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HomeMy WebLinkAbout0169 LONG BEACH ROAD u a -. • a.. k ,:.i� a i .� w . f. All. . \\ a s f c� oFtHe rOw Town of Barnsta E *Permit# Building Department Se aF missuedate HAMS ABIX : Brian Florence,CBO OCT O 3 2017 39 �� Building Commissi 0 . oner i639 aA i0reo r�xt 200 Main Street,Hyannis,MA Q 1! n _ www.town.barnstable.ma.0 �1..111!"4I 1!9 8A H N S I ABLE 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 /61 417/(I 2)C &ar�.L/ iCgLE Q r dResidential Value of Work$ ���'®� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ,,�G'0S JG�I,OV,Z6,t ,f19 uvo sae,y j"dx "• Contractor's Name Z,ag= �,QX. Telephone Numbers yy�z -tr 5 Home Improvement Contractor License#(if applicable) pD�fT— Email: Construction Supervisor's License#(if applicable) 40 33 '��-� ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner Q"I have Worker's Compensation Insurance Insurance Company Name /OL�lTL1T�c"�S Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) CyRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑.Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *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 arefired. SIGNATURE: oe a Q:MPFILESTORNIMbuilding permit formsEXPRESS.doc, I 08/16/17 Q�� . The Camnnonivea of-Massadiusetts De crf 'ndusfridAccidents r . 600 Wastliungtan J eel _ Boston,AIA 02111 • fVFV1fL117QSS��DY�lifidl arlmrs' Campens3fc=ln uraaice AffirTzvft:Buffders(CunfrachwsfEk'ddrians hmibers AppHram#Tmfwmmfinn Please Pant Le�iTX Address: •/�Il�1� Are u an employer?Che.cktheapprtfpriatebam ' T of reject r L I::a em 1 wi 4 ❑I am a beneral.contractor and I e ] { egt= . P� �— 6. ❑New oonsiztut� employees(fin andfor part time* leave h=d.tiie sub-contacfom ,, �, _ 2.EI•I am a sale proprietor or partaw listed on fine.attached sheet. I- lJ�odaEgg slop and fiave as etnplo*ees These sub-ctmfraclors have U❑Demol6orL -w Q fare 1II employees andhace wadners' ��fY' $ .9. ❑B,ui1dmg addition INO S4 MM! Comp raSUM,�`e Comp.n„ertra= requimd] 5. ❑ We are a cmporafion and its l�LE]E1eEtriral repairs cr ad gii0me 3-❑ lama homea-vn:er daiug g work officershave•e ercised their 1L❑Plumbingrepairs or addititms. myself[No vjozkEm'tag- �E�of exemgfion per MGL . 11❑Roof repaim, imm-,dnrere�d T c-152,§I{•4y,aadwe have no employees.wo wo�ss' 13.❑Otfier con3p-i1snu r-ce requihe—] 'Any agp�iCmt�at c5e[lcsbaa cal Tnns't elsQ fllo�the Se�aabeTaw���:P�eSiVaL�GPS'compeasefiaapuTcyiafo�aao� SnmeavraerswhesubmitffrisxTuiz u`imarxt i- dwysx�+�T�4s1Ewc sadtbeahaeauesider,�+*sre,•�amctsuhmitanewa�d t it ;na�+r�, rcaut<adotsffL-2dhecYt1Vf box mQststtarhao.addifi®al shad sIiousngthenzeofthesob-c mxadstdevrhethesar=ftsemdiiesh em139ayees.if tbesnlr{aat xCtmhw a employees,they=st•pmti,1&t1 ek trada&•camp.palky aumben lam art employer that;irpmfEig workers'com pe-Malian h=rancefor my empPo3ws ,Below is fftepoEq and job site i7L,�OCRr[PtfOn. . I surancecompanyltfan�le: 'Foficy41ar SeFf--ins Lim_ S / �' �''Z 1piratiouDate: /� Job Tits Ad&e= 42W �l � CifyfState ziP. Attach a,.copy afthe workers'compensxlianpalic_•declaration page(showing the popery number and expiration ante). Faire to secvm coverage as reg6xednuder Section 25A of MCL m 157—can lead to the imposition of criminal peaa}ties of a f=up to$L50D OU andfar onL-•year impuso--nt as well as civil penalties nn the form of a STOP WORK ORDERand a$me of up to$25100 a clap against the violator. He advised&-at a copy-of this statemennt.maybe Rwwarded fa the Office of Iuvestiga#io=of the DIA for 111stmcff coverage seaifrcstia>L I do If ersby cRrtyy as tits panes and utfres*fPerial y thatffie�arnurtum pm-u ed abvrs is bars acid arrrect Sit atur� Date- L ' a,�taL use miZy. �Da oat write,in tf b-area,fur be cmnpWad Fib caiy artnnvi n�rcial< City or T'awu: Perzuiff-kevze 4 L'aning Autlmrit�,(drde One): L Board of$eal fi 2.Ikel 17epartment S.City1rown Clerk 4.Electrical Inspector S.Phad-biitg Inspector S.Oth-w Coact Person: Phone#: — -- -- - 6\ Inforinatio)a at'd lastructiOUS - far$Derr employees; �� General Laws 152�=.all�o�to ode warms Pmrsaantto this sib, �Iopee is defined as."