 months from issue date • Regulatory Services . Fee Mom Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building CommissionerX.-PRESSPERMIT 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.u§ APR 2 6 2006 Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL 0VN.OF BARNSTABLE Not Valid without Red X-Press Imprint Map/parcel Number 2.46 10,15. Property Address 13 Residential * Value of Wor, Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address I 3 3 rr Z Contractor's Name. $ Telephone Number.:J8-4 8-815DU Home Improvement Contractor License#(if applicable) 121 `1 U Construction Supervisor's License#(if applicable) t 1!9;26 orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ' ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name� J4.4 4eLr �- Workman's Comp.Policy# C a — 3/S 'J V 7/ fe© 045 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping..Going over existing layers of roof) ❑ Re-side Replacement Windows. U-Value d 13 (maximum.44) <A� � NSI�S 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. (see krrI H me I rovement Contractors License is required. SIGNATURE: s t,csw T Q:Forms:expmtrg - The Commonwealth of Massachusetts.. Department:of Industrial Accidents " Office of Investigations 600 Washington Street F Boston, MA 02111 - www:mass gov%dia Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly s - Name(Business/Organization/Individual): Address: City/State/Zip: Z f�� 0� one Are you an employer? Check the appropriate box: Type of project(required): 1.XI am a employer with 4. ❑ I am a general contractor and 1,; 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 1 Remodeling ship and have no employees These sub-contractors have 8 [ Demolition workingfor me many capacity., workers' comp. insurance. Y P tY 9. [ Building addition [No workers' comp. insurance 5, ❑,,We are a corporation and its required.] officers have exercised their .`. 10.[ Electrical repairs or additions 3.❑ I am a homeowner doing all work.' right of exemption per MGL 11.[ Plumbing repairs or additions myself. [No.workers' comp: c: 152, §1(4),and we have no 12.[ Roof repairs insurance required.] t: 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 their.workers'comp.policy information. . �t I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ilk Policy#or Self-ins.Lie:M(,y C o� 3/S--3 Y 77 V O Q/5_. Expiration Date: dr Job Site Address: 17l 6 'j�•R 'jl.� VR City/State/Zip: aNT�( � il* Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties,in-the form of a:STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this,statement may be forwarded to the Office of investigations of the.DIA for insurance coverage verification. - I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si ature: /I Date: Phone#: O icial use only.,Do not.write in this area to be completed b city or town official. .ff Y P Y tY .ff 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#.' ZS zd - z. . S — r 4 .. - � � ., . --r ^�"� t -. � �' � �� � �' .R .. f 4 • �� t.. f ,:' - - . P � r ` � c4 ,..., .,��` �1 t t l- d C'!ze loom�rwaxcoeccl o�,/vcgoe __ ___ c ac`iuoe� try p� . Board of Building Regulations and Standards w t License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR .before the expiration date. If to return to: `. Registration 141411 Board of Building Regulations and Standards t expiration 4�/21/2008 , One Ashburton Place Rm1301 , �f.:/ Boston,Ma.02108 Ypyre�- Private Corporation 1 i t WSHANE CONSTRUCTION CO INC. n ilOHN'McSHANE ' . i' 161 VELLS LANE MARST ONMILLS,MA 02648 Administrator Not valid without signature i f' „ a • a a : , - t q a Town of Barnstable *permit# • S 8"8", P^ � Expires 6 monW from Issue date Regulatory Services Fee Thomas F.Geilery Director �E0N1A�� Building Division X-PRESS PERMIT Tom Perry, Building Commissioner AUG 200 Main Street,.Hyannis,MA 02601 - 3 2005 Office: 508-862-4038 TOWN OF BARI Fax: 508-790-6230 \ISTA& EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X Press Imprint 7 3 dap/parcel Number 6., t 'roperty ddress esideatial Value of Work f 009 Minimumtee of•$25.00 for work under$6000.00 owner's Name&Address _ ,L�fCK I- iN 1 C L�/ ;D L�'AAC Zontractor's_Nazne . 0, L E!✓L&2Q=�� Telephone Number�b 8 728 711= Home Improvement Confractor License#(if applicable) construction Supervisor's License#(if applicable) [3Workman'.s Compensation Insurance �ne: J 1=a sole proprietor ❑ I e Homeowner have Worker's Compensation Insurance Insurance Company Name 9 CirA- / ZE C= Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. a Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to — r ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U Vahie (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other tows department regulations,Le,Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. Sigaatur .I QForms:expmtrg Revise063004 Town of Barnstable Regulatory Services 8AM Thomas F.Geiler,Director .MAassM 039.�a`�� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: .508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, I 1 1 I l I CeY4 Dio 6414--l.t ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) L Sig tore o ._. er Date Print Name QYORM&OWNE"ERMISSION The Commonwealth of Massachusetts Department of Industrial Accidents A Office.of Investigations ' d 600 Washington Street Boston,MA 02111 S•• wrvw massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciaiWPlumbers Applicant Information Please Print Legibly 1 Name (Business/organization/Individual): Address: City/State/Zip: �'/�` Phone#• (?57 1 —7 -2 IF — 7-2-7 Y Are you an employer? Check the-appropriate box:. Type of project(required): ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction !.❑ I am a sole proprietor or partner- listed on.the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or.additions a homeowner doing all work right of exemption per MGL 1l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12. ❑ Roof repair s insurance required.] t employees. [No workers' 13.❑ Other comp.insurance required.] any applicant that checks box#1 must also fill out the section below showing their workers'conipensation policy information: +� gomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site. formation. isurance Company Name: )licy#or Self-ins.Lic. #: Expiration Date:, ib Site Address: City/State/Zip: ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). tihtre to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 'up to$250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office of . vestigations of the DIA for insurance coverage verification. to he certify under the pai andpenalties of perjury that the information provided above is true and correct atur Da tone#: Official use only. Do not write in this area,to be completed by city or town offxiat City or Town: PerniWLicense# 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#• Information and Instructions , Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. 'nrsuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, mpress or implied,oral or written." - ,kn employer is defined as.':'an imdividual,.:partuersllip, association, corporation.or other legal entity,or any two or more Athe 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 awner 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 woik-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 eq c insurance'orpartliers Limited Liability.Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members not required to workers' compensation insurance. If an LLC or LLP does have , are �3' employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial f insurance coverage. Also be sure to sign and date the affidavit. The affidavit should Accidents for confirmation o g l� 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"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 in"orrnation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or Town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for.future permits or licenses..A new affidavit must be filled out.each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would hike 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 60Q Washington Street . Boston MA 0211 L. Tel. #617-727-4900 ext 406 or-1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/d.i.a