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0033 LAZARUS LOVELL ROAD
n op , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 1 Parcel 5 CNN O AR 'cation # Health Division Date Issued ILI 15€ f ly 9• Conservation Division Appi6tion Fee C� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board DIVISIaN Historic - OKH _ Preservation / Hyannis Project Street Address 33 Ld ,PUS Village Owner /))R5 J v,n v 7'c,9 e- Address__ '54MIC , Telephone Permit Request E,mn v E P_x 15;1 PLL-t o Cc n3 F CT tM +o A n D rr,oyo Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation oo 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 Telephone Number 50 S'- V $_ 6 Y 2 Address yy Cr License # (C,5 F R - ®46 L(a y 5 057F4!// L F I'1�/� 6 ASS Home Improvement Contractor# 179717 Email Worker's Compensation # E x r MDT ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY f APPLICATION# DATE ISSUED MAP/PARCEL NO. I t ADDRESS VILLAGE r. OWNER f DATE OF INSPECTION: 4 FOUNDATION r FRAME INSULATION r FIREPLACE F ELECTRICAL: ROUGH - FINAL PLUMBING: . ROUGH f FINAL " GAS: ROUGH FINAL : I FINAL BUILDING �� Alt-° �fAid DATE CLOSED OUT } ASSQ,CIATION PLAN NO. y _ :3 The Commomwafth ofMassachuset!�Y Deparhaaeat o•f bidm3ft id Accidents• Off"of I esagations {00 Wasliiragton meet Boston Mai 02111 wnhv.7nass gavldica Workers' Compensation Insurance Affidavit:Builders/ContractorslEiectricianslPlumbers Applicant Information Please Print Legibly Name(Business/Orgmization8affividwo_U 1LIAM-3, FoGAR 1 y A Andress: 6 V Ri1�ll F G , QtylStatrJZip_ - v tU_F_ m tome,�_ 50�9-' Are you an employer?Check the appropriate box: T of project r 4. I am a contractor and I � ltt' J (required):., 1.❑ I am a employer with ❑ 6- ❑New won employees(full and/orpart-#ime)_* havehiredthe sub-contractors 2-� I am a sore proprietor or partner- listed on the attached sheet: 7- Remodel ship and have no employees These soh-aontrartors have 8. ❑Demolition w forme in an c cr �_ employees and have workers' oddng y apa. tl 1 9- ❑Building addition [No workxxs' comp.insurance comp-msuranae ' required-] 5_❑ We are a corporation and its lf3❑Electrical repairs or additions 3111 am a homemner doing all work- officers have exercised their I l_❑Plumbing repairs or additions myself[No work='vamp- right of exemption per MGL 12-0 hoof repairs . insurance mired-]T c.152,§1(4),and we have.no employees_[Na workers' . 13_❑(}ther comp-insurance required-1 *Any about that chedks boa-1 tons#also fill out the section b9ow showing ihea woacere compensatioupaHu urfinmx&3 Homeowners wba subunit this affidav t in&catbrg they are doing an vm&and then hag outside contractors most submit a new affidavit iwiltss 4 surly +'Contractors that check this boa must attad ud an additional street d wwmg the name of&e says-caaft2am and state whether orxnt these mAifies Ihare employees If the sub-contacturs haee empIc gees,the}must pmvide their workers'comp policy number- lam an employw#hat is prm*firtg workers'cony 7e&vntian insarauce for my,eH pioyeas Selaty is Ste prrHi attd}ob sits irrforrrratian. P Insurance Company Nanne_ { Policy:g or Self-ins_Lie Expiration Date: Job Site Address: City/State/Zip: Attach a dopy of the:workers'compeasation policy declaration page(showing the polic)•number and expiration date). Failure to secure covie age as requiredvnckT Section 25A of MGL c 152 can lead to the imposititm of rr,mi nal.penalties of a fine up to$1,500-00 and/or one_yearimprisonment as well as did penalties in the,form of a STOP WORK ORDEEL and a fine of up to S250-00 a day against the violator- Be advised that a copy of this statement may be forwarded to the Office of Iuntestigations of the DIA for insurance coverage-verification- Ida hereby cerhJy,11. pains andpenaWas ofpedwy that the in�orma#ian provided above is hue and correct Si2nattme: '!/• f Bate: ON Phone#: 50$- Ll a B O 61-12k Oj ff icial rise 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.Btui[ding Department 3.CityfrGv rt Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person. Phone#_ 6 a Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also slates that"every state or IocaI 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"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 certaficate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no en -ployees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit T e 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-insuranc,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 lice 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. 