—c.Yp=san m$te service of Mwffi=Md=amy C=frad ofhh-r, express or imPHe`(%oral or write." ther legal entity or or any two or me An� �&y is dsIlned as"an ind vIdA PaxfnersT�,asso�fron,�Poration or o es,of the of thegoi a Joint ems,andmclndmg the legal sepresves of a deceased employ of an kffVidnal,pant=Sbip,associaiinn or o$ieglegal entity,�y mPlo - Howevez the receives or trasEee or the o ofthe- owner of a dw Uiclg hose big not more t3am#fie �menfs andvtho resides ii�rr�, �F� dweIIiag horse of ano er who c�ploys pesous to do ,rr.5kir_c on orrepair work on such dwelling hooae . or on the grotmds or bnzZdmg alrp�rt therefn sbaIlnntbecanse of sash entploymedbe dee=edto be an employer_" M cbagterr ISZ,§25C(�also sfates that¢ev ery state or IoraI licensing agency shall wrtb Bold ffie zssaarlce ar renewal of a ncen a or permit to operator a T=skess or to conch act btu�dings in the�iumonwee for any ry applirantwho has notprorkced acceptable evideace of cpmplianmwi'ftt the ftmur=ce-cover'agrequired Adffitionany.MGL rhacpter 152.§250M sister-Neiiher tjie cammqxw=RIh nor;�ny off political sabEvisians shall Mte-r intD any con-tract{artbz p c c ofpublio wozcuntl acceptable evidence of cCE03pliance7Iith the insar mce•, req�azi s of this cl3aptea have been p=e�ed to,$ie co&sctfn c.a�hoizty." AppIican-Cs _ ' ensation affidavit co�1 y.by the boars iliat apply to your sitnation mcT if Please fill out the worker'come es and e��S)along 1affi==t��S)of n��y, Ply sub (s) �5�' ) Pin Other than.the b3sm-ance. Limi�dLia}?MY Companies(LLC)arI.iffitEdLiab�itp FarfnershzFs(LtP)'vnthnn�l°yees members orgy ,arenotrimedfin cmyworke&comp easafiom.;T,sm-ance if anLLCorL P does hags employees,apolicy is re , aed. Be advisedthatfhis affdaytmaybe saw to the Depaifinent of Industrial ` Aeeideods for conEmatjm of insurm=coverage Also be sure to sight and datetlxe affidavit The affidavit should b ezct�ed to ib a city or town that the agplicafion for the permit or license is being i�gaes notthe Deparlm-ent of h&ietn 1 AcmAemfs- Slmldy)u have any gnestons g the Law or if-you are reqoied to obtain a Wogs' comp®sationpoIlcy, please caIl flit:Dep artmeot at the number listed beIow Self-inslaed couigames sb ovld eatiar their s elf-i sura ce license number on the is ac. City or Town Officials c _ Please be sore that the affdavitis comPIcbE andp�dlegilly. The DeParfinenthas provided a space the bottom ofthe affidavit for yoIItn fill out intha event the Office oflnyesbgailons has to co�tyonr%a fiagthe applicant Please be da-a to flI in tine pe�itlricrose mmber which wM be used as a reference number- In addition,an applicant that must sulamt maple p�c=r,apphcafiom in any givenYe�,need only sabnnt one affidavit indicating cua�t and under"Job Tte/ids"the applicant should wrhe"all Ioc ab- in—(cry or p olicy infb=,don[if n=s-,w) the or mown maybe provided to the " town);'A copy of the-affdavitthathas been officially staanxped crmarlredby. city applicant as proo flhat a valid affidavit is on file for fvinre'pam�iip or licenses_ A new affidavt r,,,of be filled out earls aI=z=or eamtnotlatedln