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HomeMy WebLinkAbout0042 MAPLE AVENUE �. � � °� � 0. ��. x . , .� 1 .� .y�:. .." Il �� � 1 ,� r d ,. .. � ; .. - ,- .., �, „o m f� ;a i � :� is e�.:+. �.,. 'gip .'. .. � ,. .� ,. �," � � � � ,§ � _ .. .. .. .r. �a �', 0 ... ! c � c ... � , .. n +� - •. r a �: . � •. o i ,, :.� ,. e n. ., ,::. __�.�. �. 02©►�os�� oFt ram, Town of Barnstable *Permit# Expires 6.month s e dat Regulatory Services Fee 4 Y . rt }3ARN.STABw � MASS. Richard V.Scali,Director ATFDMp'tA1� recor CC& Building Division . Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.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 - o^ t r Property Address 2 � ��� �� c l G urg�L&I r Residential Value of Work$ !/� 1 066 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address }L( CeS-12 f 10 qZ Contractor's Name Jo /� f {�6 /�}� (� Telephone Number ��t�% i4z-o -6,R5S— Home Improvement Contractor License#(if applicable)f1 o2-� Email:/ a (P dp_(,a tw9\/1,A)L. C04n Construction Supervisor's License#(if applicable) G b 47 f Xworkman's Compensation Insurance Check one: ❑ I am a sole proprietor - Jas � ❑ I am the Homeowner [� I have Worker's Compensation Insurance T®M4®FBqRNSTA®LE L �, Insurance Company Name �.I �oe/Q T� �.(�Q�(�L/Q-� 1�JU121 14jl.,4�16 Workman's Comp.Policy# � J�� 31 S .3 LRio( _ b 13 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ' ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side i p Replacement Windows/doors/sliders.U-Value c 3 F (maximum.35)#of windows D #of doors:0 ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. copy of the me Improvement Contractors License&Construction Supervisors License is r e ired. SIGNAT Q:\WPFILES\ ORMS\build g permit forms XPRESS.doc Revised 061 13 The Caznmorrnf--�of Massachuseffs Deparhnent of hzdkstnd Accidents Office of finves4lafians 600 Wm*ington S&eet Rastan,AM 02.11 iww.rnasmgaWdia 'workers' Campensatian.Insurance Affidavit:Biiifders/Cuntractors/FIectriciansMumbers Applic2nt Please Brit Legibly Name(BusnemlOrganizationlhiEvidnao: Address: 4r-- KE, 1A P44661'f � UA utyfstatejzip= � Mk, ,02b`Ip a -CS-' gZO-6$'SS' Are you an employer?Check the appropriate box: T o -_ am a general contractor and I � f�'o Ie-t(r e'tlu��= 1.El I am a employer with 4 ❑ I g 6- ❑New constiort employees(full and/or part-time}* Ilavehir the sub-contracfrns. listed on the attached sheet; 7- ❑Remodeling 7_El I am a sole proprietor orparfner- 'I7�snlx-co:ttrarors have ship and have no employees t S_ ❑Demolitina worfcisg for in any capacity_ employees and have workers' 9_ ❑Building addition [Y [ OrIfEiS� comp-insurance comp-ms3£ant&l rewired-] 5_❑ We are a corporaticnand its 10-0 Electrical repairs or additions I❑ I am a homeowner doing all work- officers ha,.m exercised their I I_Q Plumbing repairs or additions mjSeIf [NO tvO:rkrss'gyp- right of exemptioaper MGL I2 ❑Roofregairs it,ntc=cerequiired_]F c_ 154§1(4} and we have no � ' , I employees-[No w�is' 1.3_.L�1//Other C�.�IKiQ Ll� comp_in-ox-*ce reg6re-d.1, }Any sapHumt that cbzcks boa f1 most also fll oil the section bel�sbnw tbea wo3tess'compensstiou poii-T iJR3t!ffii033- 1 Hnmmwnem who=bash this sY3dXn i,-T—x6 n they are tiring RE WOOk End then hire oslside CQI&I &S mast sobmit a neF s—ndsrit mdcsting RDzb- t03atuctors tbst check this b=mmt 3thrhed an additino4 sheet slsoscing the mmope of ilia Sob-amIIr ors xad stale Ahether tx nut those emir fisvc rmpluyees- If tl snlrcont�ctots hac a empIoSees,th¢g must gsuride tt�_r wtwkers'comp_policy ntunber I am ara employer that is prm+idirtg wor#e--rs'c-ongmmvrlio.n ifmiranca for my'e-nrpl em Heiow is the policy and job site 67 infotmatL asitance CompauTyName: Wi.Lfi uw L t 1JSu2l4l�e GO . Policy 4,or Self ins_Lic-;9: wExpiration Date. Z. Iob Sif� adiess: L �V1 yap l.,,G AN city/State,Z :G6*-,4'X&ut I(L , UTA,60�.'3& Attrch a copy of the Nmrkers'compensation policy declarstion page(showing the policy number and expiration date). Failure to secure mv-erage as required under Section 25_4 of MGL c. 152 rxn Lead to the imposition of-eriminal penalties of a fine up to S 1,5 oa.0a and/or one-yea iiaprisonment,as well.as civil penalties in lhe foffi of a STOP WORK ORDER and a fine of up to�250.0/3 a.day against the violator. Be advised that a copy of this statement maybe farwarded to the Office of Imrestigations of ffie DIA far inax-ance coverage verific atirnt I dd hereby cer j fy under thp af as Dfpedmy that the in formation pran�W abm a it bwa and correct SiEaataze: G p p I}ate= �4§e&lt A4 i9 Loll Phone#: SO Offtciu£use Only. Da not Write in tHs area,to be compfetad by cify or town of ciaL City or Town: Permit[Uceuse# Lss-ning Authority(drele one).: I.Board of Health 2.Eudding Department I CityJF awn Qerk 4.Electrical Inspector fi.Plumbing Inspector .6.Othes contact Person; Phone#: 6 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 Iegal representatives of a deceased employcr,•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 empIoyer." MGL chapter 152, §25C(6)also stales that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to constrict buildings in the commonwealth;or 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 win the insurauce requirements of this chapter have been presented to the contracting authority_" Applicants Please fill out the workers' compensation am:—davit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone nazaber(s)along with then certificate(s) of insurance. Limited Liability Companies(LLC) or Limited Liability Pa,-tDer^sL—,ps(T_.LP)vvithno employes other than the members or partners,are not requ red to carry workers' compensation insii dnce_ if a3 LLC or LLP does have employees, a policy is required, fie advised that this affidavit may be submitted to the Department of Indusu al Accidents for confirmation of insurance rover-age. Also be sure to sign and date the affidavit Tlie affidavit sboLd be returned to the city or town that the application for the permit or license is being regacsted,not the Department of Industrial Accidents. Should you have any questions regarding the late or if you are required to obtain a workers' compensation policy,please call the Department at the number listi�_d below. Self-insured companies should enter their self-insurance license number on ire arpropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Depar',ment 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-tion,an applicant that must submit multiple permitllicease applitations in any given year,need only submit one arffidavit indicating current policy information (if necessary)and under"Job Site Address"the applicant should t�nte"all locations is (cii�or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to t$e applicant as proof that a valid affidavit is on file for future permits or licenses_ Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this afa-datidt The Office of Investigations would lae to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a c 11. The Department's address,telephone and tax number: Tbfi Conamonwean of Mnsadausetts l?epalmt,nt of Indust ial Accidezfs Office of kyeshgations Gw Washington Stet Boston,IAA 02111 TfI,9 617 727-49-00 W 406 or I--RTT hCkSSAFE Revised 4-24-07 Fax-? 617-727-7749 -v;rw f_m s,5 gQvld,_a 1 °FETOh� Town of Barnstable' Regulatory Services HARNSTABM� Richard V.Scali,Director 16;9. 