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HomeMy WebLinkAbout0409 NYE ROAD � � ,� . F� i� f „?, � G :�' � ,. r „ ° ,. ,. '� � � � . a io .,. o. �: c e a — v � _ ,. ., � ° o e o • � � na u .. .A r� ., o � � - _ n � - _. _ �.- - - , .. o e a o e? TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ll Map y Parcel ZS Application # TT��"I Health Division Date Issued L? Conservation.Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address G IV Village /" . I Q 6 J Owner a ry u i P Address ®� 62 Telephone Permit Request �44 ti 0 � ' 'fie TC1 �4 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation a DU Construction Type w 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) { N",*ber of Baths: Full: existing new Half: existing new N;jimber 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 ( UILDER OR HOMEOWNER) - r Name ti Telephone Number 5~0 -3 Address 161 ro lm m a fll License # G O -5 4!� Home Improvement Contractor# Email 6Ld CA p e en eMV Worker's Compensation # _04f 6-- 316`37?5 16—6;�� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO O -Cf 19051 Aollo�SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED` MAP/PARCEL NO. j F ADDRESS VILLAGE a OWNER DATE OF INSPECTION: FOUNDATION FRAME r INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL i GAS: ROUGH FINAL L. ' • FINAL BUILDING DXTE CLOSED OUT ASSOCIATION PLAN NO. 4 _ t ?''xl a Commonwealth of Massachusetts Department of Industrltgl Accidents lap [j,,aice of Investigations 600 Washington Street Boston,MA 02111 wn*w.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors.(ElectricianslPlambers Applicant Information Please print UL biy Name(BasineWOrganniization/In&vidaal): Allf Address_ CitylStateJZip: - 3 Phone� Are van an employer?Check the appropriate box: T of project(required): J 4. ❑ I am a general contractor and 1 Type New Lio 1_ I am a employer with 6. ❑New construction employees(full and/orpart-dime).* have hied the sub-contractors. 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_ ❑Demolition working for me in any capacity. employees and have vmtkers' 9. addition [No workers' comp.insurance comp.insurance.1 ❑Building required] 5. ❑ We are a corporation and its 10..❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L_❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12. insurance required.]t c.152, §1(4} and we have no � Oth� repairs employees_[No workers' 13. comp.insurance required.]: 'Any applicant that checks boa#1 must also U out the section below showing their workers`compensation policy information. T Homeowners who submit this affidatdt indicating they are doing an wait and then hue outside contractors mast submit a new affidavit indicating such_ tCGntrwtors that check this boa must attached an additional sheet showing the name of the sub-caunactDrs and state whether or not those entities have employees. If the mb-coutractors have employees,they must provide their workers'comp.policy number. lam an employer that is pmviding workers'compensation insurance for my employees. Below is the policy and,job site information. [ , Insurance Company Name: Policy 9 or Self-ins-Lic.9:� ��" l� .� 111,M N ga ExpirationDate: 1, Job Site Address:�I (� City/State zip: ceVI R'r�41` e , IA 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 far insurance coverage verification. I do hereby certi&under thepri d psnalti of perjatry that the inform it provided above is Int e'aend correct 7; tare: Date: ele Phone#: Q,feiai use only. Do not write in this area,to be completed by city or town official. City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 5/28/2014 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 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 BRYDEN & SULLIVAN OFDENNIS INC NAME: - PO BOX 1497 PHONE FAX SOUTH DENNIS, MA 02660 (A/C, MAIL° E t' AIC "° ADDRESS: - INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation - 33600- INSURED INSURER B: - - - SHAYNE E DEWITT DBA ALL CAPE ENERGY INSURERC: PO BOX 1492 INSURER D: BREWSTER MA 