anyb„Rinem or commzeercialve±� year.Where a home ownea or citizen is obfalning P to Iete this affidavit (ie.adc)glicenseorpemktnbumleavmet�-)saidpmsonisl�IOTx �� wovldl�tntbankyoniaadvanceforyourcoupe ran andsbouIdyoubaveallyq ° - ' The Office ofIn ' please do nothesitate to&ms a cA The I?epaztras a ddre5s,telephone and faXntrmbea: ' tiI of hrlo�s . �a�o�t�aY ��f a1.Ac�id�n� • . . =C:f-- Xnvedikatio= =1&Rill Fax 9.617 727 7749 Kevisea4-24-07 rcia �o�fcfi Town of Barnstable Building Department Services • A�RNfSI'�Rf - Brian Florence,CBO BLAB& 6.19. w � 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 ABuilder I, ��D �U 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) ` k **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. . . 4 Signature of Owner Signature of Applicant Print Name Print Name Date `. QTORNIS:OWNERPERMISSIONPOOLS. Rev:09/16/17 Town of Barnstable Building Department Services Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 r�rsreffia. ` - XAM www.town.barnstable.maus bs¢ & Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION --_ Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. 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 pmcedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any.homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this Issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFlLES\FORMS%uilding permit forms\EXPRESS.doc 08/16/17 AC R CIERTIFICATE OF LIABILITY!lVSURANCE THIS CERTIpCATE IS I98UED AS nArt(ASIyaMnyi CBAT'IFICATE DOES NOT AFFI A MATTf1t OF INFORMATION BELOW TtNB CER RMATNfZY OR NEGATIVELY AMt'<NpY AND CONFERS IVO RIGH78 UPON THE CERTIFICATE 07/10/2017 TWfCATE OF INSURANCE DOE8 EXTEND OR ALTER TFfF HOLDER,THIS RESENT'4TNE OR PRODUCER,AND THE CER NOT CONSTITUTE A CONTRACT Bl_7Tl COVERAGE AFFORDED BY THE POLICIES ��RTANT; 11111 e(fig holder le ADDITI A�iiOLDER FEN THE ISSUINI3 INSURER(S). A�tsrmr And OVAL INSURED,the vT►10R121=_D MrNAcay holder(nht III p/ Policy,Cmafn pobNea nqy rr►4�re an a JAI )moat be s:nrlpnraod N SUBROG er+doN,centon ndorsemenL A a ATIC{N IS W s. fate AII/ED W to ICrDt statement on this�K+fleate does not confer rights sts to the NORtHWOOp ESHBAUGH INSURANCE AGENCY INC Kaeileen midis $40 MAIN S7 __ Sos 771-1632 Kathseen.C,edg1>;(� HYANNtS 111641 n s. — MA 02601 INUMM(8j—AFFOftW*cotes, ----RERA: TRAVELERSINOENINITYCOOFAMER1Cq DAVID COX INC mac .. PO BOX 401 -- S YARMOUTF! — COVERAGES MA 0266 IM F CERTIFICATE NUMBER; 171517 THtS IS TO CERTIFY THAT THE POLICIES OF SVSURANCE LLSTED'9EL01N}lq t4EEN ISSUED TO THE REVISION NUMBER; INDICATED, N MAY BE ISSUED O ANY REQUIREMENT,TtiRM OR CONIXTtOrd OF,wY CONTRACT OR OTHER EDOCUMENT BWITH RESPECT O WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED By EXCLUSIONS AND CONDITIONS OF SUCH POLIGES.LIMITS SHOWN MAY BEEN REDUCEp BY PgtO CLWMS® HERErN IS SUBJECT TO ALL THE TERMS, TYVR OF aNUMNq: Po r rKfMsert Poucr corrEuaq�ael+eRryLl.us�trY � :— CLAIMS•MADE E OCCUR EACH OCCURRENCE _ S_ `i PR _ N/A MED EXP An oti neon) z - --GEEN%AGGREGATE UMITAPPI PER: PER9pruj 6ADV I-- — !POLICY J l_J Loc GENERAL AGGREGATE 1 a ER: PRODUCTS•COMPIOP AGG S AUTOMOSILELWSL Ty f ANYALL AUTO en1 I S AUT06 NED F-I AUTOaULED N/A tlODILY INJURY(Pet person) S �— NON-OWNED BODILY INJURY(Pmsetldenl 5 — -- HIRED AUTOS AUTOS RTY UYSIIILLA LIAY — S OCCUR Excm L" CtAIIIII E N/A EACH OCCURRENCE 5 AGGREGATE MIORKRU00YW11t11TiOM AND NWLOVWW Luww r r Y f M /� f ANYROPRMTORIPARINEWEXECuttvE EL.EACHACGDENT A OFFICER VXCLUDED9 NrA WA GHUS91OX'742217 07/16/2017 07/16/2018 I ss dawibeN under , F-L.DISEASE•EA EMPLOYE S 100,000 F E.1.DfSEANiE-DOUCYl11fiT 5 $QO,QQO...