'DrEDNia�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 F as Owner of the subject property hereby authorize 7b 1v,) Z L j A J g; Q to act on my behalf, in all matters relative to work authorized by dais building permit application for: c4 Z VA A L�- Alm, (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. o Signature of Owner Si ature o App cant t / 9 Print Name Print Name Date } Q:FORM&O WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services �4oF rofcyy Richard V.Scali,Director t Building Division * rrrsTnst E Tom Perry,Building Commissioner =6 ,m� 200 Main Street, Hyannis,MA 02601 pTE° '�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 fir CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &ReguIations for Licensing Construction Supervisors,Section 2.15) 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 formfcertification for use in your community. Q:\WPFILES\FORMS\building permit foIms\EXPRESS.doc Revised 061313 I 4/1/2014 11:22:06 P.N PST (GMT-3) FROM: _00005-TO: 15084206856 Page: 2 of 2 ACORU® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 411/2014 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 tefms 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 endomemen s. PRODUCER DOWLING &O'NEIL INSURANCE AGENCY INC Nance T 973 IYANNOUGH RD PHONE FAX PO BOX 1990 Arc No): HYANNIS, MA 02601 ADDRESS- - INSURER(S)AFFORDING COVERAGE NAIC If INSURER A: LM Insurance Corporation 33600 J J DELANEY INC w INSURER B: 20 RASCALLY RABBIT ROAD UNIT 2 NSURERC: MARSTON MILLS MA 02648 NSURERD: INSURER E: N3URERF: COVERAGES CERTIFICATE NUMBER: 19695816 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. LIICY EFF MhWCD1YYYY LIMITS L�TRR D SUBR TYPE OF INSURANCE POLICY NUMBER COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAMS-MACE F—J OCCUR r9U- - c $ MED EXP(Anyone person) $ PERSONAL&ACV INJURY $ MOTHER: LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ POLICY❑PECOT- LOC PRCDUCTS-COMP/OP AGG $ $ AUTOMOBILE LIABILITY S t T $ .Ea aaident AN"AUTO BOCILY INJURY(Psr person) $ ALL OWNED SCHEDULED AUTCS AUTOS BOCILY INJURY,.Psr accident) $ HIRED AUTOS NON-OWNED PRC AUTOS fP� PERTY DAMAGE $ raC'RTY UMBRELLA LIAS HOCCUR EACH OCCURRENCE $ EXCESS LIAS CLAMS-MACE AGGREGATE $ DED I RETENTION $ A WORKERS COMPENSATION WC5-31 S-318101-013 11/212013 11/2/2014 PER OTH AND EMPLOYERS'UABIUTY Y/N ✓ STATUTE ER ANY PROPRIETORIPARTNER/EXECUTNE E.L.EACH ACCIDE3�1T $ SODOOO OFFICEFbMEMBER EXCLUDED7 N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE 500000 If yss,describe under $ DESCRIPTION OF OPERATIONS babes I E.L.DISEASE-POLICY UMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) Wor<ersacompensation insurance coverage applies only to the workers compensation laws of the state of MA. Th s certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. RE: 75 HORNBEAM LANE CENTERVILLE MA CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLIED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 MAIN STREET ACCORDANCE NTH THE POLICY PROVISIONS. HYANNIS MA 02601 AUTHORIZED REPRESENTATIVE I LM Insurance Corporaton 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CEAT a0.: L9695816 CL=EVT CODE: 1315396 Anne Chandler 4!1/2014 11:18:13 AM Page 1 of 1 U j Massachusetts -Department of Public Safety Board of Building Regulations and Standards i Construction Supervisor G License: CS-009961s` JOBN J DELANE 271 PLUM ST West Barnstable NIA 8 r A. Expiration . Commissioner 04/14/2016 - Office of Consumer Affairs&,BmsfttessrRegul9"lion' ME,IMPROVEMENT CONT.RACT.OR i egistration. �25529 Type. xpiration 1/15l20T6_ Individual JOHN°'J. DELANEY 4 JOHN ;DELAN.EY 271 PLUM ST W.BARNSTAB.LE, MA 02668' Undersecretary U Massachusetts -Department of,Public Safety Board of Building Regulations and Standards i - Construction.Supervisor `s x` License: CS-009961 � ! JOHN J DELANE r_ re •,jrt . ; 271 PLUM ST s I West Barnstable IRA 68 j . Expiration 04/14/2016 L Commissioner e. • 4 License or registration valid:for mdividuli use only , before the expiration,date I•f;found return to: ' Office of Consumer