02631 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 20326106 . " 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP .. LIMITS - LTR I D WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY - COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTE CLAIMS-MADE OCCUR" PREMISES Ea occur ence $ MED EXP(Any one person) $ " PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO JECT LOC PRODUCTS-COMP/OP AGG $ PRO- POLICY❑ OTHER: $ 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 LIAR OCCUR _ - EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE - - AGGREGATE $ - DED RETENTION$. $ A WORKERS COMPENSATION WC5-31S-378516-023 9/13/2013 9/13/2014 / STER ATUTE OERH AND EMPLOYERS'LIABILITY - - ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT. '$ ' 500000 OFFICER/MEMBER EXCLUDED? FYI NIA (Mandatory in NH) E:L.DISEASE-EA EMPLOYE $ 500000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. THE WORKERS'COMPENSATION POLICY DOES.NOT PROVIDE COVERAGE FOR SHAYNE DEWITT. CERTIFICATE HOLDER CANCELLATION TOWN OF HARWICH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 732 MAIN STREET HARWICH MA 02645 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD CERT NO.: 20326106 Lucy Garfield 5/28/2014 4:41:14 PM (EDT) . Page 1 of 1 Office of onsumer' fairs&' uness Regulation " HOME IMPROVEMENTCONTRACTQR a Registration 166888 Type Expiration 7,/l9/2014 DBA AL PE ENERGYi- ; k, SHAYNE DEWITTi i .9 CHASE LN. � ' � .• � — fr tr' , ORLEANS,MA 02(i53 a f Undersecretary All- 9 Massachusetts -.Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialty License: CSSL-103842 SHAYNE DEWITT` ,ter 161 Commons Wad Brewster MA 0201 9I �.�... Expiration 02/23/2016 Commissioner r . MCI- ...,,R, 4 License or registration vaLd for mdrurdpl use oply l before the expiration date If found return to: t Office of Consume A r ffairs and Business Re ulatton V JI i4 1 d"F'ti g S :I l0 Park'Plaza suite 51.70 Bostop,''NIA O121L6 K Not u lid without�signature ""<^- �"` _,zE+M 0 .0 Housing ®� Assisian+ce kill, Corporation J Cape Cod r_ HOME.OWNER I RESIDENT WEATHERIZATION 1�OR�K pE-,RIAIT&FUEL RELEASE.- PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. 1 i hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation (herein after refer ed'as "Agency")on,the property located at; 6 The weatherizatfon work done will be based on programmatic priorities.and a4labiifty of funding and it may include all or some of the following measures: Weather-stripping&caulking of windows and doors, insulation of attics, sidewalls&basements,attle and other ventilation measures and possibly replacement of badly deteriorated windows. in consideration of the weatherizzaation work to be,done at my home I agree to the following: i. I give permission to the"Agency"its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property., 2. The Housing.Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five(5)years after the weatherization work Is completed. /I have read the provisions of#his.a ment listed and freely give my consent. Home Owner:(Slanatur 1 Date: , Agent (signature) Dade:- �j _ '_-! HAC approved Weathedzation Company : Adam T Incorporated _ All Cape Energy Alternative Weatherization Building Pear-fomcance Contracting LLC a Cod Insulation Cape Save Frontier Energy.Solutions Lohr Home Improvement Resolution Energy i4c•i'd.:.::!{i il'-:}lyl a:�gtiPp ;A.�r tt:C?:i lC?:.'a.::J'14 y.y�::IP2�i�\'!••7-.lei .G.h' �I& S yo Town of Barnstable *Permit# Expires 6 months from issue date yT ^ Regulatory Services . — t snxxsrABLE 16 9. Richard V.Scali,Director ArED MA't A - Building Division , JUN - 3 2014 Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA o2601 ABLE www.town.bamstable.ma.us OF SARNST Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number J - `I Property Address N '1 2 _. [Residential Value of work$ J�d 00 O Minimum fee of$35.00 for work under$6000.00 . Owner's Name&Addressy UUq Contractor's Name ��r Telephone Number_ �Dk Home Improvement Contractor License#(if applicable) /7.)