��._ NIA DESCRIPTION OF OPMTMS f LOCATIONa I Y!NMCUM(ACO M tot,AOQIrbrW anearb tleMduM,mall d altadled N rears ewme M ngWnd�i +•._— WOtkers'Compensation benefda will be paid to MassaMusetls employem Only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay daims for beneflta to employees In states DOW then MasSa tusetts Ifthe Insured hires.or has hired those employees outside Of Massachusetts. This certificate of Insurance shows the policy In force On the date that this certificate was issued(unless the expiration date on the above policy Precedes the issue dale of This ewt*Aa of insurance), The status of this coverage can be monitored de11y by accessing the Proof 0f Coverage-Coverage verification Search tool at www.mass,gov/IWd/workers••campensatbMnvestigatmr./, CERTIFICATE HOLDER CANCELLATION " SHOULD ANY OF THE ABOVE OESCR(BED POUCIES BE CANCELLED BEFORE TK EXPIRATION DATE THEREOF. NOTICE WILL BE DEt.IVE ID W Town of BamStabie ACCORDANCE WITH THE POLICY PRO VIISIONS. 200 Main St AUTHDRMIIIQaUprTAME . Hyannis MA 02601 t / Daniel M.CrovI CPCU,Vice Presidard—Residual Market—WCRIBMA 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ` i Massachusetts Department of Public Safety s Board of Building Regulations and Standards 10 License: CS-063537 Construction Supervisor DAVID R COX — PO BOX 401 SOUTH YARMOUTH MVJ7 I )I Ilk Expiration: Commissioner . 10/15/2017 • t c%xe tpnrzz.�rz�ruoetr�l/a C���la�Jtcc�zcdet! .Office of Consumer Affairs&Business Regulation M. POME IMPROVEMENT CONTRACTOR registration: :1:pOg97 TYP? . xpiration:`;_ %25f201S Private Corporatior DAVID COX,INC. David Cox 19 LAVENDER LNT_s W.YARMOUTH, MA 02673'`--' Undersecretary r ; oFTME Town of Barnstable � *Permit f < `� • Regulatory Services Expira romissued e • ssaNSTABLA ' Fee MASS a639. h Thomas F.Geiler,Director 1 DMA't Building Division aK ��1 Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstabid.ma.us Office: 508-862-403 8 EXPRESS PERMIT APPLICATION - RESIDENTIAL,.ON, Fax: 508-790-6230 Not Valid without Red X-Press Imprint Map/parcel Number__ Property Address o v ` a �. ; Q/Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ,u � Contractor's Name=_ 115 ,¢i//jf) Telephone Number ' Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) v, ]Workman's Compensation Insurance Check one: ❑ I am a sole proprietor 5 E P l 1} ��am the Homeowner I OU'UN OF BARNSTABLE I have Worker's Compensation Insurance isurance Company Name_ ,/pf/A-7/s7,*�' lorkman's Comp. Policy opy of Insurance Compliance Certificate must accompany each permit. xmit Request(check box) ED/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/doors/sliders. U-Value #of doors (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is 4reqed. _ r NATURE: PFILESTORMSIbuilding permit formAEXPRESS.doc i sed 070110 y The Commonwealth of Massachusetts t Department oflndustrial Accidents i. t• Office of Investigations Up. � 600 Washington Street i� �' 4 / Boston, MA 02111 3Vww.mass.gov/Bill Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: ZAW» Zxw, Zak City/State/Zip: � yam/? �� Phone #: 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 6 El New construction employees(full and/or part-time).* have hired the sub-contractors 2. ❑ Lam a sole proprietor or partner- listed on the attached sheet # 7.. [''Remodeling ship and have no employees These sub-contractors have 8. []'Demolition working for me in any capacity. workers' comp. insurance, 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, §](4), and we have no 12.❑ Roof repairs insurance required.] t employees.[No workers' comp. insurance required.] 