Affair&and Business Regulation 10'Park'Plaza-Suite 5170, I, Boston,MA 02116: f. Not"vand_wiftiouYsignature i , L 10 of Town �of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee 3 a a a "sr*tMM NAM t' Thomas F..Geiler,Director PERMIT X-PRESS Building Division Tom Perry, CBO, Building Commissioner - APR O 6 2��2 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma us Office; 508-862-4038 OF NMML 0 EXPRESS PERAUT APPLICATION - RESIDE UW ONLY Not Vaild without Red X-Press Imprint Map/parcel Number 2O 7 Z.o3 Property Address 7 2 mf•lj�l_ Aut , ✓e,;(16 Residential Value of Work 10oZ/0-0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �,A I,( L 4 . +� f�� (y Id Contractor's Name d ��L�1�2�/i Telephone Number q,70 6 kg:5— Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: El I am a sole proprietor ❑ I am the Homeowner WI have Worker's Compensation Insurance Insurarce Company Name ��f7�/c� �vj /�G t1t 1 tt N Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over -existing layers of roof) ❑ Re-side • #of doors. Replacement Windows/doors/sliders.U-Value_ eJ� (rriaximum..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 r red. 5iGNATURE: 1WPFIL.ESIFORMSUilding permit formslEXPRESS.doe !vi_qPri mn I 10 r 12 12:08:07 FN_ PST (GAIT-8) FROM: , insurancevisions.� Page: of 2 " ` Morro CERTIFICATE OF LIABILITY INSURANCE DATE. 124120iYYYY) 12 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 f' 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 it lieu of such endarsemen s. : PRODUCER DOWLING &O'NEIL INS AGENCY INC. CONTACT NAME: 973 IYANNOUGH RD PHONE IAA t.Exn•(508)775-1620 ac N : HYANNIS, MA02601 . E-MAIL ADDRESS: - INSURER(S)AFFORDING COVERAGE ' NAIC A _ NSURERA.: NIRED- - INSURER III • - J J DELANEY INC 20 RASCALLY RABBIT ROAD UNIT 2 INSURER C MARSTON MILLS MA 02648 NSURERD: -- .—�---- ------ --- - • ---- INSURER E NSURERF: COVERAGES CERTIFICATE NUMBER: 12240074 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 POLICY EXP LTR D SUBR •POLICY NUMBER �9DPOILIC Y EFF MMlbD1YYYY ,-- LIMITS TYPE OF GENERAL LIABILITY _ EACH OCCURRENCE E COMMERCIAL GENERAL LIABILITY DAMAGE TO Ea RENTED $ CLAMSaAACE OCCUR MED EXP(Anyone person) $ PERSONAL R ACV INJURY $ GENERAL AGGREGATE $ GENLAGGREGATE LIMIT APPLIES PER: PRCDUCTS•COMPIOP AGG,b POLICY F PRO- LOC — AUTOMOBILE LIABILITY acci anlSl LIMIT ANv AUTO BOCILY INJURY{Par person) ALL AUTCS OWNED SCHED8 AUTOS y BOCLY INJURY(Par acciient) NON-OWNED P��CPERTY DAMAGE HIRED AUTOS AUTOS (Psr e,ER $ UMBRELLA LlAB OCCUR - - EACH OCCURRENCE ; EXCESS LIAB CLAMS-MACE AGGREGATE $- DIED RETENTION$ A WORKIERS COMPENSATION WC2-31 S-318101-011 11/2/2011 11/2/2012 we LIMIT AND EMPLOYERS'LIABILITY YIN J TORY LIMBS _ TATU MY PROPRIETOR/PARTNERIEXECUTIVE - E.L.EACH ACCIDENT $ SOOOOO OFFICER/MEMBEREXCLUDED7 ❑N NIA (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE $ 500000 N yes,dasurbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY L MIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I.VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space kc required) - Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE � THE EXPIRATION DATE THEREOF, NOTICE•WILL BE DELIVERED IN BUILDING DEPT IA_9Pr� ACCORDANCE WITH THE POLICY PROVISIONS. 200 MAIN STREET HYANNIS MA 02601 DREPRESENTAIrvE . Jeff Eldridge 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are.registered marks of ACORD CEAT NO.: 12240074 CL_ENT CODE: 1315536 :essica Lirck 1124/2012 12:05:20 PM Page 1 of 1This certificate cancels and supersedes ALL.previously issued certificates.' The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street w: Boston,MA 02111 ww .mass. ov/dia .w g Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): . J. •Address: v G - P City/State/Zip:.��� �1� M6d Phone.#: �Lg- o '•(o�YS� AFI an employer?Check the appropriate box: Type of project(required):. 1. m a employer with 3 •4. [] I am a general contractor and I * have hired the sub-contractors 6. El New construction . . employees(full and/or part-time). . 2.❑ I am a•sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Ej Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. o workers'co right of exemption per MGL Y � comp. 12.❑Roof repairs i insurance required.]t c. 152, §1(4),and we have no employees.(No workers' 13.�OtherJ� �.l(j rw�c91! S comp.insurance required.] ciQ '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 subcontractors have employees,they must provide their workers'comp.policy number. lam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: L n1•' s ' j 015a) Expiration Date: 01 Z �{Z � 1�� ,Job Site,Address: City/State/Zip:����%%ul/�� 4 V,:5,3?—. Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u er the ain -and penalties of perjury that the information provided above is true and correct. Signature-' 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#: 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 individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced,acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public.work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented'to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 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 permittlicense 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 fo 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 lndustdal Aecidems Office of Investigations 600 Washingtori Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax##617-727-7749 Revised 11-22-06 • www.mass..gov/dia f APR-05-2012 15:01 508 697 2018 508 697 2018 P.01 f •• b i j' t Town of Harastable # ! Regubtory Servicca7%mos It.COW,Dirwar Building Division T=Parry,BaUdlag Commbalow 2W Msla 8treA 11yaYwls.MA 0MOI j w�uto�ra.baraaioblama.w Mae: SOB462,g038 Fax: 509-790-WO " property Owner Must Complete and Sign This Section IfUdWABL A Y, '� .as Ow=of the subject ptMPanT hetrby avebo e - 7�6►2 to act on say beb4 i io all=ahem relative to wosh authorind by this bWftg pmmit. r i (A4dme of Job) s **Pool fences and dam are the reeporabilityof the applicant. Pools Zno,,(boj�lodbelon ace is installed and pools are not to be n 4 final ins e a arc performed and accepted. .4 conee tuxe oEA1)pliQaat pzineName Pn'ntNsme ' Iaate o-ro�e;o9roNrocn.9 I j i Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License:CS4)OM61 SETTS O JOHN J DR 9� - 271 PLUM SIP � W BARNSTjO 7 7 y gna Expiration Commissioner t 04114/2014 of of,C o ✓uaagadzuee Office Consumer Affairs&Bo"'ness Regnlahon dME1MPROYEMENT`CONTR14GTOf2 Registratiton• 2g Type. Expiration t4 Individual i J0 ,1 DELA'NE-, J.OHN Dtrl NE 279 PLu ST lQ� W.BAE7NSTABLE,, g °" ' Undersecretary ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map - •Parcel , Permit# g / Health Division !609�L-/37' Date Issued Conservation Division ����G Y� Application Fee Tax Collector ` a Permit Fee Treasurer SEPTIC SYSTEM MUST OE Planning Dept. ' INSTALLED IN COMPLIANCE WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address q2 P' AU/ � n� Village Owner';�A� LyAfi9 Address Telephone Permit Request >� � l f��`t d i�, � try i&L7J ! Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District_ / Flood Plain,— �` Groundwater Overlay Project Valuation Zl.Jr& (O Construction Type i' �✓1� Lot Size Grandfathered: Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family )9C' Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes l Wo On Old King's Highway: ❑Yes �KVo Basement Type: Xull ;Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) 4R�10 0 Basement Unfinished Area(sq.ft) � Number of Baths: Full: existing 2— new Half:existing new f Number of Bedrooms: existing new Q Total Room Count(not including baths): existing _ 0 new First Floor Room Count 114 Heat Type and Fuel: as ❑Oil 0 Electric ❑Other Central Air: ❑Yes *No Fireplaces: Existing New Existing wood/coal stove: ❑Yes , *b Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage: xisting ❑new size 17,.K2 Shed:❑existing ❑new size Other: - t Zoning Board of Appeals Authorization O Appeal# Recorded❑ s Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use II , per_ BUILDER INFORMATION Name Telephone Number ' %61 Address ' Q �Z l ,�'4I,���'� :�4 License#�� . , �_ �✓ 9'1 � &'11 / ? �- 121111 6 Home Improvement contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO e;;nl - SIGNATU '�✓, s �✓ DATE �'' FOR OFFICIAL USE ONLY PERMIT NO. t - DATE ISSUED ` MAP/PARCEL NO. • ADDRESS' VILLAGE 3 OWNER • r r " , DATE OF INSPECTION: _ 1� r 4. FOUNDATION FRAME U< S-2�1—V 4 INSULATION � i FIREPLACE , ^ , rn ELECTRICAL: ROU( =a Fr FINAL! t7'? ` PLUMBING: ROUE c FINAL �- 1 ,, •f GAS: ROUC3 n x FINAL ;. FINAL BUILDING '� f DATE CLOSED OUT = ASSOCIATION PLAN NO. I "Zu c� �-7MAPLS, Akk , C&Wr6ul x t 0 rtA p E f 't o "j/17.1' j�" S rz- 64LAOW �)crsTljv� �oH�� �� S�n��Vlv•l l h�� �e.-y�e�.� � � L d kv. 1 � i 1.91 b 4ko It r " DO-A {Mid W Qrvu V.Wd A 6 ��L1C��►�1 v fMFTp�� The Town of Barnstable ' ,RYSTABLL Department of Health Safety and Environmental Services MASS Building Division 367 Main Street,Hyannis,MA 02601 508-862-4038 508-790-6230 PLANT REVIEW Owner: l -0 5J Q I l Map/Parcei: ' (-) (o Project Address:Li 9- `V V Builder: •-.� . I")Q_ VtQ _ The following items were noted on'reviewing: 2_ . or e Alp r er�S Reviewed by: Date: f The Commonwealth of Massachusetts Department of Industrial Accidents pA 600 Washington Street Boston,Mass. 02111 Workers' Co ensation Insurance Affidavit-General Businesses name �! , t/G address' / � J J ' 1 ,ten�/� city Li/, _A49 A)"14 state: �y r lr i ziu:v �=1�(1 phone# work site location(full address): n/ pk e ft t& 6-A M y r , i ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Restaurant/Bar/Eating Establishment working in any capacity. ❑Office❑ Sales(including Real Estate,Autos etc.) ❑I ai,an em loyer with em loyees(full& art time). ❑Other �I am an employer providing workers'.compensation for my employees working on this job. company name: pi l/e� 7) - Lot 9.c . . .y city /�/ / /� .n/ �/ Y��L'1 °% phone#: insurance-cot: .:. . : olc #.. : .:; h am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: address:.:: : : city:. phone#.E 4. insurance co. :2! 90 :# company name:::,:: :.:. address city. phone#c insurance sb.: ::•:. olicv• 6. Fallure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that e copy of this statement a forw3rdedtoAc Office of Investigations of the DIA for coverage verification. I do hereby cert er th ns d p nalties of ury that the information provided above is true and c rrect Signs Print name Phone# official use only do not write In this area to be completed by city or town official city or town: permittlicense# ❑Building Department - ❑check if immediate response is required ❑Licensing Board p q ❑Selectmen's Office ❑Health Department J contact person: phone#; ❑Other (mvaed Sept 2003) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has -not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions e11 nter mto any contract fort a performance ot pubhc work u—nti acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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"lave'or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. I City or Towns 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 lie used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 8910 of Immulgoons 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone# 61( 7) 7274900 ext.406 oFTME roe Town of Barnstable "0 Regulatory Services S rJAMSTs ram, : Thomas F.Geller,Director MASi639• �,�� Building Division lFD MA't ' Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862-4038 P emit no. Date ' AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERIYM APPLICATION MGL c.142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, -improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adj scent to such residence or building be done by registered contractors,with certain exceptions,along with other re q uirements. A,, . �G� U ( LGI � � Estimated Cost , V,!� Type of Work. Address of Work: 7/� �`� d"� AA, z1,ikj?M0 Owner's Name: _T Date of Application: 2"0 I hereby certify that: Registration is not required for the following reason(s): DWork excluded bylaw []lob Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: Ogg PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FAR ITRATIO PROGRAM OR GUARANTYWFUND UNDER MGNOT L c 142A. ACCE55 TO THE . SIGNED UNDER PENALTIES OF PERJURY jhe-reb ppl for a permit as the a�en of the o r:o �J �� �a� �/ �y Date Contractor Name Registration No. OR Date Owner's Name TZO T�bie ds.11b(cotttiascai) 1<ass1l Fuels pz-es grip tiYe pxetesgcc far dita sstd'I•waFsza3ly AssldentLil$AOdia�t gaud� �MMI x�lr�s�c�alina hYAXfMIJM Celling Till Floar >3zs 4 P�cw Equipment ElFcierse}� Cluing Glaring4� R.yEluw F''` t Am'VA) u.yalue� R-yxIu R-yalue R.yaluer . A Y%lu° Pam° 'S701 to 6900 Hesting Degret D17'V 6 ?arms! 38 13 I9 10 Normal 0.40 f9 ]0 30 19 6 is AWE Normal 9 t2/. 0.s0 31 13 NIA 19 10 6A Norma! T . 0.44 38 19 19 10 NIA f3 AFtIE u . 0. 3a 13 25 NIA 6 fS AFUE Y 15Y, 0.44 19 19 ]0 Normal 15'/4, 0 3Z 30 25 NIA NIA � 'l. 03Z 38 13 NIA Normal X 38 19 2T NIA 6 QO AFV1r y . 0.42 13 19 10 90.AFV z 18'1. 0.42 38 i9 19 10 6 AA 1g'l. O,so 3a 1, ADDRE5S OF PROPERTY: �U � 32/ . �. SQVARE FOOTAGE OF ALL EXTERIOR WALLS: ' SQVARE FOOTAGE OF ALL GLAZING: 3. 4. % aLAZING AREA(03 DIVIDED BY#Z): g, SELECT PACKAGE(Q--AA-gee chart aboye): OTI-MR MORE INVOLVED METHODS OF DETERMINRN G map'Gy ggQtJauMENTS ARE AVAILABLE, ASK US FOR THIS WORMATION, q X�4 /V 610WIA) j4 , 1 dt� Iva- r �, 1 1 0 BU,DING INSPECTOR APPR VAL. NO,, YES; q-f0rms-fl 80303 s RESIDENTIAL BUILDING PERAUT FEES APPLICATION FEE $50.00 New Buildings,Additions Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE �} � square feet x$96/sq.foot= Z AZ3 x.0031= s P—`��- plus from below(if,applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq.foot= M,Z00 x.0031= plus from below(if applicable) �.0 GA-RAGES(attached&detached) square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.,ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf' 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck (number)x$30.00= ` . ,l Fireplace/Chimney 1 x$25.00= 4 (number) i Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) U Permit Fee proicost FEB-19-2004 11:20 COSTELLO GREYDRNUS 731 961 3900 P.02 'down of Barnstable Regulatory ServiwS ' AA I �'�Offi�7" o DIrador ,tip + zsilda�g x3f��.on > z TamVE77M ]jnilding Co=mMopAr �. : K, 7Ap a�htr�t, yl►�cl�l M&Msot i Pax, 'rD�790. 0 { Property Owner Must ? . Complete and sign Tills S.cction. 4 ,,�.1 Y�.,.. -• .�' s ,ts"act Oa,��be°h�lf,. hereby 4uth®tiaa �i bi LU tmttete leutive to work mth for I�.r ddtes®of Job) c of cRojet ate 1 t TOTAL P.02 • BOar+!of Building Re � 1 - HOME 1 eg►strat►o n l ions�and gt °dardsR .►MP\OVEryEVTCONTRACTOR I ptra on 125529 I S/2006 I rY,pe indiv t JOHN J.DELA idualN�y i ' '� ' , f. 1 JOHN pE�NEY', 271 PLUM ST W.BARNSTggLE MA 02668 rr+►nistrat°,� l S M M F B L IAG*'EOUR�SOR BOARD O TRUCTION SO Pe no PE 1• license`CQ r 009961 Nuimsber �2 21684 p4 3OMN g 026 W BARN ABLE. NfA i t t r f X Affyo,/y#Aw f Awn m WS O r 9'S• d CC/YTet` UlLLS iAl now Jb accardbrAw WAWA WOW WO i 4U Ma., s mfmmb ch N AN Awo CZOW77 770 rIL ul'AM or CZW7 D -r-5e-,Pr.AOMM5 Mom Now A. .. , -. i