-t7.,)- Email: Lp S►t�Ji-U�d� �c�s�° <Ca�, Construction Supervisor's License#(if applicable) os2q Workman's Compensation Insurance Check one: I am a sole proprietor ❑ I am the Homeowner a ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 0-1b06053 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 sr,8 CJ-N ❑ Re-roof(hurricane nailed)(not stripping. Going over, existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. , A copy of the ome Improvement Contractors License&Construction Supervisors License is it SIGNATURE: QAWPFILESTORWbuilding permit forms\EXPRESS.doe 1 Revised 061313 77ite Corasarror€wean*ofMassachusd'fs Deprartr nmt,+fffird=ft ial Accidents 600 TYr;yhington,reef Boston, 42M wnw.rnass.goldira W-arkers' Campen-aticinInsu_ranceAffidavit:Bt-jilders/Contra:ctors/ ectriciansXlumbers Applicant Infarmation Please Print Legibly Flame 0jsmess 0Tmizafiontf &idnal): 5�,� 1•o�,^r Address. O- QL City/State/Zip: Phone 4 �;ke 057 Are you an employer?Check the appropriate bfix: Type of n' ] �:r project`ect uire _ -0-. I 83ni s contractor and I �l 1._fP I am a employer with tt 6_ New Luc#on employees{full and/or part-time}* have hied the sub-co ractors. 2._❑ I am a sole proprietor or partner- listed oti the attached sheet 7- ❑Remodeling slap and hive no employees These sub-contractors have g- ❑7}et=lition w for me in an c ci �- �la�and have workers' odzng Y � t5 _ 9. 0 Building;addition [No workers' comp:rmu=nre, comp.,nsurance.1 required . 5_. We are a cotporationand its 10_.0 Electoral repairs or additions 3111 am a home ow er doing all work officers have exercised their 11_0 Plumbing repairs or additions myself,LNo workers'camp- right of exemption per MGL 1 fn Roof repairs insurance required.]b c_1.52,§1(4),and wehffMna employees_[No workers' 13_.�Other . comp-insurance recitnred-f *Any WpEctut that checks boa#1 nmst also fill out the section below showing ih&workers'compensation policg infprmx&zL T Someownffs who submit this affidavit indicating dicey Rm domg all uu&sad then hire outside coutrmiurs mnst stabotit a new affdavit in itatin such_ lUntractors&A check this boar must attached as additional sheet showing the name of the sub cam;=tors and state whether or not those entities have employees- If the sib-coat mctnlshwe employe�--s,the}nmrst provide&sr workers'comp.policy number. lam an employer thatisprm idL-W workers'coniperurrtio:n inrurarice for my emplirym Relate is thepat<cy.anal job site informatian lasmance Company Name: �14 Pow;g or self Infi_I.i t �Lt/0..(��+ �!v 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 requiredunder Sections,25A of MGL c 152 can lead to the imposition ofairai„al penalties of a fine up to$1,500.00 and/or one-year mqmsonment,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 maybe forwarded to the Office of Investigations of else DIET for inauance coverage verification- 1 do hereby certify [h.a penalties ofperjscry that the irrjormatian pratdded oboe e' tine and correct Sitnsatnre: Date- Phone 0: Sao IO 6l 7 Lf 026cial use only. Do not write in this area,tv be completed by cii}or town official City or Town: PermitUcense# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other 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_" 1 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 othe`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 'another who employs persons to do mainten e,construction or repair work on such dwelling house or on the groan or building appurtenant thereto shall not bec e of such employment be deemed to be an employer." MGL chapter 152, 25C(6)also stales that"every state or 1 cal licensing agency shall withhold the issuance or renewal of a license r permit to operate a business or t construct buildings in the commonwealth for any applicant who has no roduced acceptable evidence o compliance with the insurance-coverag-required."' Additionally,MGL chapt r 152, §25C(7)states"Neither she commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public w k until acceptable evidence of compliance