'Fhe Gomrmonwe th of Massachusetts Depai went of 7ndustrzal Accidents Office of kvestigations 600 Washington Street Boston,MA G21 I I W.A 617-727-4900 at406 or 1-9 MASWE Revised 4-24-07 Fax#617-727-7-749 w.mass-govldia THE ta Town of Barnstable Regulatory Services '.`'E„ g Richard V.Scali,Director � i639• .• 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, Oq L , as Owner of the subject property hereby authorize wi�'�Ctrn iJ ! o 4a r-f V to act on my behalf, in all matters relative to.work authorized by this building permit application for: aruso,Z63z- (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. ignature f Owner ' Signature of Applicant Tubs ; Print Ne Print Name Date j I Q:FORMS:O WNERPERMIS SIONPOOLS Town of Barnstable Regulatory Services P�QFe rotyy Richard V.ScaIi,Director Building Division anxxsrnsI-E Tom Berry,Building Commissioner 659. ��� 200 Main Street, Hyannis,MA 02601 RFD a www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: cityAown 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. t 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,RuIes &ReguIations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 i ,r { Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor 1 &2 Family License: CSFA-064245 WILLIAM J FOGftt . 46 VERMEER CT OSTERVILLE WA .,ro" Expiration Commissioner' 10/2812016 ` �e rpo��um.�oeaura.///n��C�/f�z��nc�rice/(a .. • -.� C\ 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: 1:79717 Type: Office of Consumer Affairs and Business Regulation t.. 10 Park'Plaza-Suite 5170 xpira ion 9L2/2016 Individual t . Boston,MA 02116 WILLIAM J. FOGARTY III 4 , {t ; WILLIAV FOGARTY I11 ':. f 46 VERMEER CT OSTERVILLE,MA 02655 Undersecretary N valid rthout gnature F l f R r tu.. YDCr��'Y H a M 3 I.�At-z.A t�.�s Email �.o C F L%- 50 8 73`9 v Exi57"iNCr �Dt7iTid�t Q J � I Exr 10G- F.<T.IJPLl LO 6 0 P ra[- A tom,. S-rl_�le. � ���ra�n �caa►61 iuA,...-��ri�t�oQ ���., �, �6L1L1 �(21119L� -ro-Y %L g . Lf';•t'N DR� �.i`t• 757 A 13 �, • .�-�. �. ,per .,, i TOAL 12-8-14 XvvyBevrn LAZARUS SHUBEL ROAD , 10:17am CENTERVILLE,MA I of I KeyBeam®4.600d km Beam Engine 4.6026 - Materials Database 1429 Member Data Description: Member Type:Beam Application:Floor Top Lateral Bracing:Continuous Bottom ateral Bracing:Continuous Standard Load: Moisture Condition:Dry Building Code:SBC Live Load: 40 PLF Deflection Criteria: L/360 live,L240 total Dead Load: 10 PLF Deck Connection:Nailed Member Weight: 16.0 PLF Filename:KYB1 Other Loads Type f Trib. Other Dead (Description) Side Begin End Width Start End Start End Category Replacement Uniform(PSF) Top a 0.W, 13' 9.00" 14' 0.00" 30 15 Snow Additional Undorm(PSF) Top 0' 0.00" la 9.00" T 0.00" 20 10 Live �R © 13 9 0 13 9 O Bearings and Reactions Input Min Gravity Gravity Location - Type Material Length Required Reaction Uplift 1 0' 0.000" Wall Steel 3.500" N/A 4766# -- 2 13' 9.000" Wall Steel 3.5W' N/A 4766# - Maximum Load Case Reactions Used for applying point loads(orline loads)to carrying members Live Snow Dead 1 932# 2796# 1970# 2 932# 2796# 1970# Design spans 13' 3.759' Product: W 6 x '16 (60ksi) PASSES DESIGN CHECKS Design assumes continuous lateral bracing along the top chord. Design assumes continuous lateral bracing along the bottom chord. - r IAllowable Stress Design Actual - Allowable Capacity Location Loading Positive Moment 15.86'k# 28.05'k# 56% 6.81T Total Load D+S Shear 4.77k# 32.66k# 14% U Total Load D+S LL Deflection 0.3188" 0.443T' U501 6.88' Total Load S TL Deflection 0.5436' 0.6656' U293 6.88' Total Load D+S control: TL Deflection Coe G Q TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION `r1 ? • Map Parcel Application # �b � � pp Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee. Ln Date Definitive Plan Approved by Planning Board 7/1 g/1 Z rk Historic OKH _ Preservation / Hyannis v Project Street Address ��Z�ru.g zdl,� [_Village enyen/'i yle- Owner vJ- -FOeL Address Sa•�e Telephone 7- Permit Request ,�fir�C7�' CLrL AeD ck Drt Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 000 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structur Historic House: ❑Yes C�'No On Old King's Highway: ❑Yes ®'No Basement Type: C�"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: Yexisting ❑ 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 Oris/ T Telephone Number 97r--41t -10 rD Address ? ,.