13.❑ 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must arched 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.#:_jM tple �3Y22 Expiration Date: Job Site Address: /,l, !� l� l,�y ,�jJ City/State/Zip: ,,,•��Jf �1��"1 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 S250.00 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 and the pains and pena of perjury that the information provided above is true and correct: Si ature: 01 Date. Phone.#: j FOther only. Do not write in this area;to be completed by city or fawn bfftciaL n: - Permit/License# ority(circle one): Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector • J Information and Instructions Massachusetts General Laws chapter]52 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 implied,oral or written." xP or P 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 onto 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 tbis 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 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 Iaw or if you are required to'obtain a workers'. compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the-affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out iii the event the Office of Investigations has to contact yod 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 permitAicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in.advance for your cooperation and should you have any questions, please do not hesitate to give us a call. . The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Sheet Boston,.MA Oj 111 Tel. # 617-727-4900 ext 406 or 1-877-MA.SSAFE Fax# 617-727-7749 DAVID-2 OP ID: KG ACORO DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1 06/29/11 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). CONTACT PRODUCER 508-771-1632 NAME: Northwood Ins.Agency,Inc. PHONE FAX 540 Main Street,Suite 9 508-393-2955 (AIC No Eli: AIC No): Hyannis,MA 02601 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Travelers Insurance Company INSURED David Cox, Inc. INSURER B P.O. Box 401 S Yarmouth, MA 02664 INSURERC: INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A COMMERCIAL GENERAL LIABILITY 6801481 M796 03/14/11 03114/12 DAMAGE ( RENTED PREMISES Ea occurrence) $ 300,000 CLAIMS-MADE D OCCUR MED EXP(Any one person) $ 5,000 X Business Owners PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 17 POLICY 7 PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X WC STATUTH- AND EMPLOYERS'LIABILITY TORY LIMIT- O ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 6KUB91 OX742211 07/15/11 07/15/12 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION TOWNBAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 230 Main Street Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD f Massachusetts- Department of Public Safctc Board of Building Regulations and Standards Construction Supervisor License License: CS 6M7 Restricted to: 00 DAVID R COX PO SOX 401 nx S YARMOUTH, MA 02664 Expiration:, 10/15/2011 (ummisaiiMer Tr#: 5W -.. 0mcc 'j' 'Hess eg adon a j License or registration valid for lndividul use only Ree'st at On. V 00497 CONTRACTOR before the expiration date. If found return to.. RegisiraHan:,:::1a049? . �! Expiration: 3/25l2012 fie: Office of Consumer Affairs and Business Regulation Private Corparaticn 10 park plaza-Suite 5170 D ;= COX, INC Boston,MA 02116 David Cox 19 LAVENDER LN W. YARMOUTH, \�A•O?b'.7;::, ivy + Undersecretary Not valid without signatures . Ty Town of Barnstable Regulatory Services n�sxsusr� ' � g Thomas F. Geiler,Director ` Building Division Tom Perry,Building