with the insurance requirements of this chapter h'ave been presented to th contracting authority." Applicants — Please fill out the workers'compen tiion of ndavi completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)na me(s), addr ss(es)and phone number(s)along with their cerniacate(s)of insurance. Limited Liability Companie (LLC)o Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to w rkers' compensation insurance. If an LLC or LLP does have employees, a policy is required_ Be advised this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance cove . Also be sure to sign and date the affidavit 17he affidavit should be returned to the city cr town that the appli a r the permit or license is being requested,not the Department of Industrial Accidents. Should you have any qu ons ding the law or if you are required to obtain a workers' compensation policy,p-ease call the Departm t at the ber listed below. Self-insured companies should enter their self-insurance license number on the appropri line. City or Town Officials Please be sure that the affidavit is complete d printed legibly. The De artment has provided a space at the bottom of the affidavit for you to fill out in the event e Office of Investigations h to contact you regarding the applicanL Please be sure to fill in the permitllicense n ber which will be used as a ref ace number. In addition,an applicant that must submit multiple permitllieense app cations in any given year,need o submit one ai�davit indicating current policy information(if necessary)and under' ob Site Address"the applicant sho write"all locations in (city or town)."A copy of the affidavit that has b officially stamped or marked by the ci or town may be provided to the applicant as proof that a valid affidavit is on e fur future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is ob g a license or permit not related to any business or commercial venue (i.e.a dog license or permit to bum leaves e .)said person is NOT required to complete N ffidavit. The Office of Investigations would lfice to ank 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 T number: ommonwealth of Massachusetts Darment of Indal Accidents Mice of kvestigatzorts 600 Washingtoa Street Boston.,MA 02111 Tel.#617-727-49-OQ W 4-06 or 1-VT MASSAFE Revised 4-24-07 Fax#617-727-7749 WWW mass-gavlcha * * anaNsrwBr.E. • . 9� 16 9. ,�� Town of Barnstable ArfD pM't� Regulatory Services Richard V. Scali,Director Building'Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property, Owner Must Complete and Sign This Section If Using,A Builder TX rr-Zq N V 1A f z c o� , as C 'caner of the subject property .... hereby authorize `-(� il'. to act on my behalf, in all matters relative to work authorized by this building pe t application for: , v (Address of Job) i Signa e of weer r r Date' Print N e + If Property Owner is applying for permit,please complete the Homeowners License Exemption.Form on the ' reverse side. QAWPFILESTORMS\building permit forms\EXPRESS.doc Revised 061313 Town of Barnstable Regulatory Services P�°F1 TOtyy Richard V.Scali,Director Building Division,: BARN5rABM Tom Perry,Building Commissioner s 9. �� 200 Main Sftreet, Hyannis,MA 02601 AF�MF � , www.town.barristabl-:ma.us Office: 508-862- 0 Fax: 508-790-6230 t HOMEOWNER LICENS XEMPTION Please Prin DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/to n e zip code The current exemption for"homeowners" as e ended to includ caner-occu ied dwellin s of six units or less and to allow homeowners to engage an individual for hire,who oes not posses license,provided that the owner acts as supervisor. DEFINITION O HOMEOWNER Person(s)who owns a parcel of land on which hie/sh resides.or rids to reside,on which there is,or is intended to be,a one or two- family dwelling, attached or detached structures acce ory to su se and/or farm structures. A person who constructs more than one home in a two-year period shall not be consider4a ho eowner uch"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall�be r