�1� Lw License # /O000 Home Improvement Contractor# /`fy=1 Worker's Compensation # "&V ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE / DATE 711 Z FORJOFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. a, ADDRESSr VILLAGE OWNER DATE OF INSPECTION: FOUNDATION (3) -50lf3&-%(o FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH F I N A L` V2 GAS: ROUGH FINAL47 FINAL BUILDING CQ 4 d DATE CLOSED OUT ASSOCIATION PLAN NO.7 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 Please Print Legibly Name(Business/Organization/Individual): . CQ0� e Address: City/State/Zip: Mo0j, 40Z Phone.#: Ofo Are y an employer?Check the appropriate bog: Type of iect'(required):. . 1. I am a employer with 4. El Iamageneral contractor and I employees(full and/or.part-time). * have hired the sub-contractors 6. ew construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling These sub-contractors have ship and have no employees 8. ❑Demolition working for me in any capacity. employees and have workers' 9.. Building addition [No workers'comp.insurance- comp:insurance.# ' i required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all officers have exercised their work 11.El Plumbing repairs or additions. o myself. � �•. workers' co right of exemption per MGL 12.❑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.isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: . Policy#or Self-ins.Lic.#:`�c1 1 S 3 Y3j' 2! c-93/ Expiration Date: O Z Job Site Address: l��'oi7lc � �� City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. . I do hereby;eer1V0iJft,, der the p ' s nd penalties of perjury that the information provided above is tr a and correct Simafore: A Date: . Phone#: —/0�Q 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#• I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more .of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individualg+ ar�ersluR,association orpothei legalhentityaae"mploying employees. However the owner of a dwelling house having not more tl an t] b apartment'-Ld who reside's therein,or,the occupant of the dwelling house of another who employs persons o do WhAdnance,constfuction or repair work q4 such?dwelh g'house or on the grounds or building appurtenant thereto'shall not bedause"'of such employment.b�deemec�'to'be an employer.,, MGL chapter 152, §25C(6)also states that"every.state or local licensing agency`shall withlold,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.theperformance 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-contiactor(s)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 carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 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 ihat,the affidavit is complete and punted legibly.°The Department has provided a space at the bottom of the affidavitsf6ftyou to"fill 6i in the event the Office of Inveshgatio:ks Ylas",�6)atact your gazdu3g,th ,applicant. Please be sure to fill the permrt/hcense number which will be used as a reference number. In addition,w applicant that must submit mt'#41e permitl1x'e'nse applications in any given year;ribed only s buiit,or affida"fgdicatarig current ... nolicy 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,&x�number: r .TheCommonwWth ofMassachustts Department of Industrial Accidents Office of Investigations 600 Washington Street BOstan,MA 02111 Tel.#617-727-4900 ext 406 or 1-977-MASSAFE Revised 11-22-06 Fax##617-727-7749 w .mass.govfdia f ;aco CERTIFICATE OF LIABILITY INSURANCEF12/20/2011DATE`MM'°° �../ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT F. Cordaro NAME: Andrew G. Gordon, Inc. PHONE (781)659-2262 FAX, No:(781)659-9725 680 Main Street E-MARIL bill@agordon.com ADDP. 0. BOX 299 INSURERS AFFORDING COVERAGE- NAIC# Norwell MA 02061 INSURER A:Preferred Mutual Insurance 15024 INSURED INSURER B:Liberty Mutual Ins Co. — ARWC Cape Cod Carpentry, Inc INSURERC: 12 Remington Lane .INSURER D: INSURER E lPlymouth MA 02360 INSURERF: COVERAGES CERTIFICATE NUMBER:Sample 122011 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY'CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES Ea occurrence $ 100,000 A CLAIMS-MADE OCCUR ` PP0100591897 7/23/2011 /23/2012 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.1 