commissioner 200 Main Street,Hyannis,MA 02601 www-town.barnstable.ma.us . Office: 508-852-403 8 Fax: 508-790-6230 Property Owter,must Complete and Sign. This Section If Using A Builder as dwner of the-snbject.property, hereby authorize `1 ,ll�+>�(11 ( ;moo to.act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) ignature of Owner Date Print Name If Prove Frovertv Owner is applying for permit please complete.the Homeowners License Exemption E ' orm o. p n .the reverse side. Yip r Town of Barnstable 0 Regulatory Services Thomas F. Geiler,Director x6aa Bonding Division �En { Tom Perry,Building Commissioner 200 Mam.Sircct, Ayamnis,MA 02601 �r.towmbarnstabI�ma..us ' Offf_�,c: 508-862-4-03 8 Fax: 509-790-6230 HOMEOSVNER L.ICET`SE EXEMPTION ' Platte Print DATE JOB LOCATION: number street village "HOMEOWNER": name borne phone# work phone# cup-RENT MAn-Nd ADDRESS: city/wwn state zip code ' Tl_ie current cxrmption for"homeowners"was extended to include owmer-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. DEFBM70N OF BOMMOwj�,MR Person(s)who owns a parcel of land on which he/she resides or intends to reside, cm which_thcre is, or is intended to- be, a one or two-family dwc1ling, attached or detac hed structnres accessory to such use and/or farm structures. A person who constrgcts more than one home in a two-year period shall not be considered a bomeow=. Such "homeowner"shall submit to the Bmlding Official on a form acceptable to the Building Official, that he/she shall be respotisihle for all such work petformed.under the building permit. (Section 109.1.1) The undersigned`home:owmer"assumes responsibility for compliance with the State Building Code and other•' #g Iicable codes, bylaws,lines and re 'o lafions. The undersigned'homowwncr"certifies that,hdshc.understands the Town of Barnstable Building Department i7-MI ,impcction procedures and rtg fi-cments and that helshe will comply with said pmc=h=cs and requirements. signature of Homcmma Approval of Build ng•OfUCial Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the ' State Building Code Section 127.0 Constructibn Control_ HOAarowmmR EXEMPTION .The code states that: be3meawnc g work far which a btnlduig parrot is required shall be exempt from the provisions of this scctioo.(Secticn I D9.1.1-I•crnsing of eanstruetion Supervi.sars),provided that if the homcavymer engng=a paaori(s)for hire to do such worYti that such Homeawnec shall art as sups visor,• X j=y bomeaws?as who use this CX tion errs unawart that they are assuring the responnblHfies of a supervisor(sea Appendix Q, Wes&Regulations for Lie—Ting Construe$on Supavisaa,Section 2.15) This lark of awi=c=bFt=results in smous problems,particularly vhcn the hommwncr hams unlicensed pgsons. In this ease,our Board cannot proceed ad inct the unlicensed person as it would with z licaiscd supervisor. Thy homeowner acting as supervisor is uttinratcly iuponsible. . To cruum that the homeowner is fully:ware of his/herresponsrbilitics,many convrnmitics require,as part of the permit application, ta.t the bomrownc ratify tbat bdshe emdcstands the responnbilitics of a Supervisor. On the last page of this issue is a.Perm eurnmfly used by ,cril towns. You may ran t amcnd and adopt such a fbnTJeavfieatioo far use in Your eorrvrnmity. 0 5'Jiy�le oFtrt�r Town of Barnstable . kper.it� Qy Expires 6 montks jrarn issue date Regulatory Services Fee * saruvsrnsr.E, } v� MASS- Thomas F. Geiler,Director 03;9. �0 AlFoy a Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number /�C��OT ( Property Address /�j��` 6�,���'� ,,�G�f;�'� �O�'t-G�,• ceww DResidential Value of Work Ar'0101.I®� Minimum fee of$25.00 for work under$6000.00 i Owner's Name&Address.. 