s onsi for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for,c p ance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she under e Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply wit i procedures and requirements. Signature of Homeowner `Approval of Building Official Note: Three-family dwellings containing 35,000 c bic feet or largy will be required to comply with the State Building Code Section 127.0 Construction Control. l I HO , OWNER'S EXEMPT The Code states that: "Any homeowner perfo ming work for whi a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 L''�nsing of constructio Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that!uc Homeowner shall act\ supervisor." Many homeowners who use this exemption are unaware that they are as ming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Sec 'on 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed perso . In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The home caner 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. r Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 AICOR�® DATE(MWDDIWYtl) CERTIFICATE OF LIABILITY INSURANCE 05/28/2014 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 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 Erica PRODUCER HART INSURANCE AGENCY,INC. N^�E= --- - - H.O'Connor 243 MAIN STREET I NC.N ExU6 508 759-7326 x205 ac No):508-759-7366 PO BOX 700 E-MAIL DR 83: BUZZARDS BAY,MA 025320700 — _ INSURE RLS)AFFORDING-COVERAGE NAIL R _-........_...._— __ INSURERA: PENN-AMERICA INS CO 32859 INSURED Scott Lohr dba Lohr Home Improvement _IHsuRER_1:_.ACADIA INSURANCE COMPANY 31325 23 Grand Oak Rd Forestdale,MA 02644 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. INSRADDL SUER,....... _.. ._.... ._...._....... ._._..........�_.,..,__.......__......-_... ..._-....—_. LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF M DDMVY OMITS A GENERAL LIABILITY PAV0027252 05/15/2014 05/15/2015 EACHOCCURRENCE E 11000,000 COMMERCIAL GENERAL LIABILITY I ! I I dAMA(-`aE�'1 R TE ,1 PR�MIUSIEa acwrtanrl E 50,000 _I. CLAIMS-MADE i_ OCCUR I I I I MEDEXP An o�ercon E 5,000 _ I PERSONALSAOVINJURY E 1,000,000 I GENERAL AGGREGATE E 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS•COMP/OPAGG E 1,000,000 POLICY PRO- i^ LOG E AUTOMOBILE LIABILITY II COMBINED SINGLE LIMIT ANY AUTO _ I I { BODILY INJURY(Per Person) E ALL OWNED SCHEDULED AUTOS AUTOS, •BODILY INJURY Per exidenq E NON-OWNED I I PROPERTY'IMMAGE _ HIREDAUTOS AUTOS ( { I (Perjd E UMBRELLA Lips OCCUR ! EACHOCCURRENCE E EXCESSLIAe ...,...,_ CLAIMS;MADE I I I _AGGREGATE E DED RETENTION$ E B WORKERS COMPENSATION WC202000536000 05/15/1014 05/15/2015 1 STATU- OTH- AND EMPLOYERS'LIABILITY YIN I ...To ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT E SOO,OOD OFFICERIMEMBER EXCLUDED? FN NIA -....._ (Mandatory in NMI DISEASE-EA EMPLOYEE E 500,000 It Yea,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT E 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAttach ACORD 101,Additional Remarks Schedule,I more space Is required) ERTIFICATE HOLDER CANCELLATION Fax#:(508)775-3344 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 236 SOUTH STREET ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS,MA.02601 AUTHORIZED REPRESENTATIVE 601114 I • 01988.2010 ACORD CORPORATION. All rights reserved. CORD 25(1010/05) The ACORD name and logo are registered marks of ACORD r Massachusetts -Department.of Public Safety Board of Building Regulations and Standards Construction superN'isor. License: CE053961 } '..'ITS SCOTT A LOHR 23 GRAND OAK RD Y FORESTDALE NIA 026 _ '.IsExpiration —� 0610912015 Commissioner. °�` dD 'CCQ License or registration valid for individul use only Office of Consumer Affairs&B siness Regulation g before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Registration:,F;:172172 Type: Office of Consumer Affairs and Business Regulation R 112 016 DBA 10 Park Plaza-Suite 5170 Expiration: .513 _ - Boston,MA 02116 LO HOME IMPROVEMENT -1 SCOTT LOHR 23 GRAND OAK RQi FOREST DALE,MA 036'--' Undersecretary j Not valid without signature �►A�p.....