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 X POLICY JECT PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED " PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION _ - NC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 100 000 OFFICER/MEMBER EXCLUDED? N/A C1-31S-343139-031 7/30/2 11 7/30/2012 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) SAMPLE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SAMPLE ACCORDANCE WITH THE POLICY PROVISIONS. SAMPLE SAMPLE, MA AUTHORIZED REPRESENTATIVE F. Cordaro/CORWIL (,ci -. liti1 itJ ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD i • • � w y a:. F `. �`jiu3K;:Grw`vL,m'+r.Y..:�o.n -,.'--=.I.�-.�.-�+fw.�.' -,:' i��+'uzn+rvnrFY'+1.1k.up.yRbN•.` IVius`.tchusctts-`Department of Public S tfetN i Bolird ot'Buildinl� Regulations and Standard:�M en i Construbtion.Supervisor$-Lic se ..b License: CS 99292 - , DANIEL MUSIC NANT WOO ;012 REMINGTON LANE ►t: f f PLYMOUTH,'MA 62360.r Expiration:' 7/16/2013 .{ v ('onnn..wnc.r`'t 4 Tr#: 19160 s . r Al e, br ` .�:.M�.>'+.dC I1�tit Q "I'rtlrirttaiert Ii PtihltG Sifct�"" - �� rx r *' 1 ti pfzBt" tlrn��ielaftvs�«�"Iat#:S.►rivart�t, Cci'rvffitacion Survcsr L�ce`ris . rLicense C'S 100701 50 • Restricted to '00��,k F '� �' - . w ;�-;,DANIEL TOUSIGNANT s . �30 COLT LANE .s x PLYMOUTH'x MA 0 n. � }::.:,�a��i_,.w.'* �.-Xi`.t�,c�{`mot• "�Xplfatfatl.��/5�?012 _ / ✓1z�. - office.of C onup er, tfa�rc&B�I�s xl1 gttran t*s"► enss or reg►stratlon val►d for:indrvidul use on1.y : 10M7:IMPROVEAAENI COiVTF2CTDR ¢ #t r '.beforetl�e expirlµtiori dafe.•If;found return toa{ a Registration144032 / Tip Office of Consst'irier Affairs and Busines§Regulation Exp�ratiori: 8/312012�/ Private CorpbRi 1.0 Park Plaza-Suite 5170 ti Boston,MA 02116 C COD CARPENTRYCic}C bANIEL,TOUSIGNINT t 12 REMINGTON LN PLYMOUTH, MA 0236�0 �F<•: Undersecretary ' v d rthout signature,, �1FlErati Town of Barnstable Regulatory Services BAPrSTABM Thomas F.Geiler,Director i639. `�� 6. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstabIe.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit. Z.O."as Z-0 V.,-// 'IPJ /i�/e (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. S atur f Owner i atur f Applicant Print N e Print Name ate Q:FORMS:OWNERPERMISSIONPOOLS 6/2012 ,*'THE Town of Barnstable Regulatory Services * BMMSTaaLE, II Thomas F.Geiler,Director mass. 94�p i639• A,O� Building Division rF0 MA'I Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwe�l_i"'of six units or.less and to allow homeowners to engage an individual for hire who does not possess a license,provrded that the owner acts as supervisor. '1 V DEFINITIOIY'`•OIj9C[WdWNER '!a' Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which ttere 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 Qfficial`on a form acceptable to the Building Official,that he/she shall be responsible for all such work per ormedyun der the bu>Idm , ermit (Section,-109 1s 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. `f 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 Contr61. 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:i.l` Licensing ofc nStruction SuperY pis) provided that if the homeowner engages a person(s),for,hire to do suvh ! work,that such Homeowner shall act as supervisor. a.z, 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 communit y. Q:forms:homeexempt ,may_ - _ � i 4 _ f SS C t t . L J w t t ± r i .- -- -- -- - --- -- - - ---� - - ---- t - © _ /-f t P 33. t a ! i 1 • ! ! — r _ Oro i k i V . t i E ? � - - - - { ! f k 0 a __ u--t — -i-- — `— -- — --- — — -- — — — -- - 4 ,ke - _.- • � F � F 1 g t { � � ( i f ! j ! f � i 1 , 62h-oln, A- . OFIKE r Town of Barnstable *Permit# Fires-6-months from-issue date Regulatory Services , • snxxsrns�, • 9cb Mass. �'i63q. Thomas F.Geiler,Director �0 JUL. 0 9 2012 Building•Division Tom Perry,CBO, Building Commissioner. 200 Main Street,Hyannis,MA-02601 'OWN OF BARNSTABLE - www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number. �' 7 f Property Addresses L-ftA-_JUt ,U 020�;-3 a Residential Value of Work , 00 0 a Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address (--AQ5, ,uC)sj t Occ Contractor's Name 4--,co AUkACZ, Telephone Number 50 B -Sci!Lk' 16 Home Improvement Contractor License#(if applicable), i 2 Ll 7"'i 3 Construction Supervisor's License#(if applicable) O(�47 Q Q ❑Workman's Compensation Insurance Check one: K-I am'a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name IN&M 1 as Policy# IM ' 0S 11- J Ct - 12- zCj I Z Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑.Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane.nailed)(not stripping. Going over existing layers of roof) ❑ Re-side , #of doors �fdD -rreg Replacement Windows/doors/sliders.U-Value -0 3 i (maximum.35)#of windows' I >¢ v�Yl wtvtdcr *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note*. Property.,Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\decollikWppData\Local\Microsoft\Windows\Tern ary Internet Files\Content.0utlook\DDV87AAZ\EXPRESS.doc Revised 072110 I r oF�roii, , BARNSTABM is ,�� Town of Barnstable Regulatory Services Thomas F.Geiler,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 SA1l i Ck4 I , as Owner of the subject property hereby authorize VAS P O I�UVt,Q-7 to act on my behalf, in all matters relative to work authorized by this building permit application,for: Ca4heVq'(&. (Address.of Job) ':i - -2-0 t 2 Signature of Owner Date �A4^ r—,IM Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. 't C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 r. . 380 ���ez cap 79 Mayfair Rd South Dennis, MA 02660. Page 1 of 2 Mid Lic. #069680 . cepeeodwindows.corrt H.I.C. #124793 (866) 398-1511 • Toll Free 3981511 • Dennis, MA PHONE DATE': TO Mrs. Judy Toal 972 897 3600 6/5/2012 33 Lazarus Lovell Rd. JOBNAMEJtocAT]b Centerville MA 02632 Andersen '.'Woodtaright" Insert Windows _. Andersen .:"400_.Serie.'s" New Construction gliding window; r JOB NUMBER JOB PHONE a ' 3600- / REVISED>: SAME �We hereby,submitspecifications:and estimates for l Remove twelve pair of wooden double hung sash/balances,; two:;wooden picture window sashes, and one .wooden casement window. Rep lace/instal.l with twelve Ariders:en "Woodwr ;ght".._insera .:. double :hung windows, two Andersen ."W:oodwr_igh.t";' picture wndow'.sashes, acid one: Andersen". "400.>Series" gliding window, replacing the wooden casement window over .the kitchen sink New: 1An dersen gliding window over kitchen si k` will be a'` "New Construction" style:.:window and: may require new exterior/interior trim. * New Andersen "Woodwright", double hung::ins'ert windows,';and new Andersen 400 Series gliding: window will have a white vinyl exterior .with:a clear pine interior, 'IT Scene." screens stone colored hardware, and applied grilles with spacer :bar 1Vew windows will have. the :same .;. grille patterns as the existing windows-:.have,. :and:. he..double .tiung insert windows will :have tiltwash ability and all windows will have high performance Low E4::arg:ori gas filled insulated glass. 2. Insulate the cavities of the: new Andersen wando.ws. _ 3. Take old windows to the town landfill:, . 4 Make arrangement for deliveryof new Andersen windows.. 5. Supply interior/exterior trim and framing materials where,.needed for kitchen sink window,:: and any interior window stops that we might brake.: Any window:stops. :that are already broken : will be supplied on a cost basis,, per:::'conversation:Jon 6/2/2012. ,.New interior' trim will :be 2 1/2" clear colonial casing with clear Andersen stool ..cap, . and" the exterior. trim will be lx4 or lx5 primed pine to fit the opening 6. Supply town of Barnstable -building permit. at' cost, ` ( estimated "cost of $ 50.00 ) , payable upon first scheduled payment. * This proposal does not include any painting, staining,. or other :work-not described above. * __All Andersen products described..above. _will`be_pr:epaid_by the hoitte_owner ** If this proposal is satisfactory, please sign. the YELLOW copy and return with payment schedule. We Propose hereby to furnish material and labor=complete in accordance with the above specifications,for the sum of: Cont'd dollars($ Cont'd Payment to be made as follows: Labor: 50% Downpayment. to start 'at time of start, plus permit fee. . . . . . . . . . . .$ 1, 420.00, Labor: 50% Upon completion at* time'-of completion. . . ... . . . . . . ... . . . . . . . ... . . . . . . .$ •1,370.00 Total labor, permit. and materials to complete this job less new windows. . . . . .$ 2,790.00 Al material is guaranteed to be as specified.All work to be completed in a professional manner according to standard practices.Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon'written orders,and will become an extra Signature charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tomado,and other necessary insurance.Our Note:This proposal may be r workers are fully covered by Worker's Compensation insurance. withdrawn by us if not accepted within 15 days. Acceptance of Proposal—The above prices,specifications and con- ditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. Sign (re r� Signature Date of Acceptan i 380 4 79 Mayfair Rd South Denrils, MA 02660' Page 2 of 2 capecotlwtndows:corn .}. {866) 398 114 T611 Feee • {508) 398,4511 Denrt sf MA ".PHONE HATE;; TO Mrs. Judy Toal 972-897-3600 6l5/2fl12 33 Lazarus Lovell Rd. . JOB NAME{LOGATION Centerville `N!A 02632 ` Andersen "Woodwright" Insert Windows Andersen "400 Series" New ConStructaon gliding window: JOB NUMBER JOB PHONE 3600. / REVISED SAME �� :U�te.hereby submit spectticafians and.esUmates for .--. `i` _; - � .� ** Please make a cheek payable ao Vasco Nitnez Carpentry in the amount of $ 11`.,240.91 for your `new',Andersen products described; above, and please include this cheek with your signed propoisal , Allow;377 4 weeks-;for; delivery. w We Propose hereby to furnish material and labor—complete in accordance with the above specifications;for the sum of: Fourteen Thousand Thirty and 91/100 Dollars. dollars($ 141030.91f Payment to be made as follows: Labor: 50% ".Downpayment, .to start at 'timeiof .start, plus permit fee: : . . . . ,$ 1, 420.00. Labor:= 50 Upon completion.at ::time 'of completion: . . . ... ... . . . . . . $ 1,370.'00 Total labor, permit and materials ,to complete this, job less new windows. . . . . .$ 2,790.00 All material is guaranteed to be as specified.All work to be completed in a professional manner according to standard practices.Any alteration or deviation from above specifications Authorized if involving extra costs will be executed only upon'written orders,and will become an extra Signature z A charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry tire,tornado,and other necessary insurance.Our Note:This proposal may be workers are fully covered by Worker's Compensation insurance. withdrawn by us if not accepted within 15 days. Acceptance ®f Proposal—The above prices,specifications and con- ditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. Sign;X Qst� tlj Signature Date of Accepta (O 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 Please Print Legibly Name(Business/Organization/individual): VASCO N UJNEZ Address: SOUTH DENNIS,MA 02660 City/State/Zip: Phone Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.PI am a sole proprietor or partner- listed on the attached sheet.t ?• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers' comp.insurance 5. ❑ We are a corporation and its 9 ❑Building addition 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 insurance required.]t employees.[No workers' 12.❑Roof repairs comp.insurance required.] L13-9]Other *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 arc 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 nami of the subcontractors and their workers'comp,policy information. lain an employer that Is providing workers'compensation Insurance for my employees Below is the policy and Job site Information. Insurance Company Name: j Policy#or Self-ins.Lic.#: �-4 c� I = -T Expiration Date: cI ^ ( - 20 i 2 Job Site Address: 2 n City/State/Zip:-_(-fv ii l l� , l'AA -02&32 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 certi y under the ains and penalties of perjury that the Information provided above is true and correct Si ature: , 22w Date: ^ 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 M Information and Instructi• ons Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency 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 Additionally,MGL chapter 152,§25C( of compliance with the insurance coverage required" 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 carry,workers compensation employees,a Policy is required. Be advised that this affidavi ma be insurance. in tted to Etta Depaltlnent of have Accidents for confirmation of insurance coverage. Also be sure to sip be returned to the city or town that the application for the permit or li e is being requested and ,not the it. TheDepartment davit should Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers, p�m�t of compensation policy,please call the Department at the number listed self-insuranc below. Self-insured companies should enter their e license num ber 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 a li Please be sure to fill in the pern►ir(license number which will be used as a reference number. In addition,an applicant g PP cant. 