46 Contractor's Name ` � ��Jz �,,�/�i Telephone Numbera� J , Home Improvement Contractor License#(if applicable) Z�� Construction Supervisor's License#(if applicable) -PRESS Zorkman's Compensation Insurance ;`SAY 4 2010 Check one: ❑ I am a sole proprietor TOWN OF BAR STAB.LE 'I am the Homeowner P'I have Worker's Compensation Insurance Insurance Company Name :2�%l ZiL'f�5� Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) [P/Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping: Going over. existing layers of roof) ❑ -Re-side #of doors. ❑' Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required:Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ` 'Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License'& Construction Supervisors License is equired. SIGNATURE: •Q:\WPFILES\FORMS\building permit formslEXPRESS.doC ReVi zpri n4nR00. The Commonwealth of Massachusetts l Department oflndustrialAccidents 1 Office of Investigations 600 .,Washington Street Boston, PJA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeiblv Name (Business/Crganization/It)ciividitai): — Address: / Gi+r1J�l�J ? � — --- City/State/zip:_- �.3 Phone #: ? A e you an employer? Check the appropriate box: Type of project(required): I 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction fit11 and/or Part-time),* have hired the sub-contractors employees (2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-conuactors have l g. Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp, insurance.t required.] 5. ❑ We are a corporation and its 10,❑ Electrical repairs or additions 3.❑ 1 Evm a homeowner doing all work officers have exercised their 11,❑ Plumbing repairs or additions myself. [Na-w�rke;5'.comp,. . . .. . right of exemption per MGL 12. 00f.repairs insurance required.l t c. 152, §l(4),and we have no employees. [No workers' 13.❑ Other _— comp, insurance required.] *Any applicant that chocks box tl1 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 ernptoyces, if the sub-contractors have employees,they must provide their workers'comp.policy number. lam ate employer that is providing rvoe-kers'cornpen.sation itesue•ance for my employees. Below is floe policy andjoh site inf'ormati��rr. Insurance Company Name:_ p���'�15 `S .- Policy #or Self•ins. Lic. #; C�o�'�/l�.C! Exiration Date:— P Job Site Address: A--) �� 11sfZJXeSAZ 14CROR 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$1,500M and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I da hereby certify ae er the pains and penalties fperjaery that the information provided above is true and correct. Si ature: - Date: ��/�� ld- Phone#: ' -- Official use only. Do not write in this area, to be completed by city or town official, i City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/To►vn Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact]Person Phone#: 04/30/2010 08:39 5032970506 PAGE 01/01 r Town of Barustable RegUlatory Services ` i 1 ThOMIX F.V9094 Mr-tor ■ )Building Division Tom IP,,7,)1nI04M,COmmts.tanRr 2(Q Mo►u shwk ftyMis,MA M-60, fgyrw-fu.w.6�rMt�ble.ma.mR ,. otr�: sas-asa�aazs x�f: sos,��o��an � Pn4perty C)wxruer MUSt Complete and Sigh This$ecdoll If Ijd h/zG�lOG�1� `ux1d71� or of x6 subject prOPOKY in saou rn>b�l ut mil to4ttrn relsrirn to work}uthor$ud by ihlt burg F Fi? 0I job) a�(pnafiulc of C)?4wr a� If �C V,. Q.£is applying for permit please complete OWk��sr�eoR►netx License.Exemption Form on the reverse side. 3 -`y .-.�rre4•�1ante�r.�u��7 FrOrn.'r'.ztny Geddis FaxIC:Notthwood r+su^ance �-aee[OT t L aOX S'tww v'.r.vr riv!rayv.a yr �CvI CERTIFICATE OF LIABILITY INSURANCE OP ID Ke x�Y DAVID 2 04 20 10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Northwood Irks. '.AlgenGy, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 540 Main Sheet, Suite 9 ALTER THE COVERAGE AFFORDED MY THE POLICIES BELOW. Hyannis HA 02601 Phone:508-771-1632 Fax:508-393-2955 INSURERS AFFORDING COVERAGE �NAfC# !kBUR@D Travelers Ineurance Company INSURER 3 �--- -- — - - . . iald Cox, inc. - INSURER S Yarmouth4MAA 02664 I aJ;URER D. WBURER COVERAGE$ ThE FCt.iCk'S irF WSI,nAtJCE.LIrTEL 9F.U:, J H?.VE BEEN IS Lk p'u l'-F:^1::pE .rlAt.kD AAO'.'=-OR THE PWI "'PERIOD iND!CATED t.CTArITNSTANDINi. .-Nrr R +,T RW..SA S;OI'011'0taN OF Ar;-'CNTRLCl OP 0 hER Ue:.UrAE-4T'r+!Tr RE3PEC't.-1NwmlI r.-:+!$CE4TIFIC,'A trr BE' SUER OR %�a'r FEF iAH:,?tE iN5U`n,raC$AFFCr.CED BY SHE P01.1C ES DESCRIA_D-tE EN I5 _F.A15.EY.""_UuIO`JC,A`.D OMGIT!JNS''F I PO C:£:A3G F:E'3ATE Lih:ITS„HO'F'N S4AY t•W,VE SEE-`I PE-JICED ti'PF,D CLAWS fir.._..—._�_..�.... POUOY'P7tJMBEii I r L M�.��..—.., L'R tdBRD TYPE OF IP: JCE _j IDATc{A1hf1DLr11'I^i iDATE,nS D YIYY'r ' 1 i OENE RAIL LIABILITY I Baer r;ccVR�,E,:Ce• s 1000600 CComvEF'CIAL_e .14811.1:+ I ; . ,_. i i I' PPENbS'ES'Ea o�0) _3000`0 0 CLAIMS MAL`E 03/ alF '.)Cr VED?)P(4n!r Ina Frrscq 5000 _siteas owners s100000 0 i I4v N=R L✓du;:'F-" Tl _ 2000000 ( LJIAITl-P-IBC PER. - !rFvCl4C'''�•r_a-Np/u?4:. 2000000 PE:' I I f ;AUTOMOBILE LL424JTY r;1I IBt`IrG SIP,i LE L!tAl1' r I ANY nr!"0 ;E9 arolca�•) P` ALL UW'JED AUIrJ� nq IIJ,JI t S _ ,:I+ED'.A.EOr,L!YO: fy �l�atl�dfi•:Y+: I iP�D i rp? I BODILI+N AIRY 1 { I tJ:'.•OWNEC AUT05 i I I{P3i axiddnu. ) 1 I4 I I(P��FEFRi GAlvrWc' 1 a i 0AM40E LIA$ILTY 1 AUTO ONLY•EA ACCIDE I rNl'uLI-{, I I I TI-ERTFWAi - EA A-, }¢ i; 1 i I AUTO ONLY AsG 1=921 UMBRELLA LIABILITY ` EACH 1CC•!RP,EN^'c _r_IJk J';LAIN$MADE I i I Cr EiATE o �— OEDUC"IBLc rRETENT 01, I 1 AND ENPLCtiVA'LIABUTY rCP',utmT Ec A ' PRUrkETCR'PAR rNERY XE-.,V E —� 6KU891OX742209 07/15/09 07/15/10 EL SACI-A^' __tJr s 100000 I pF=1�ER�IEIN6ER EX�....� ' I(MandotoryInNH}. EL LI_EA5E•EA EE $100000 {!t y*s,desonba under .. A,FFCY!;';b7N5 DNuty. E L 75E.4F.POU':;LInI1T $500000 OTHER I I CRP -0 O OPsr LGOA / HICLSS i EXCLIJ94ONt ADDED NY 9NDORmAENT i specIAL PROVISIONS ' CERTIFICATE HOLDER CANCELLATION SHOULC ANY OF THE ABOVE DESCRIBED POLCIES BE CANCELLED(AFORE THE EXPIRATION TOWNSAR DATE THEREOF,THE IS4.14I N01NSURER VALL ENDEAVOR TO MWL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEM BUT FAILURE TO DO SO 9:-IA LL INP03r.NO 031.44TION OR LIA U"(.OF At'.}Y KIND LiPO'J THE NdSUROA.ITS A.OBNTS OR TOWN OF BARNSTABLE REfRESBd1�nvEs. n 361 MAIN ST7l Et AMOR m4mmwfi I HYAWIS MA 02603 ACORD-25(2009/01) 01988-2009 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered mails of ACORD J � ✓1 � ,I Board of Building Regulations and Standards I License or registration valid foi•individul use only HOME IMPROVEMENT CONTRACTOR I before the expiration date. If found return to: Board of Building Regulations and Standards Reg istr4i i.AWL,, 100497 One Ashburton Place Rm 1301 . I Expiration 6/,18/2010 Tr# 268012. 1: I e� Boston,Ma.02108 I Type Private Corporation r , �. DAVID COX INC, David Cox .19 LAVENDER LN���\ W.YARMOUTH,MA 02673 Administrator_ Not valid without s' nature _ ublic Safety )arlme"t o f P Dl• tnd Stantlurds 0"etts- ,mil ttions` of Buildin S per'Jisor License B0`trd uction w 1 Coi Al 63537 t r } License tedt0l't- �'t'e"�;} r h p Restric o R� ` r, ra pAVID , F0 gOX 0266 4 S YARM�UTH MA . 1011512011 • EXpiration� 5822 , C:omnu