�►�a - Assessor's map and lot number ........ 1?••••••�. • ' THEToy a ..:. , SEPT' SYSTEM MUST Sewage Permit number .... .... "�` INSTALLED� EC IN COMPLIANCE " A Z BAHBn9eTa LE, House number .. ............. e y WITH TITLE 5 '° 39.a-0� E AND �aY . TOWN .OF "BAR, &VC 4S BUILDING INSPECTOR APPLICATION FOR PERMIT TO CQ?.n S+C `t C* ..... ..................................... ........................ + � TYPE OF CONSTRUC TION .... . ................................ ... .......In.............19 .. " TO THE INSPECTOR OF BUILDINGS: . The undersign._ejd, hereby applies for a permit according to the following information: Q . ` /�(� �• Location .. .►.... .....� .......:!nVC� !�......1.� ..����!�. .... ..V l�\ :.....1.....1R.;.a.............. ProposedUse M.ie.............................. .................................................. .............................................. ....... .. Zoning District ... K C�'... .Fire District .....G ..`..Ch� ................................ ... Name of Owner uN...,11r.:QY., ....................Address ... fA !::A.....2A...C :1.�.1 ...... Name of,Builder"4.� tF�: M � .......... :Address— Name Name of Architect .............!.!�.. ... `. .. . ....... �t4 � ....�.t \�s.�..........Address ...Q-.�... �rr�.......1�.��1 t�h`r44 .......................... Number of Rooms .....5............................................... ........Foundation ....caa. rK. �........... ......................... Exieriorl .W-0.0. % ........................................................Roofing .:; ...!...........:............................................ Floors.y..W. .......................................................Interior ..5 ...... .................................. :....... - ...... .......Plumbing ..p v....s..... ;.. ..... .... :d..:. Fireplace ...N18......................p ................. . .................Approximate.Cost ....]5.&....0.0..................... .................. Definitive Plan Approved by Planning Board -------------------_-----------19_._____. Area .......I& '........ Diagram of Lot and Building with Dimensions 9 g Fee ........ix.Gli........................... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name am .. .. .. `...... '...1................... MCKEON, JACK 24300 One Story . No .....11............ Permit for .................................... - f Single )Family Dwelling ......... .................... ...................... I' Location Lot #10. .,....409. . Road` f• w ........... .... .. .... ..�.... ......... ..... _ . Centerville.......... .:............ _ Jack McKeon Owner ............. .. ........................................... i= Type of Construction ,Frame ..... ............... ........... ............... n r Plot ............................ Lot . August 20. 82 (' I - Permit Granted Date of Inspection ...........19 Date Completed ..... � �. .............19 � 'v� P a "n e ' v7- 17, 22, P . L v 7 1 Ft 20 i_► P-F: 43; M s:q �tSSuMED P�a��r r� T ' vuD�G� i1�TIT CN��)T ZII, C JE "GEC 1 L, �i.. icy' cr s x�nWo CERTIFIED PLOT PLAN-ViT NEW CONSTRUCTION ONLY � TOP. OF FOUNDATION IS FEET IN ABOVE . LOW POINT OF ADJACENT JDAMIS iAW� ASS• ROAD. (Al yc It°) SCALES /"= D DATE t R/�5 A �. 7J08mo, n� oLD D) E E/V9! EE I e .l / � � 1 CERTIFY THAT THE D Rt:®ISTERED SHOWN ON THIS PLAN ,IS LOCATED � ON THE GROUND AS INDICATED AND CIVIL LAAIDCONFORMS TO THE ZONING LAW ENOINEER SURVEYOR DR. ,�' OF BARNSTAB.hE, ASS. 7 12 MAIM 'S.T RE ET H YA N f1!S, M1�S S. SHEBT .®F DATE 0. LAND SURVEYOR TOWN OF BARNSTABLE Permit No. ----------__ 1 »nA ; Building Inspector Cash rua yt� � i070� p OCCUPANCY PERMIT Bond No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to J.arrk )Vlry.Pnn I i Address 1 or- Wiring Inspector Y '� �".-/� % ��;._.-�'�� Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN 1 REQUIREMENTS. ...................................._.............._, 19..... __ ........................................ .... ..................._ Building Inspector