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 town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the or 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 homeowner 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 his please do not hesitate to give us a call, should you have any questions, The Department's address,telephone and fax number: The COMMoriWealth of Massachusetts Depaftent of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-87?-MASSAFE Revised 5.26-05 Fax#617-727-7749 VAW.mass.gov/dia ill;trs;tchusetts- Department of Public Sul•eO : (9Tlio Wo•wvwza.wivcalllc o/.'n11Zajjnckj,b1, s a Bound of Buildin,.Regulations ;ind Standards Office of Consumer Affairs&Busirfess Regulation Construction Supervisor License ME IMPROVEMENT CONTRACTOR f i One- and Two-Family Dwellings Weiistration: 124793 Type: p Individual License: CS 69680 iratlon 8/25/2013,: i Vasco E.Nunez, Ili VASCO E NUNEZ III (. 79 MAYFAIR RD I Vasco Nunez, III S DENNIS, MA 02660 j 79 Mayfair Rd. j S. Dennis,MA 02660 Undersecretary �--- �- -:;;I—` Expiration: 10/3/2012 I d ('nnnui..ivai'�' Tr#: 3426 t Town of r * o� X p Barnstable *Permit �(/�O 7�4 -P S IP IT Expires 6 months fr2m/issue date JUN 2 2 2007 0 Regulatory Services Fee Thomas F.Geiler,Director TOWN OF BARNSTABLE Building Division2-- Tom Perry, CBO, Building Commissioner �,� 7lb/6? Az.—* 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY (� Not Valid without Red X-Press Imprint Map/parcel Number Property Address 3 [Residential Value of Work i e 0. Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name�! � .Q 1(�( , Telephone Number ` a Home Improvement Contractor License#(if applicable) Pd __ 0 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance ChP&one: M I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) (��Q E► 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 (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Vertyr must sign Property Owner Letter of Permission. ment Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 0 �FTHklp� Town of Barnstable °� l�eulat® y Services= a . inxtrA Thomas F.Geiler,Director v nv�SSss. � _ 1639. BuRding Division.. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 { www.town.barnstable.maxs Office: 508-862-4038 Fax: 508-790-6230 = Property Owner Must Complete and Sign This-S tion If Using A Builder I, &A Kf ,as Owner of the subject property 4 hereby authorizes to act on my behalf, , , in all matters relative to work authorized by this building pemut application for. . : �� La�or�S Lire .l �� C.e.�. �c,�L�.. . .. • (.Address of Job) C 1 Signatur o erDate- Print-Na e - • 5 Q TO RMS:O W NERD ERMIS S ION The Commonwealth of'Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, M4 02111 `'M ,.• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print I_.egibl yy Name (Business/Organization/Individual): * J�`l'�lXI1. Address: P. 0 COOK �3 i City/State/Zip: GJ(1 i s, Mft- 01U01. Phone#: -1 9 C - `i'.J�j Are you an employer? Check the-appropriate box: Type of project(required): 1,El am a employer with 4. ❑ I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.&m am a sole proprietor or pal suer- listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have Demolition working for me in any capacity. workers' comp,insurance. 9. ❑ Building addition [No workers' comp. insurance 5• ❑ We area 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.❑ lambing 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. 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. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a . fine up to$1,50Q.00 and/or one-year imprisomnent, 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 u er a atn and penalties of perjury that the information provided a ve is true sand correct Si ature: Date: 1 o� Phone#: V - Official use only. Igo not write in this area,to be completed by city or town official. City or:Towvn: Permit/License# Issuing Authority (circle one): 1.Board of wealth 2.Building De partment 3.City/Town Clerk 4.Electrical inspector 5:Plumbing Inspector 6. Other, - Contact Persona: Phone#: